Clinicopathological study of Parkinson’s disease withischemic enteritis due to intractable constipation〇 Nao Nishida1, Takashi Kurashige2, Yoshimasa Sueda2, Tsuyoshi Torii2, Kazuya Kuraoka3,Kiyomi Taniyama4
1 Department of Postgraduate Clinical Education, 2 Department of Neurology,
3 Department of Diagnostic Pathology, 4 President,

National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure, Japan【Introduction】
Parkinson's disease is a progressive neurodegenerative disease characterized clinically by rest tremor, rigidity, bradykinesia, and postural instability. Parkinson’s disease affects the central nervous
system and peripheral autonomic neurons. We report on a case of Parkinson’s disease with ischemic enteritis due to reducing bowel peristalsis, which caused ileus, and gut distention by bowel
sympathetic nerve degeneration.

【Case:83-year-old woman】【Physical findings】【Chief complaint】 Abdominal pain
【Medical history】
60-year-old:She was diagnosed Parkinson’s disease.
82-year-old:She couldn’t walk because of frozen gait and orthostatic hypotension after the operation of lumbar
spinal canal stenosis.
83-year-old:She was suffered an left-side-abdominal pain, a constipation, and an abdominal protuberance for 2weeks.She couldn’t relieve her bowels by herself. presented to our emergency department.
【Past history】 caesarian section【Medication】 senna 577.9mg，pantethine 600mg，levodopa/carbidopa 300mg, ropinirole 8mg, entacapone
300mg, istradefylline 20mg, Ameji pyridinium methyl sulfate20mg, bethanechol 30mg, apixaban 5mg,
gabapentin ena hydrocarbyl 300mg, rabeprazole10mg,【Family history・life history】 no special instruction

movement: move by herself. no rigidity and thrill. walk: couldn’t assess

CS

Complete blood count WBC 20200 /μl (Neut 94.2 %), Hgb10.3 g/dl, Plt 25.4×104 /μl
Serum chemistry80

TP 6.7 g/dl, Alb 3.4 g/dl, AST 33 U/l, ALT 7 U/l, LDH 293 U/l, CK 465 U/l, BUN 37 mg/dl, CRE 2.2 mg/dl, Na148 mEq/l, Cl 108mEq/l, K 3.7 mEq/l, Glu 86 mg/dl, CRP 5.4 mg/dl, PCT 20.44 ng/ml, eGFR 17 ml/min/1.73m2
Coagulation system PT-INR 1.63, APTT 37.8 sec., Fib 223.4 mg/dl, D-dimer 1.5 μg/ml
Venous blood gas analysis pH 7.354, pCO2 37.2 mmHg, pO2 26.7 mmHg, HCO3 20.2 mmol/l, cLac 5.3 mg/dl,
Urine Protein 3+, WBC 3+ (>100/HPF), Bacteria 2+ (1.1×106)

NA(μg/kg/hr)
ECF (ml/h)
BP(mmHg) HR(bpm)150【Neurological findings】【Laboratory data】【Clinical course】

MEPM
0.5g

<Vital signs>Consciousness: GCS 15(E4V5M6),
Blood pressure:101/47mmHg, Pulse rate：47bpm,Body
temperature:35.2℃, Respiratory rate:19/min, SpO2:98%(room air)<Head and neck>Conjunctivae: no anemia and jaundice<Thorax>Heart: no murmur, Lung: no rales<Abdomen>Lower abdominal bloating was observed. Her bowel soundwas weak. She had epigastric tenderness, no spontaneous pain andperitoneal irritation sign.
<Extremities>cold foot, no edema

144
BP was not detective

1000anurea

RR(/min)
40

BT(℃)
BT(℃)
36.536.5

2035.535.5

034.534.5

16:15 17:00 18:00 19:00 20:00 21:00 22:00 23:00 0:00

16:00
pH
K(mEq/l)Lac(mg/dl)
Glu(mg/dl)【Colonoscopy】【Diagnostic imaging】

50

1:00

0:00

2:00

7.3543.7
5.3
90

3:00

4:00

5:00

6:00

Fig.1A non-contrast CT scan (83 y.o)Fig.1B X-ray(77 y.o)Fig.2 Internal findings of the colon (83 y.o)
AB

CA

6:30

4:00 6:36 die
7.101
7.1
9.7
1
75

Fig.3 Clinical course from her hospitalization to her death
NA: noradrenalin, Lac: lactic acid, CS: colonoscopy, MEPM: meropenem,
ECF: extra cellular fluid

Non-contrast CT scan revealed gut distention from thesigmoid colon to small intestine(Fig. 1A)
The restiform body (arrow) made the sigmoid colon narrow(Fig.1A).
Gut distention was already observed by X-ray at the age of77(Fig.1B).

No mucosal ulcer from the anal side of the stenosis to therectum (Fig. 2A).
Sigmoid colon was constricted mildly enough to pass thescope(=) (Fig. 2B).
Mucosal ulcer exited from the oral side of the stenosis to thedescending colon (Fig. 2C).

【Sympathetic nerve degeneration】【Pathological findings】

Table. Distribution of ischemia, nerve degeneration, and Lewy bodies

A

Fig. 4 Macroscopic and microscopic findings of the sigmoid colon stenosis
BC

200μm

except ulcer lesion ofsigmoid colon

200μm

strangulated lesion

ulcer in descending colon

Hemorrhagic necrosis in mucosal layer became rampant without mucous ulcer (Fig. 4B).
Inflammatory cell infiltrated in all layers in mucous ulcer lesion (Fig. 4C).
No inflammatory cells in the sigmoid colon (Fig. 4A).
No obstruction of superior and inferior mesenteric artery.

ischemic nerve
colitisDegeneration
esophagus ±stomach±ileum+
+++
colon
+++
+++
rectum±Fig. 5 Lewy bodies and Lewy neuritesHELewy Body
Lewy Body(stained by H.E.) (immunehistochemical study)++++++++++++++
Fig. 6 Sympathetic nerve degeneration

psyn#64

50μm(Lewy body, arrow and Lewy neurite, arrow head atesophagus)

HE

25μm

tyrosine hydroxylase

50μm

100μm

(plexus, circle, anddegenerated sympathitic nerve, circle at colon)【This case…】
Parkinson’s
diseasesympathetic nerve
degeneration

gut
distention

hyper intracolonicpressure
constipationischemic colitis

restiform body

【Conclusion】
 We experienced the case who died from ischemic colitis which was led by high colonic pressure. Insufficient stool over two weeks might have caused an
upregulation of the inner pressure of colon.
 Constipation with Parkinson's disease can lead to death and thus prevention is vital.