Nonocclusive mesenteric ischemia: fulminant pancolitis

Question: A 79‐year‐old woman was admitted to our hospital for a screening colonoscopy. In the early morning, 6 h after taking the laxatives, she presented with generalized abdominal pain associated with abdominal distension, vomiting, and bloody loose stool, and she later developed hypotension. Upon physical examination, there was slight abdominal wall rigidity, but no guarding or rebound tenderness. Laboratory findings revealed leukocytosis of 16,900/mm3; aspartate aminotransferase (AST), 1950 U/L; amylase, 181 U/L; alkaline phosphates (ALP), 791 U/L; lactate dehydrogenase (LDH), 1790 IU/L; creatine phosphokinase (CPK), 3300 IU/L; and c‐reactive protein (CRP), 22.1 mg/mL. The presepsin was 748 pg/mL (normal value, <314 pg/mL). A plain X‐ray of the abdomen revealed air‐filled and dilated colon loops without thickening of the bowel wall (Fig. ​(Fig.1A).1A). Axial contrast‐enhanced CT study showed small bowel demonstrating increased and prolonged bowel wall enhancement, and there was an absence of contrast enhancement in the colon loops (Fig. ​(Fig.1B).1B). Colonoscopy revealed a focal area of pale and edematous mucosa interspersed with petechial hemorrhage and superficial ulceration of the recto‐sigmoid colon (Fig. ​(Fig.1C).1C). Narrowing or obstruction of the celiac trunk, superior mesenteric artery, or inferior mesenteric artery were not observed (Fig. ​(Fig.11D). Figure 1 (A) A plain abdominal X‐ray showed air‐filled and dilated colon loops as the sign of paralytic ileus. (B) Abdominal noncontrast computed tomography (CT) scan showed intestinal segments dilated and distended by air‐fluid levels, ...