Case Presentation: A 63-year-old female with a history of polycythemia vera (JAK2 mutation), subarachnoid hemorrhage with previous vasospasm, hypertension presented with diffuse colicky abdominal pain and hematochezia for one-day duration. She had no weight loss, weakness, or anorexia. The patient described liquid bowel movements with overt blood. She had been managed with aspirin 325 mg daily, dipyridamole 50 mg TID, hydroxyurea 200 mg daily at home. She underwent monthly phlebotomies that had been uncomplicated per her outpatient hematology provider. Her vitals were stable, albeit for mild hypertension at 152/76. Initial labs were significant for WBC 6.9, hemoglobin 13.8, and platelets of 447. INR was normal at 1.1. She previously had a stool toxin, Campylobacter negative. CT abdomen/pelvis showed thickening of the gastroesophageal junction and adenomyomatosis. She had a screening colonoscopy two months ago that was negative for colonic abnormalities, only non-bleeding internal hemorrhoids. During her admission, she was prepped and underwent a flexible sigmoidoscopy. Findings included congested, erythematous, inflamed and ulcerated mucosa in the descending colon, sigmoid, and rectum likely secondary to colon ischemia. The hematology service was consulted for phlebotomy and the patient had 500 ml of blood removed with resolution of symptoms. Confirmation biopsies came back a week later showing descending colon and rectum with atrophic colonic epithelium consistent with ischemic changes. The biopsy was negative for evidence of chronic colitis, as well as negative for dysplasia or malignancy.
Discussion: Ischemic colitis from PV is reversible but requires quick and precise diagnostic effort. Although enhanced abdominal computer tomography and CT enterography are the gold standards for IC, a colonoscopy or a flex sigmoidoscopy can also be used for definitive histopathological diagnosis. Colonic lesion biopsy can more accurately separate IC from chronic inflammatory bowel diseases in this population of patients. Treatment of IC relies on controlling the primary cause. In this case, that involved expedited phlebotomy for PV; other therapies have included anticoagulation with LMWH and initiation of mesalazine.
Conclusions: Polycythemia vera (PV) is a myeloproliferative disorder characterized by increase in red blood cell, white blood cell, and platelets. Thrombotic complications are unfortunately not rare, and can include cerebral infarction, thrombophlebitis, myocardial infarction, and ischemic colitis. Here we demonstrate an acute case of ischemic colitis (IC) (biopsy-proven) from PV, only the 4th documented case in the literature, that occurred 1-2 months after a normal colonoscopy.
To cite this abstract:Shi, H; Lee, K. ISCHEMIC COLITIS IN POLYCYTHEMIA VERA. Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract 991. https://www.shmabstracts.com/abstract/ischemic-colitis-in-polycythemia-vera/. Accessed November 15, 2019.