Chronic longitudinal NSAID-related ulcer of the colon ("colon single-stripe sign") in Munchhausen syndrome.

chronic gastrointestinal bleeding. Colo− noscopy showed a longitudinal ulcer ex− tending from the ascending to the trans− verse colon (l" Fig. 1 a). Biopsies taken from the ulcer ruled out malignancy and inflammatory bowel disease. Despite ex− tensive diagnostic workup, including an− giography and CT scan, the cause of the ulcer remained unclear. The patient de− nied taking nonsteroidal anti−inflamma− tory drugs (NSAIDs). The patient received empiric treatment with antibiotics, ste− roids, and mesalamine (5−aminosalicylic acid, 5−ASA), but the ulcer persisted for 6 months on repeated endoscopy. During this period the patient required the trans− fusion of 17 units of red blood cells. Re− peated gastrointestinal hemorrhage fi− nally prompted right hemicolectomy. The resection specimen showed a 23−cm− long antimesenteric ulcer of the ascend− ing and transverse colon with a maxi− mum width of 3 cm (l" Fig. 1 b). Histolo− gical analysis disclosed chronic ulcera− tion with reactive epithelial changes (l" Fig. 1 c). Three months later the pa− tient again presented with lower gastro− intestinal bleeding. Colonoscopy showed a new longitudinal ulcer in the descend− ing colon and additional smaller ulcers in the ileum (l" Fig. 1 d). Despite repeated denial regarding NSAID intake, diclofenac and its metabolites were detected in the patient’s urine by high−performance li− quid chromatography. In the face of these results, the patient finally admitted to chronic NSAID consumption. NSAID−induced ulcers in the colon are usually reported as ring−like ulcers with the formation of diaphragms, or as well− circumscribed single or multiple flat ul− cers, especially in the right colon and around the ileocecal valve [1]. The unu− sual longitudinal appearance of the pres− ented ulcer has previously been referred to as “colon single−stripe sign” and is thought to be related to ischemia [2]. The occurrence of the colon single−stripe sign in a patient with chronic NSAID intake and the antimesenteric location of the mucosal defect support the concept that NSAID−related colonic ulcers may be caused by local ischemic injury due to lib− eration of vasoconstrictive metabolites and/or vascular spasms [3].