Mesenteric arteriovenous malformation with associated inferior mesenteric vein occlusion: a rare cause of ischemic colitis

Priyata Dutta; Aciel Shaheen; Michael Zijlstra; Wael Al-Yaman; Neil Shah; Kevin Wenzke

doi:10.5946/ce.2024.254

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Brief Report Mesenteric arteriovenous malformation with associated inferior mesenteric vein occlusion: a rare cause of ischemic colitis: Priyata Dutta¹, Aciel Shaheen², Michael Zijlstra², Wael Al-Yaman², Neil Shah², Kevin Wenzke²; Clinical Endoscopy 2025;58(3):482-484.
DOI: https://doi.org/10.5946/ce.2024.254
Published online: March 20, 2025

¹Department of Internal Medicine, Trinity Health Ann Arbor Hospital, Ypsilanti, MI, USA

²Department of Gastroenterology and Hepatology, Trinity Health Ann Arbor Hospital, Ypsilanti, MI, USA

Correspondence: Priyata Dutta Department of Internal Medicine, Trinity Health Ann Arbor Hospital, 5301 McAuley Dr, Ypsilanti, MI 48197, USA E-mail: dpriyata@med.umich.edu

• Received: September 22, 2024 • Revised: November 11, 2024 • Accepted: November 13, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Arteriovenous malformations (AVMs) are congenital or idiopathic abnormal connections between arteries and veins. Visceral AVMs are abnormal tangling of arteries and veins bypassing normal capillaries, resulting in hypoxia of surrounding tissue due to the stealing phenomenon.¹ Very few cases of ischemic colitis secondary to inferior mesenteric arteriovenous malformation (IMA-V) are due to AVMs. Herein we aimed to provide a brief report on IMA-V type IV complex AVM, a rare etiology of ischemic colitis, its pathophysiology, and management.

A 67-year-old male with a medical history of myasthenia gravis was admitted to Trinity Health Ann Arbor hospital with worsening lower quadrant abdominal pain, continuous rectal mucous discharge, and tenesmus with significant weight loss over several months. There was no history of abdominal trauma, surgery, or lower gastrointestinal (GI) bleeding. On admission, the patient was hemodynamically stable with a blood pressure of 113/75 mmHg and a heart rate of 86 beats per minute (bpm). Basic laboratory work revealed a hemoglobin level of 12 g/dL, normal white blood cell count, and a C-reactive protein (CRP) level of 22 mg/dL (normal CRP, 0.3 to 1.0 mg/dL). The patient was administered ceftriaxone and metronidazole for empirical coverage. Computed tomography (CT) revealed colitis in the distal descending colon extending through the rectum. Subsequent colonoscopy revealed severe congestion and edema up to the descending colon, with an abrupt transition to normal mucosa (Fig. 1A). The biopsies from the descending colon and rectosigmoid area demonstrated increased vascularity, mucosal edema, and chronic inflammation, consistent with granulation tissue compatible with the healing pattern of ischemic colitis. Thereafter, CT angiography revealed extensive long-segment circumferential wall thickening involving the entire sigmoid colon and rectum, with adjacent fat stranding, fluid and mesenteric vascular congestion, and hypo enhancement of the sigmoid colon and rectum, suggestive of ischemic colitis. It also revealed a tuft of arterial and venous vessels that appeared to be supplied by the sigmoidal artery of the inferior mesenteric artery (IMA) with chronic occlusion of the inferior mesenteric vein (Fig. 1B). Subsequently, the patient was referred to the interventional radiology (IR) for an inferior mesenteric angiogram for embolization, which demonstrated a complex mesenteric AVM (Yakes type IV AVM) formed by five feeding arteries into the nidus; one branch from the superior hemorrhoidal artery, two branches from the sigmoid artery, and two branches from the left colic artery. Early draining veins were identified as large parallel superior hemorrhoidal and sigmoidal veins. Due to unsuccessful attempts at AVM embolization for the complex anatomy and inferior mesenteric vein occlusion (Fig. 1C), colectomy was performed. The patient subsequently underwent robotic descending and sigmoid colectomy with a Hartmann pouch without any complications. Eventually, the patient underwent a scheduled colostomy 7 months later without complications and was discharged with outpatient follow-up.

Ischemic colitis secondary to AVMs can be classified as primary (congenital), resulting from a vascular defect, or secondary (acquired), resulting from abdominal trauma or iatrogenic surgical etiology.¹ Although the hepatic, splenic, superior mesenteric, and gastroduodenal arteries are commonly involved in AVMs, involvement of the IMAs territory is rare.¹^,²

Ischemic colitis is mostly observed in patients aged 60 to 70 years old.¹^,³ Its clinical presentation includes a wide spectrum of symptoms such as rectal bleeding, diarrhea, vague abdominal pain, and gastrointestinal bleeding.¹^,⁴ Lower GI bleeding results from vascular congestion secondary to the stealing phenomenon.⁴ In AVMs, there is an abnormal connection between the artery and vein, where the normal capillary bed can be present partially or absent. In this situation, blood can shunt from the artery to the vein, resulting in the disruption of blood flow and causing a stealing phenomenon. If this occurs in the IMA, it can present with abdominal pain, lower GI bleeding, and, rarely, ischemic colitis from reduced arterial blood flow and venous congestion. Hence, the clinical presentation is highly dependent on blood flow.⁴

