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Difficulty: MediumPathology and Biopsy Interpretation

A 68-year-old man presents to the emergency department with a 12-hour history of severe, crampy left-sided abdominal pain and two episodes of bloody diarrhea. He has a history of hypertension, hyperlipidemia, and peripheral artery disease. Vital signs are within normal limits. Physical examination reveals tenderness in the left lower quadrant without rebound or guarding. Laboratory studies show a mild leukocytosis. A flexible sigmoidoscopy demonstrates patchy areas of mucosal erythema, edema, and superficial ulceration sharply demarcated at the splenic flexure. A mucosal biopsy is obtained. Histopathologic examination of the specimen reveals superficial mucosal necrosis with preservation of cellular outlines (ghost cells), lamina propria hemorrhage, and small, hyalinized, 'withered' crypts. There is a notable paucity of acute inflammatory infiltrate. Based on the biopsy findings and clinical presentation, which of the following is the most likely diagnosis?

  1. Ischemic colitisAnswer
  2. B
    Ulcerative colitis
  3. C
    Clostridioides difficile infection
  4. D
    Crohn's disease
  5. E
    Microscopic colitis

Answer

Ischemic colitis
The correct answer accurately synthesizes the clinical presentation (acute bloody diarrhea in a vasculopathic patient), the endoscopic location (watershed splenic flexure), and the classic histopathologic features (ghost cells, withered crypts, hemorrhage). These findings reflect mucosal infarction due to transient hypoperfusion.

Step-by-Step Solution

1
Analyze the patient's clinical risk factors and presentation.
The patient is an older adult with atherosclerotic risk factors presenting with acute crampy abdominal pain and bloody diarrhea.
Establishing the clinical context points toward a vascular etiology.
2
Evaluate the endoscopic findings.
Inflammation is sharply demarcated at the splenic flexure.
The splenic flexure (Griffith's point) is a watershed area highly susceptible to hypoperfusion.
3
Synthesize the histopathologic biopsy results.
The biopsy shows mucosal necrosis, ghost cells, withered crypts, and lamina propria hemorrhage without significant inflammation.
These histologic features are pathognomonic for ischemic injury, confirming the diagnosis.

Key Concept

The histopathologic hallmark of ischemic colitis includes mucosal necrosis with ghost cells, hemorrhage, and withered crypts, typically occurring in watershed areas of the colon in patients with vascular risk factors.
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Topics

Pathology and Biopsy Interpretation

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