P3671 - Ischemic Proctitis Masquerading as Crohn’s Disease

Cierra Smith, DO¹, Tyrell Daniel, MD¹, Heitham Abdul-Baki, MD¹, Michael Landau, MD², Ethan Powell, DO¹, Stacey B. Miller, MD^3
1Allegheny General Hospital, Pittsburgh, PA; ²Allegheny Health Network, Pittsburgh, PA; ³AHN Wexford Hospital, Wexford, PA

Introduction: The colon is the most common part of the gastrointestinal tract to develop ischemia. Rectal involvement is uncommon & isolated rectal ischemia even more so due to rich vascular supply. Here we present a case of isolated ischemic proctitis in a patient with suspected inflammatory bowel disease (IBD).

Case Description/Methods: A mid 30s patient with history of postural orthostatic tachycardia syndrome & migraines was initially seen for a 2 month history of 6-7 loose stools a day. This was associated with cramping, intermittent bleeding & was temporally related to development of erythema nodosum. Initial work up, including infectious, thyroid & celiac studies, upper, lower & capsule endoscopy, was unremarkable. Notably Sacchromyces cerviciae IgG was elevated to 31.
They presented 3 months later with hematochezia. Endoscopy noted diffuse ulceration throughout the rectum with two visible vessels treated with epinephrine & clips. Biopsies showed non-specific inflammation & stool was Clostridium difficile positive for which they completed 14 days of oral vancomycin. After 1 month, diarrhea improved with evidence of endoscopic & microscopic healing with the treatment of C. difficile alone.
Six months later, they represented with hematochezia. Infectious disease workup was unrevealing & endoscopy showed multiple rectal ulcers & active colitis. Endoscopic findings were consistent with Crohn’s disease and they were started on usetekinumab. Due to clinical progression, therapy was transitioned to infliximab 2 months later with initial clinical & endoscopic improvement.
A year after starting infliximab they presented with recurrent rectal bleeding & severe abdominal pain. Endoscopy revealed ischemic proctitis & necrosis requiring laparoscopic proctectomy with end colostomy. Pathology was consistent with ischemia without evidence of IBD. Multidisciplinary review with gastroenterology, colorectal surgery, radiology & pathology revealed no clear etiology of ischemia. No evidence of trauma, volvulus, prolapse, mesenteric compromise, vascular anomalies or vasculitis was identified & review of prior endoscopic results still seemed most consistent with Crohn’s disease.

Discussion: Ischemic proctitis is a rare clinical entity, often the result of a low flow state, thromboembolism, severe atherosclerotic disease or aortic interventions. Our patient’s case presented diagnostic challenges based on the chronicity of their course, no overt risk factors for rectal ischemia & overall clinical picture consistent with IBD.



Disclosures:


Cierra Smith, DO¹, Tyrell Daniel, MD¹, Heitham Abdul-Baki, MD¹, Michael Landau, MD², Ethan Powell, DO¹, Stacey B. Miller, MD³. P3671 - Ischemic Proctitis Masquerading as Crohn’s Disease, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.