Rectal perforation due to enterocolic lymphocytic phlebitis

F. Ramadani, A. Kühn, A. Meyer, B. Egger

Objective

Enterocolic lymphocytic phlebitis is a recently described new entity. It is extremely rare and characterized by phlebitis of the bowel wall without any arterial involvement or systemic vasculitis.

Methods

Case report: A 90 year-old woman was admitted with severe abdominal pain and with signs of general peritonitis. A CT scan revealed massive free intra-abdominal air and a surgical approach was performed after discussion with the patient and her family. At explorative laparoscopy rectal perforation was found and due to the peritonitis the intervention was converted to a laparotomy. The perforation of about 15mm in the upper rectum presented with a marked peri-lesional induration as it is seen in perforated rectal ulcer disease. For security reason an oncological anterior rectal resection and Hartmann procedure was performed. However, histology did not demonstrate any malignancy but an abscess around the perforated ulcer together with multiple other small colonic ulcers and a general vasculitis of the medium sized bowel veins. In addition a moderate diverticulosis was described. A follow-up panendoscopy was performed some days later, showing multiples specific ulcers in all investigated parts of the bowel and the presence of lymphocytic phlebitis at histology of the tissue gathered by biopsies. A treatment with low dose steroids was introduced in order to treat the ulcers and calm down the important oedematous lesions. Further follow-up was then completely uneventful and the patient dismissed home.

Conclusion

Enterocolic lymphocytic phlebitis is an extremely rare entity. It most commonly manifests with signs of an acute abdomen. Patients may present with an abdominal mass, mimicking, clinically and radiologically, a tumor of the intestinal tract. This fact has been attributed to the concomitant oedema and inflammation of the disease which is associated to extended venous thrombosis of the medium sized bowel veins. Whereas etiology and pathogenesis is still unexplained, surgical resection is the treatment of choice because usually curative. In our case, the pathology turned out to be present all along the whole bowel investigated. Since curative resection of all these lesions is highly unrealistic, future complications cannot be excluded. However, publication of this case may help to better understand and also treat this rare clinical manifestation.