Chronic ischemic ileitis after ileocecal resection and ileocolic anastomosis

The management of precancerous colonic lesions has radically changed with the progress in endoscopy, especially therapeutic endoscopy. Large or suspected polyps were formerly managed surgically. Endoscopic submucosal dissection has completely changed the management of this kind of lesion, exposing patients to fewer postoperative complications.

We report the case of a 76-year-old women with a history of ileocecal resection with ileocolic anastomosis for benign cecal tumor. A few years later, she presented with chronic abdominal pain, clinically significant weight loss, and recurrent digestive bleeding requiring hospitalization for repeated transfusions [1]. An initial colonoscopy performed during a hemorrhagic period revealed large and longitudinal ulcers on the ileal side of the ileocolic anastomosis. On the anastomosis, there was bleeding ulceration requiring the placement of a clip. Some biopsy samples were taken on the terminal ileum. Histological examination revealed fibrino-granulocytic and necrotic tissue originating from the bottom or the edges of an ulcer. Abdominopelvic computed tomography showed terminal ileitis, without occlusion of a digestive vessel ([Fig. 1]). Conservative treatment was proposed given the patient’s poor general condition and important cardiovascular comorbidities.

Fig. 1 Abdominopelvic computed tomography scan showing thickened aspect of the ileal mucosa in front of the ileocolic anastomosis, corresponding to postsurgical ischemic damage of the ileum.

Unfortunately, symptoms did not improve with medical treatment. A second colonoscopy was performed a few months later ([Video 1]) and revealed chronic ischemia. The mucosa appeared thin, atrophic, pale, and without vascularization as evidenced by the absence of bleeding during the biopsies ([Fig. 2], [Fig. 3]). In addition, we found a supracentimetric ulcer associated with a fibrous ileal stenosis [2] [3]. After a multidisciplinary board meeting, surgical management with resection of the ischemic ileum and creation of a new anastomosis was planned.

Video 1 Chronic ileal ischemia following cecal resection with ileocolic anastomosis for huge polyp.

Fig. 2 Appearance of chronic ischemia of the terminal ileum, with pale mucosa and no vascularization.

Fig. 3 Endoscopic view of the ischemic ileitis, with no bleeding after biopsies (red circles) typical of ischemic phenomena.

This is the first reported description of chronic ischemic ileitis after resection of a noncancerous colonic lesion. It illustrates the importance of endoscopic management of precancerous lesions by endoscopic submucosal dissection, thus avoiding more invasive management and allowing organ preservation.

Endoscopy_UCTN_Code_CCL_1AD_2AF

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Terlouw LG, Moelker A, Abrahamsen J. et al. European guidelines on chronic mesenteric ischaemia – joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study Group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United Eur Gastroenterol J 2020; 8: 371-395
• 2 Trotter JM, Hunt L, Peter MB. Ischaemic colitis. BMJ 2016; 355: i6600
• 3 Theodoropoulou A, Koutroubakis I-E. Ischemic colitis: clinical practice in diagnosis and treatment. World J Gastroenterol 2008; 14: 7302-7308

Publication History

Article published online:
15 May 2023