Colon Ischemia Associated with Buerger's Disease: Case Report and Review of the Literature

Kyeong Soo Lee, Chang Nyol Paik, Woo Chul Chung, Kang Moon Lee, Sung Hoon Jung, Jae Wuk Kawk, Ji Han Jung, and Jun Hyun Baik

INTRODUCTION
Buergers Disease (Thromboangiitis Obliterans) : A nonatherosclerotic inflammatory disease affecting the small- and medium-sized arteries and veins of the extremities. Characterized by occlusive segmental and often multiple inflammatory lesions of arteries and superficial veins with thrombosis and recanalization of the affected vessels.

INTRODUCTION
Most common in the Orient, SEA, India, and the Middle East. Usually affects 20 40 yoa men. Typically occurs in young smokers, its remissions and relapses are correlated to smoking. Involvement of large arteries such as mesenteric vessels is extremely rare.

CASE REPORT
Reported here are two cases of colon ischemia in patients who were previously diagnosed with lowerextremity Buerger's disease. In case 1, the patient developed colonic obstruction, and surgical resection was performed. Histopathologic findings were compatible with the chronic stage of Buerger's disease. In case 2, angiography revealed abrupt occlusion of the inferior mesenteric artery with numerous collateral vessels, just like the corkscrew appearance found in the extremities.

Keyword : Thromboangiitis obliterans, Mesenteric involvement, Colon ischemia.

CASE 1
ANAMNESIS Male, 65 yoa Came to the ER w/ CC of periumbilical and RLQ pain for 2 mos. 2 mos ago: RLQ pain and bloody diarrhea treated as ischemic colitis in local clinic. The pain worsened as he developed constipation and abdominal distention in the last 3 days.

CASE 1
He was diagnosed w/ Buerger's disease at the age of 49 when he developed migratory thrombophlebitis. 5 years afterwards he developed ischemic manifestation and underwent amputation on the right lower limb up to the mid-thigh level. He smoked one pack of cigarettes daily since he was 20 and had quit smoking 3 years ago.

CASE 1
PHYSICAL EXAMINATION Mild distention of the abdomen, diffuse pain after palpation, and bowel sounds. LAB RESULTS WBC : 12,600 /L Hb : 11,3 g/dL PC : 336,000 /L Aspartate : 33 IU/L Alanine : 26 IU/L Albumin : 3.5 g/dL

Fasting Glucose : 99 mg/dL

BUN : 12.2 mg/dL Cr : 1.1 mg/dL Na : 139 mEq/L K : 3.8 mEq/L Tot Bilirubin : 0.2 mg/dL

SIGMOIDOSCOPY :

Marked luminal narrowing without any mass lesion.

PLAIN ABDOMINAL XR

Several dilated loops of the large bowel and multiple air-fluid levels.

ABDOMINAL CT

Marked intestinal distension with segmental bowel wall thickening and pericolic hazziness in sigmoid colon

CASE 1
MANAGEMENT Hartmann Procedure : rectosigmoid resection with end colostomy and rectal stump dt/ bowel obstruction.

HISTOPATHOLOGY

Resected bowel specimen shows chronic-stage Buerger's disease with focal lymphoproliferative cell infiltration and a recanalized thrombus, and preservation of the architecture of the vascular wall. (H&E stain, 100.)

CASE 1
FOLLOW UP: Successful end to end anastomosis was performed 6 mos afterwards. The patient stops smoking and theres no disease progression eversince.

CASE 2
ANAMNESIS Male, 49 yoa Came to the ER w/ CC RLQ pain and bloody stools for 5 days. Intermitten abdominal pain for several mos. He was diagnosed with Buerger's disease at the age of 34 when he developed a gangrene formation in the right toe. He underwent amputation of the right toe after angiography showed occlusion of right anterior and posterior tibial and popliteal arteries.

CASE 2
He smoked one pack of cigarettes daily since he was 18.

ANGIOGRAPHY OF THE LOWER EXTREMITIES

The right anterior and posterior tibial arteries are occluded, the collateral vessels that supply the plantar arch have a corkscrew appearance.

CASE 2
LAB RESULTS WBC : 9,280 /L Fasting Glucose : 85 mg/dL Hb : 12,3 g/dL BUN : 14 mg/dL PC : 203,000 /L Cr : 1.2 mg/dL Aspartate : 41 IU/L Na : 140 mEq/L Alanine : 38 IU/L K : 3.8 mEq/L Albumin : 3.8 g/dL Tot Bilirubin : 0.8 mg/dL

EMERGENCY SIGMOIDOSCOPY

Circumferential ulceration and hard coated exudates with mucosal edema, segmental involved and clear distinction between normal and lesion in the proximal sigmoid colon.

MESENTERIC ANGIOGRAPHY

The inferior mesenteric artery is completely occluded. The left colic artery is opacified through to the marginal artery of the middle colic artery.

CASE 2
MANAGEMENT : Conservative treatment and low residual diet no complication. FOLLOW UP : Now he quits smoking and has a good condition.