Image of the month: A case of phlebosclerotic colitis

Case presentation

A 74-year-old man presented with recurrent right lower quadrant abdominal pain and diarrhoea for many years. He had no systemic disease. However, he had taken Chinese herbs for more than 50 years. Physical examination revealed right-sided abdomen tenderness. Laboratory examination showed his white cell count to be 3,680/μL and C-reactive protein of 4.6 mg/dL. Heavy metal testing results were within the normal range. Plain radiograph revealed serpiginous calcifications over the upper-right quadrant of the abdomen (Fig 1a). Computed tomography (CT) showed dendritic calcifications along the superior mesenteric vein and wall thickness of ascending and transverse colon (Fig 1b). Colonoscopy with biopsy demonstrated fibrous thickening, sclerosis in submucosa and dilated tortuous veins. Operation was suggested, but the patient refused. The patient continued to be bothered by recurrent symptoms and hospitalised three times during a follow-up period of 1 year.

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Fig 1.

Radiological images. (a) Abdominal radiography shows multiple serpiginous calcifications (black arrows) scattered along the medial aspect of the ascending colon. (b) An enhanced CT presented with not only transmural ­calcifications of dendritic distribution mostly along the SMV (black arrows) and right-sided colon, but also upstream bowel dilatation and wall thickening (white arrows).

Phlebosclerotic colitis (PC) is usually found in Asian or Asian immigrants in Western countries.¹ PC is characterised by impairing venous return from the colon due to sclerosis and fibrosis of mesenteric veins, resulting in chronic ischemia, intestinal obstruction, and even perforation.² The etiology and pathogenesis remains unclear but may be related to long-term use of Chinese herbs, alcohol abuse or ingestion of other toxic materials.^1–3 Diagnosis of PC is often delayed due to nonspecific clinical symptoms. Abdominal radiograph and CT sharing characteristic radiologic findings in common with multiple fine, tortuous, serpentine calcifications along mesenteric vessels and the involved colon play an important role.^1–4 CT provides additional information about complications and colon wall thickening, especially in the right colon. Colonoscopy findings, including dark purple discolorations of the mucosa with mucosal edema and erythema, erosions, or ulcerations, are used to verify the diagnosis.¹ There is no consensus on treatment. Total colectomy or subtotal colectomy is the mainstay of treatment in most cases in the literature. However, Yu et al recommend conservative treatment for initial mild cases.⁴

Author Contributions

YKL reviewed the case and wrote the manuscript. MHD contributed to the case and manuscript revision. YPH contributed to manuscript review.

Consent for publication

Consent was obtained from the patient to publish the clinical details and images from this case.