Case report 1429 Acute mesenteric infarction: an important cause of abdominal pain in ulcerative colitis Peter M. Irving a , Elspeth M. Alstead b , Ralph R. Greaves b , Roger M. Feakins c , Richard C.G. Pollok d and David S. Rampton a We present four cases of acute mesenteric infarction in patients with active ulcerative colitis: one presenting prior to the diagnosis of ulcerative colitis, two at the time of diagnosis, and one many years after the diagnosis had been made. Intestinal ischaemia is an important part of the differential diagnosis in patients with ulcerative colitis presenting with abdominal pain. Conversely, in patients presenting with bloody diarrhoea after mesenteric ischaemia, ulcerative colitis should be considered. Eur J Gastroenterol Hepatol 17:1429–1432  c 2005 Lippincott Williams & Wilkins. European Journal of Gastroenterology & Hepatology 2005, 17:1429–1432 Keywords: mesenteric thrombosis, ulcerative colitis, ischaemia, inflamma- tory bowel disease a Department of Gastroenterology, c Department of Histopathology, Barts and the London NHS Trust, London, UK, b Department of Gastroenterology, Whipps Cross University Hospital NHS Trust, London, UK and d Department of Gastroenterology, St George’s Hospital, London, UK. Correspondence and requests for reprints to Prof. D.S. Rampton, Department of Gastroenterology, Barts and The London NHS Trust, London E1 1BB, UK. Tel: +44 207 377 7442; fax: +44 207 377 7441; email: d.rampton@qmul.ac.uk Received 1 June 2005 Accepted 18 September 2005 Introduction Thromboembolic events are a well-recognized complica- tion in inflammatory bowel disease (IBD), which confers about a threefold increased risk of either deep vein thrombosis (DVT) or pulmonary embolism (PE) [1,2]. While DVT and PE are the most common thromboem- bolic events seen in patients with IBD, thrombosis elsewhere, such as in the mesenteric vasculature, can occur and should be considered as a cause of abdominal pain in patients with IBD. Case 1 A 33-year-old woman presented in May 2003 with a 2-week history of cramping abdominal pain associated with anorexia and vomiting. She also gave a 2-month history of diarrhoea and intermittent rectal bleeding. She had been taking a low-dose oral contraceptive pill (microgynon) for 4 months and had recently been prescribed iron supplements for anaemia. She had no past medical history or family history of note and had stopped smoking 2 years previously. On examination she was uncomfortable, pale, pyrexial (37.51C) and tachycardic (90 beats/min). She had central abdominal and right iliac fossa tenderness but no peritonism. She had a leucocytosis [13.8  10 9 /l (normal range [NR], 4–11)] and thrombocytosis [715  10 9 /l (NR, 150–400)]. Serum urea and electrolyte concentrations, liver function tests and amylase were normal. Over the following day the patient’s pain worsened and localized to the right iliac fossa. A clinical diagnosis of appendicitis was made. However, at operation she had an abnormal, thickened colon extending from the caecum to the mid-transverse colon. The remainder of the colon and small bowel appeared normal. A right hemicolectomy was performed. Histological examination showed ischaemic colitis with arteriolar and venous thrombi. There were no features of vasculitis or inflammatory bowel disease in the resected specimen (Fig. 1a). Post-operatively the patient received anticoagulation with low molecular weight heparin and subsequently with warfarin. She continued to have bloody diarrhoea, a worsening thrombocytosis and raised inflammatory mar- kers. Flexible sigmoidoscopy showed severe colitis with diffuse mucosal erythema, granularity, oedema, ulceration and spontaneous bleeding. Biopsies were consistent with ulcerative colitis (UC) and had no features of either infective or ischaemic colitis. Immunocytochemistry for cytomegalovirus and stool samples for Clostridium difficile toxin were negative. A thrombophilia screen was negative. Treatment with intravenous steroids improved her condition temporarily, but the patient subsequently developed an anastomotic leak and worsening colitis, and therefore had a completion colectomy and ileostomy formation. Histological examination of the resected colon confirmed the diagnosis of active UC (Fig. 1b). The patient recovered well and was discharged on warfarin for 6 months with advice to use alternative forms of contraception. Her thrombocytosis resolved within 4 months of colectomy and she is now entirely well on no therapy. 0954-691X  c 2005 Lippincott Williams & Wilkins Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.