A case of colitis

A 65-year-old man presents with a 1-week history of increasingly intense and continuous low abdominal pain that does not appear to be exacerbated by eating. The abdominal pain was preceded by exertional chest pain that settled with anti-anginal therapy prescribed by the patient’s GP. Routine blood tests are normal on admission and the patient denies taking an NSAID or paracetamol.

An abdominal CT (image A) is organised followed by a colonoscopy. The colonoscopy detects the presence of ulceration (image B) at the caecum and proximal ascending colon, but the appearance is normal elsewhere. Mucosal samples are taken.

Apart from hypertension that is managed with ramipril, the recently started anti-anginal drug nicorandil and low-dose aspirin, the patient is well and able walk several miles without shortness of breath.

Unfortunately, the patient deteriorates a couple of days later and becomes septic. A repeat abdominal CT confirms the presence of a perforation at the level of the caecum, and the patient undergoes an emergency hemi-colectomy. Analysis of the resection specimen confirms deep ulceration with a perforation at the centre of an area of ulceration (image C). 

Case Question 1

What is the most likely diagnosis?

a)     Ischaemic colitis

b)     Aspirin-induced colonic ulceration

c)     Ulceration secondary to mucosal biopsy samples taken at colonoscopy

d)     Crohn’s disease

e)     None of the above