LAUSR

A 23-year-old male was evaluated in the ED with severe abdominal pain and bloody diarrhea. Computed tomography (CT) of the abdomen and pelvis showed pancolitis with the most severe inflammation seen in the distal colon; subsequent flexible sigmoidoscopy revealed severe colitis to the extent of the exam. Histological evaluation confirmed chronic inflammatory colitis with moderate activity. He was diagnosed with ulcerative colitis (UC) (Montreal classification E3). Oral prednisone 40 mg daily was initially prescribed followed by vedolizumab 300 mg every 8 weeks. Despite these therapies, he ultimately required hospitalization due to symptom persistence. On admission, his blood tests showed C-reactive protein (CRP) 130 mg/L, albumin 3.1 g/dl, and hemoglobin 10.6 g/ dl. Colonoscopy revealed severe pancolitis with deep ulcerations (Mayo endoscopic subscore 3) (Fig. 1). GI stool panel and serum and rectal cytomegalovirus DNA polymerase chain reaction tests were negative. As an induction strategy, methylprednisolone 40 mg daily (i.v.) and infliximab 10 mg/kg with methotrexate 15 mg weekly were initiated. Though his stool frequency and abdominal pain improved and CRP decreased to 19 mg/L, on hospital day 6 he subsequently had a substantial bloody bowel movement and experienced lightheadedness. His hemoglobin level dropped two points to 8.4 g/dl. His blood pressure and heart rate were 101/58 mmHg and 76/min, respectively. He was transfused with 2 units of packed red blood cells. Flexible sigmoidoscopy was repeated that showed friable and deeply ulcerated mucosa in the distal transverse colon that bled when it was provoked with a water flush, which was subsequently treated with argon plasma coagulation (APC; Figs. 2A, B). He then received a second dose of infliximab. His clinical symptoms subsided and CRP normalized. Nevertheless, on hospital day 10, he had another episode of massive hematochezia and his hemoglobin further dropped to 7.7 g/dl. He was hemodynamically stable at the time. A dynamic contrast-enhanced CT scan showed no evidence of active bleeding or clear source of bleeding. Esophagogastroduodenoscopy was performed and was normal. Colonoscopy revealed a mild improvement of colitis, but identified a single small ulcer with an exposed dark vessel in the distal transverse colon (Fig. 2C). Three hemostatic clips were successfully placed and epinephrine (1:10,000) was injected (Fig. 2D) for hemostasis. In addition, the previously treated deep ulcer was re-treated with APC and injection of epinephrine. The patient stabilized with no further bleeding, achieved clinical remission, and was discharged on hospital day 15. After four months of observation and follow up, he has not had any further episodes of massive gastrointestinal bleeding.