A

CASE OF BLOODY DIARRHEA

Resident: Quang Nguyen, MD
Attending: Muneeb Ahmed, MD
Program: Beth Israel Deaconess Medical Center, Boston, MA

CHIEF COMPLAINT & HPI

Chief Complaint

37-year-old male who presents with abdominal pain and blood diarrhea

History of Present Illness

Symptoms started approximately one month ago, initially with
constipation and progressed to abdominal pain and watery diarrhea
Initially diagnosed with uncomplicated diverticulitis and treated with
antibiotics
Symptoms persisted and progressed to severe abdominal pain,
decreased oral intake and hourly bloody diarrhea

RELEVANT HISTORY
Past Medical History
None.

Past Surgical History

None

Family & Social History

Denies history of Inflammatory bowel disease, gastrointestinal malignancy, or autoimmune

disease

Review of Systems

Negative except per HPI

Medications

Dilaudid, Ativan and Ciprofloxacin

Allergies
Nickel

DIAGNOSTIC WORKUP
Physical Exam

Vital Signs: T: 98.0 HR: 86 BP: 115/70 RR: 18 SaO2: 98% on RA

General: young male, no acute distress, resting comfortably
Abdominal: Palpable tender masses within the left upper and lower quadrant; soft, non-
tender in the right abdomen without peritoneal signs
Rectal: no perianal lesions, no stool on digital rectal exam
Otherwise, negative physical exam findings

Laboratory Data

21.8

14.0
41.9

599

DIAGNOSTIC WORKUP
1) What are the salient imaging findings?
A: Small colonic outpouchings with irregular wall
thickening and pericolonic fat stranding
B: Circumferential, symmetric colonic wall thickening,
luminal narrowing and fascial thickening.
C: Focal asymmetric colonic mural thickening
with luminal narrowing
D: Small, oval pericolonic fatty nodule with
hyperdense ring and surrounding inflammation

CORRECT
1) What are the salient imaging findings?
A: Small colonic outpouchings with irregular wall
thickening and pericolonic fat stranding
B: Circumferential, symmetric colonic wall thickening,
luminal narrowing and fascial thickening.
C: Focal asymmetric colonic mural thickening
with luminal narrowing
D: Small, oval pericolonic fatty nodule with
hyperdense ring and surrounding inflammation

Continue with case

SORRY, THATS INCORRECT

1) What are the salient imaging findings?
A: Small colonic outpouchings with irregular wall
thickening and pericolonic fat stranding
B: Circumferential, symmetric colonic wall thickening,
luminal narrowing and fascial thickening.
C: Focal asymmetric colonic mural thickening
with luminal narrowing
D: Small, oval pericolonic fatty nodule with
hyperdense ring and surrounding inflammation

Continue with case

DIAGNOSTIC WORKUP
Initially diagnosed with colitis, likely inflammatory
spanning from rectum to splenic flexure (i.e. Ulcerative Colitis)
Colonoscopy

Erythema and congestion in the rectum & sigmoid colon with

biopsy of sigmoid colon

Pathology

Colonic mucosa with

ischemic-type injury

DIAGNOSTIC WORKUP

DIAGNOSTIC WORKUP
2) What are the salient imaging findings?
A: Contrast blush that takes upon a
rounded shape
B: Focal tangle of vessels centered
in the mesentery.
C: Dilated arteries with prominent
accumulation of contrast material
in the bowel parenchymal
D: Abnormal clusters of small arteries
with intense opacification of the bowel wall

CORRECT!
2) What are the salient imaging findings?
A: Contrast blush that takes upon a
rounded shape.
B: Focal tangle of vessels centered
in the mesentery.
C: Dilated arteries with prominent
accumulation of contrast material
in the bowel parenchymal
D: Abnormal clusters of small arteries
with intense opacification of the bowel wall
Continue with case

SORRY, THATS INCORRECT.

2) What are the salient imaging findings?
A: Contrast blush that takes upon a
rounded shape.
B: Focal tangle of vessels centered
in the mesentery.
C: Dilated arteries with prominent
accumulation of contrast material
in the bowel parenchymal
D: Abnormal clusters of small arteries
with intense opacification of the bowel wall
Continue with case

DIAGNOSTIC WORKUP

- Focal tangle of abnormal vessels involving a sigmoidal artery centered within the mesentery & an
early draining dilated marginal vein (which fills well before mucosal vessels fill)
- Finding is most consistent with a focal arteriovenous malformation with associated shunting.

INTERVENTION

Two 4 mm x 8 cm coils were sequentially placed to focally occlude the marginal artery at the
site of AVM shunting. No significant filling of the major portion of the AVM.

CLINICAL FOLLOW UP
Clinically improved with decrease in frequency of diarrhea
and resolution of bloody bowel movements
Sigmoidoscopy

Abnormal mucosa with erythema and congestion

Pathology

Colonic mucosa with crypt regeneration, focal crypt atrophy

& and basal apoptotic debris.
Overall features are in keeping with an ongoing
ischemic type injury including demand related vasculitis.

Underwent uncomplicated left hemicolectomy &

end transverse colectomy

SUMMARY & TEACHING POINTS

Inferior mesenteric arteriovenous malformations (AVMs) are rare with less
than 15 reported in the English literature
AVMs can be classified as congenital or iatrogenic, secondary to abdominal
trauma or colonic resection.
Common clinical symptoms and signs of inferior mesenteric AVMs include
abdominal pain, mass or bruit.
Serious manifestations of mesenteric AVMs include signs of portal
hypertension such as variceal bleeding, ascites and splenomegaly, which is
present in approximately 50% of patients with splanchnic AVMs

May result from increased blood flow into the portal system and compensatory increase
in hepatic vascular resistance.

SUMMARY & TEACHING POINTS

Patients less commonly present with symptoms of non-occlusive
ischemic colitis (i.e. abdominal pain, diarrhea, hematochezia).

This is thought to be due to a steal phenomenon from decreased arterial blood flow to
the colon beyond it and increased venous pressure distal to it.

Transcatheter embolization has been most useful in patients who are

critically ill.
If treatment with embolization fails, colectomy may be necessary. Surgical
resection of the AVM and abnormal bowel segment has been the treatment
of choice.

REFERENCES & FURTHER READING

Justaniah AI, et al. Congenital Inferior Mesenteric Arteriovenous Malformation Presenting
with Ischemic Colitis: Endovascular Treatment. J Vasc Interv Radiol. 2013 Nov;24(11):1761-3.
Turkvatan A, et al. Inferior mesenteric arteriovenous fistula with ischemic colitis: multi-
detector computed tomographic angiography for diagnosis. Turk J Gastroenterol 2009;
20:6770.
Jung JO, et al. Ischemic colitis associated with segmental arteriovenous malformation
mimicking inflammatory bowel disease in a familial adenomatous polyposis patient. Dig Dis
Sci. 2007;(52): 27032706.
Metcalf DR, et al. Ischemic colitis: an unusual case of inferior mesenteric arteriovenous
fistula causing venous hypertension. Report of a case. Dis Colon Rectum 2008; (51):1422
144.
Nemcek AA Jr, et al. SIR 2005 Annual Meeting film panel case: inferior mesenteric artery-to-
inferior mesenteric vein fistulous connection. J Vasc Interv Radiol 2005;16:11791182.