Ischemic colitis in a young woman
Creators: name: Prabin Sharma
name: Parasuram Krishnamoorthy
name: Kurtis, Samuel
name: Fleischer, Joseph
Publisher: name: F1000Research
Year: 2016

description: We present a case of ischemic colitis in a 36 year old healthy woman with no risk factors. The patient presented after the acute onset of severe abdominal pain in the setting of constipation for two weeks and some rectal bleeding. She reported occasional small bowel movements and one day of nausea and vomiting. She denied fevers, chills or rigors, rash, ill contacts, vaginal bleeding and similar illness in the past. She had no prior history suggestive of Inflammatory Bowel Disease. Initial evaluation including complete blood count, Chem7, liver function tests, abdominal X-ray, pregnancy test, lipase, amylase, LDH and lactate were all normal. Multiple trials of enemas and laxatives were given in the emergency department without significant relief. Abdominal CT scan demonstrated marked mural thickening of the distal transverse, descending and sigmoid colon consistent with infectious or inflammatory colitis, without sigsn of bowel obstruction or free air. The patient improved symptomatically with IV fluids, antibiotics, analgesics and antiemetics. Infectious and autoimmune work up including ESR, ANCA, ASCA, TSH, stool studies for culture, gram stain, ova and parasites were done. All results were negative, including specific testing for Enterohemorrhagic E.coli, Salmonella, Shigella, C-diff, and Campylobacter. A Colonoscopy was performed on day two of hospitalization, which revealed an extensive segment of inflammation, edema and necrotic membranes extending from the descending colon into the mid transverse colon consistent with ischemia. Biopsies demonstrated features which confirmed the diagnosis of acute ischemic colitis. The patient had never had symptoms of heart disease, had never had a pregnancy loss, and had no family history of bleeding or clotting disorders. She also denied any use of oral contraceptives, hormonal supplements, or tobacco. Coagulation profile, Factor 5 Leiden, Anti-thrombin III, Protein C and S deficiency were all tested for and all normal.  The physicians were left with the obvious question of why a healthy 36 year old woman would develop ischemic colitis, an entity generally associated with the elderly or sick. After extensive further questioning, the patient admitted to taking the weight loss drug Phentermine daily for the past two years. Because she felt well and was pleased with her weight loss, she continued to take the medication far beyond the prescribed duration of 12 weeks. After a dramatic improvement in her symptoms, the patient was discharged home with strict instructions to avoid any weight loss pills. She remained asymptomatic during the follow up period. Based on our exhaustive work-up and her ongoing misuse of this medication, we concluded that the drug Phentermine was the cause of her ischemic colitis. Our subsequent literature search has uncovered only one prior case report of ischemic colitis attributed to this medication. Phentermine, a sympathomimetic derivative of amphetamine, has also been associated with behavioral changes, pulmonary hypertension, and valvular heart diseases. With the increased usage and abuse potential of anti-obesity drugs, better awareness and surveillance is needed among clinicians to prevent such outcomes. It seems quite possible that the adverse event we witnessed in our patient, despite its rarity in the literature, is more common than currently realized.<br>