EP840 - A Surgical Surprise of Ischemic Colitis Presumed to be Colonic Lymphoma

Purpose/Background: This is a case of a 71-year-old female who presented with right lower quadrant abdominal pain and anemia requiring blood transfusions. CT revealed a 5.9 x 3.8 x 4.4 cm excavating mass arising from the ileum with irregular thick walls, central luminal air, and inflammation. As well as significant atherosclerotic calcifications in the abdomen and pelvis with stenosis of the distal abdominal aorta. The radiologist favored colonic lymphoma as the leading diagnosis. A colonoscopy was performed including intubation of the terminal ileum, which revealed a 2 cm friable ulcer and soft tissue mass at the ileocecal valve. The entire cecum was ulcerated with visible muscle. The biopsy was nondiagnostic and revealed ulcerated colonic mucosa with reactive epithelial changes. Flow cytometry revealed no immunophenotypic evidence of a lymphoproliferative disorder or acute leukemia. The patient continued with persistent abdominal pain.

Methods/Interventions: The patient underwent surgical intervention for symptomatic relief and to obtain a tissue diagnosis. We performed a diagnostic laparoscopy, our intra-operative findings consisted of a firm mass with densely adhered right colon to terminal ileum, transverse colon and omentum. There was a white cakey discoloration on the overlying omentum. Therefore, a laparoscopic en bloc extended right colectomy, distal ileal resection, and partial omentectomy was performed.

Results/Outcomes: The final pathology revealed localized mucosal necrosis with associated foci of transmural ischemic necrosis with fibrosis and fat necrosis, patchy submucosal fibrosis, intraluminal fibrosis with near luminal occlusion, with marked fibrous serosal adhesions and chronic serositis. The margins were grossly normal, lymph nodes were negative, and there was no evidence of malignancy.

Conclusion/Discussion: Herein we discuss an interesting case of presumed right colonic malignancy that final pathology revealed was localized ischemic colitis. This case underscores the importance of having a comprehensive differential diagnosis, especially in a patient with severe vascular disease. It also demonstrated a multidisciplinary team approach and minimally invasive surgical intervention for positive patient outcomes.

Figure 1
CT axial image of 5.9 cm ileal mass.
Figure 2
Intra-operative findings of mass with densely adhered right colon to terminal ileum, transverse colon and omentum.