Endoscopic image simulating a rectal neoplasm in a case of ischemic colitis

A 67-year-old woman whose mother died of colon cancer underwent a colonoscopy for abdominal pain and diarrhoea lasting two months. The colonoscopy revealed inflammatory lesions ≥5 cm from the anal margin to the mid-sigmoid colon (Fig. 1), with biopsies consistent with ischaemic colitis. An abdominal computed tomography (CT) scan showed involvement of the upper rectum and the sigmoid and descending colon. The patient followed a poor clinical course, so a new colonoscopy was performed two weeks later. The new colonoscopy showed that the lesions had progressed, with apparent neoplastic stenosis in the upper rectum; however, biopsies once again confirmed the ischaemic nature of the lesion (Fig. 2). The patient underwent resection of the affected segments and transverse colostomy, and the study of the specimen confirmed the diagnosis of ischaemic colitis (Fig. 3).

Figure 1.

First colonoscopy image: rectal and sigmoid mucosa with oedema, erythema, and wide and deep ulcerations with a fibrinopurulent base.

Figure 2.

Second colonoscopy image: expansive, bumpy, friable and stenosing lesion in the upper rectum.

Figure 3.

Histological study image: Panels A–C) Hyalinisation of the lamina propria, atrophic crypts and a severe inflammatory component. Panel D) Extensive areas of bleeding are also observed, all consistent with ischaemic colitis.

Ischaemic colitis is the most common form of intestinal ischaemic lesion. The clinical picture ranges from mild and transient to fulminant. Lower rectum involvement is seen in 5% of cases,¹ as in our patient.

Colonoscopy is the technique of choice, although complications as a result of reduced blood flow due to overdistension and increased intracolonic pressure have been reported.² A severe inflammatory response can cause the mucosa and submucosa to overlap and simulate a neoplasm, as in our case.³