Based on the hemodynamic status, clinical picture, and radiological features, colonic ischemia can be classified as mild, moderate, or severe.² Moderate ischemia is considered when patient has any of the three following risk factors such as male sex, tachycardia, hypotension, blood urea nitrogen greater than 20, hemoglobin less than 12 g/dL, lactate dehydrogenase greater than 350 IU/L, serum sodium less than 135 mEq/L, leukocytosis of 15×10/L or more, abdominal pain without rectal bleeding or colonoscopy findings of mucosal ulcerations. In contrast, severe ischemia was defined by more than three of the previously described factors or any of the following findings: abdominal peritonitis, gangrenous findings on colonoscopy, pneumatosis on CT imaging, and either pan-colonic distribution or isolated right colonic lesion on imaging.⁵ While patients with mild and moderate disease severity can be treated conservatively, those with severe ischemia or peritoneal signs should be referred for immediate surgical intervention.² Take opportunities during rounds to introduce your thoughts on differentials and care plans even if it is at risk of being rejected or minimized, this learn the art of not anchoring.⁶ In our case, because of the stable hemodynamic status, the initial plan was to defer the surgery and refer the patient for IR-guided embolization. However, owing to the complex anatomy, inferior mesenteric vein occlusion, and failed embolization, surgery is considered the preferred treatment option.

Early identification of risk factors, high clinical suspicion, and proper investigation are crucial to promptly establish a clinical treatment plan to reduce the risk of life-threatening complications associated with ischemic colitis. Informed consent was obtained for this brief report.

Conflicts of Interest

The authors have no potential conflicts of interest.

Funding

None.

Author Contributions

Conceptualization: PD, AS; Investigation: PD, AS, NS, MZ, WAY; Supervision: KW; Writing–original draft: PD; Writing–review & editing: all authors.

Fig. 1.

(A) Colonoscopy demonstrates significantly congested and diffusely erythematous mucosa of the descending colon. (B, C) Axial computed tomography showing arteriovenous malformation (circle) and extensive long-segment circumferential wall thickening involving the entirety of the sigmoid colon, suggestive of sigmoid colitis (arrow). (D) Mesenteric angiogram delineating an approximately 4 cm sized tangle of irregular vessels near the inferior mesenteric artery branch point. Five arteries feeding into the nidus and draining veins were noted in the form of large parallel superior hemorrhoidal and sigmoid veins (arrows).

REFERENCES

1. Stefanova I, Huddy JR, Richardson J. A rare case of acute congestive ischaemic colitis related to combined superior and inferior mesenteric arteriovenous malformations. J Surg Case Rep 2020;2020:rjaa083.Article PubMed PMC PDF
2. Maqboul I, Demyati K, Abdoh Q, et al. An arteriovenous malformation associated ischemic colitis in the setting of acute gastrointestinal clostridium difficile colitis and intestinal amebiasis: a case report. Int J Surg Case Rep 2023;105:108063.Article PubMed PMC
3. Dinh Luan N, Minh Hien T, Anh Huy L, et al. Diagnosis and management of calcaneal Yakes type IV AVM: two case reports. Radiol Case Rep 2021;16:3621–3627.Article PubMed PMC
4. Chang CT, Lim WX, Liu TT, et al. Inferior mesenteric artery arteriovenous malformation, a rare cause of ischemic colitis: A case report. Medicine (Baltimore) 2023;102:e33413.Article PubMed PMC
5. Amini A, Nagalli S. Bowel ischemia. StatPearls Publishing; 2025.PubMed
6. FitzGerald JF, Hernandez Iii LO. Ischemic colitis. Clin Colon Rectal Surg 2015;28:93–98.Article PubMed PMC

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Mesenteric arteriovenous malformation with associated inferior mesenteric vein occlusion: a rare cause of ischemic colitis

Clin Endosc. 2025;58(3):482-484. Published online March 20, 2025

DOI: https://doi.org/10.5946/ce.2024.254

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Figure

Mesenteric arteriovenous malformation with associated inferior mesenteric vein occlusion: a rare cause of ischemic colitis

Fig. 1. (A) Colonoscopy demonstrates significantly congested and diffusely erythematous mucosa of the descending colon. (B, C) Axial computed tomography showing arteriovenous malformation (circle) and extensive long-segment circumferential wall thickening involving the entirety of the sigmoid colon, suggestive of sigmoid colitis (arrow). (D) Mesenteric angiogram delineating an approximately 4 cm sized tangle of irregular vessels near the inferior mesenteric artery branch point. Five arteries feeding into the nidus and draining veins were noted in the form of large parallel superior hemorrhoidal and sigmoid veins (arrows).

Fig. 1.

Mesenteric arteriovenous malformation with associated inferior mesenteric vein occlusion: a rare cause of ischemic colitis