Colon

• Vascular ectasia of the colon that arises secondarily to liver cirrhosis and portal hypertension that may lead to gastrointestinal bleeding

Images hosted on other servers:

Images hosted on other servers:

Images hosted on other servers:

Contributed by Catherine E. Hagen, M.D. and Dustin W. Parsons, M.D.

A 33 year old man with a medical history of chronic hepatitis C infection presents with bright red blood per rectum. His hemoglobin is found to be 10.6 (reference range: 13.2 -16.6) and albumin is 2.9 (reference range: 3.4 - 5.4). He is also noted to have several scattered telangiectasias on his chest and proximal arms. A colonoscopy is performed, which demonstrates an angiodysplastic-like lesion of his right colon, as well as a few telangiectatic vessels. Endoscopic biopsy is shown above. Which of the following is the most likely cause of his bleeding?

1. Infectious enterocolitis
2. Ischemic colitis
3. Osler-Weber-Rendu syndrome
4. Portal hypertensive colopathy

D. Portal hypertensive colopathy. The patient's history of chronic hepatitis C infection point toward a possibility of liver cirrhosis. This possibility is further supported by low albumin levels, which may indicate reduced hepatic synthetic function. Given his anemia and bleeding symptoms in the context of liver cirrhosis, the most likely cause of his bleeding symptoms from the options listed is portal hypertensive colopathy. Moreover, the histology demonstrates telangiectatic vessels, which further supports the diagnosis of portal hypertensive colopathy.

Answer A is incorrect because infectious enterocolitis may be caused by a number of different pathogens, including bacterial organisms, parasites and viruses. Notably, patients will often present with fevers, abdominal pain, nausea, vomiting and diarrhea (DEN Open 2023;3:e242). Given this patient's clinical presentation and absence of aforementioned symptoms, infectious enterocolitis is less likely. Histologically, such infectious colitis typically has an acute self limited colitis pattern and lacks vascular ectasia.

Answer B is incorrect because ischemic colitis often clinically presents with sudden onset abdominal pain, diarrhea and hematochezia. Common associations include a history of atherosclerosis, hypotension, atrial fibrillation, prior valvular or coronary artery surgery or cocaine use. Histologic findings may include edema, crypt withering, hemorrhage of mucosa and submucosa, lamina propria hyalinization, granulation tissue, microvascular thrombi and areas of necrosis (World J Gastroenterol 2008;14:7302).

Answer C is incorrect because Osler-Weber-Rendu syndrome, also called hereditary hemorrhagic telangiectasia (HHT), is a rare autosomal dominant condition characterized by mucocutaneous telangiectasias and arteriovenous malformations (AVMs) of visceral organs. It can present with significant bleeding from a variety of sources, including the gastrointestinal tract and lungs. Clinically, it is diagnosed with the Curaçao criteria, which considers 4 criteria: recurrent epistaxis, mucocutaneous telangiectasias, AVMs of visceral organs and first degree relatives with similar symptoms. The patient above only meets 1 criterion (presence of mucocutaneous telangiectasias) and thus is unlikely to have HHT (QJM 2020;113:586).

Which of the following histologic features is most commonly associated with portal hypertensive colopathy?

1. Architectural distortion
2. Crypt abscesses
3. Granuloma formation
4. Vascular ectasia

D. Vascular ectasia of the lamina propria is a common histologic finding in portal hypertensive colopathy (Hawaii Med J 2010;69:39, Arq Gastroenterol 2013;50:153). Answer A is incorrect because architectural distortion of colonic crypts can be appreciated in several conditions, such as ulcerative colitis, Crohn’s disease and diversion colitis (bioRxiv 2023 Feb 3 [Preprint], Hum Pathol 1993;24:211). Architectural distortion is not a histologic hallmark of portal hypertensive colopathy. Answer B is incorrect because crypt abscesses may be observed in a number of conditions, including ulcerative colitis, self limited colitis and diversion colitis. However, crypt abscesses are not considered a histologic finding in portal hypertensive colopathy (World J Gastroenterol 2010;16:583, Hum Pathol 1993;24:211). Answer C is incorrect because the presence of granulomas should raise suspicion for Crohn’s disease but granulomas may also form in response to the presence of parasitic ova. Granulomas are not considered a histologic finding in portal hypertensive colopathy (Trends Parasitol 2021;37:176, J Crohns Colitis 2017;11:3).

Comment Here

Reference: Portal hypertensive colopathy