Hyperamylasaemia and ischaemic colitis
A 66-year-old gentleman was brought to A&E as a blue light call with an immediate preceding history of sudden onset severe central and lower abdominal pain, associated with nausea and vomiting. He also reported several episodes of fresh bleeding per rectum (PR) on the same day of admission, prior to which he reported a 2-week history of intermittent constipation and loss of appetite. He reported no recent fevers or other associated symptoms or illnesses.\nThe patient had a known extensive vasculopathic history comprised of hypertension, ischaemic heart disease, a previous stroke, atrial fibrillation and an abdominal aortic aneurysm (AAA) of 4.3 cm. He had undergone a colonic polypectomy 2 years ago, with otherwise normal colonoscopy and there was no family history of bowel cancers. Drug history included Acenocoumarin (Sintrom), a new coumarin anticoagulant.\nAt paramedics’ arrival he was hypotensive at 68/38 mmHg and tachycardic at 140 bpm, but responded to initial fluid resuscitation, BP 89/52 mmHg, pulse 120 bpm in A&E. Abdominal examination elicited lower abdominal tenderness and a palpable AAA. Rectal examination showed fresh blood.\nAmylase (3776 U/l), lactate dehydrogenase (492 IU/l), urea (11.8 mmol/l) and creatinine (149 μmol/l) were all raised. Arterial blood gas (ABG) analysis revealed a metabolic acidosis of pH 7.33 and a raised lactate of 3.49 mmol/l with an accompanying base excess of -5.3 mmol/l. His Modified Glasgow Score for pancreatitis was 1, indicating a low suspicion for this diagnosis.\nConservative management was started, consisting of intravenous fluid resuscitation, antibiotics, nil-by-mouth, nasogastric-tube insertion, urinary catheterization and close observation. Chest X-ray did not show any sign of perforation (). An urgent CT scan reported circumferential bowel wall thickening in the descending and sigmoid colon and pneumatosis, indicative of possible transmural infarction (). Flexible sigmoidoscopy and subsequent colonoscopy () found ischaemic colitis of the sigmoid colon characterised by sloughy mucosa and ulceration.\nThere was negligible clinical improvement with conservative management; therefore, on day 3 of admission, it was decided to proceed with laparotomy + Hartmann's procedure. Pre-operatively, haemoglobin was 10.2 g/dl, platelets 162 × 109/l and INR 2.0, therefore 2 units of fresh frozen plasma were given.\nMacroscopically, the excised colonic sample was 360 mm × 35 mm, with areas of bowel wall measuring up to 8 mm thick and ischaemia extending to one margin of the sample. Microscopically, histology showed extensive partial thickness infarction characterised by mucosal ischaemia and submucosal oedema. There was also a focal area of full thickness ischaemia. A stricture was noted on histology, but no malignancy was present and the lymph nodes identified were reactive.\nIntensive therapy unit (ITU) care was required in the immediate post-operative period and the patient made an uneventful recovery, albeit a minor wound infection around the 7th post-operative day, which was successfully treated. The patient was discharged home and has made good progress since. By 6 months post-operatively he had gained 1 stone in weight and has since had a successful reversal of the colostomy.