Enterocolic lymphocytic phlebitis preceding the development of inflammatory bowel disease: report of a case.

A 37-year-old previously healthy male presented himself to the Emergency Care Department due to right lower quadrant (RLQ) abdominal pain, which had begun several hours earlier. Physical examination revealed marked abdominal tenderness with signs of peritoneal irritation and positive rebound tenderness. Laboratory tests were notable for leukocytosis (15.6 K/dL) with neutrophilia (79.4 %). Abdominal ultrasound showed a hyperechoic structure surrounded by thickened bowel wall in the RLQ, which according to the radiologist was highly suspicious for indicating acute appendicitis. Based on the above, it was decided to proceed immediately to exploratory laparotomy with appendectomy. At surgery a firm cecal mass was found near the ileocecal valve. The appendix was normal. Due to the high clinical probability of malignancy a right hemicolectomy was performed. Gross examination of the surgical specimen revealed a thickened cecal wall and ulceration of cecal mucosa. Histologic examination revealed a colonic mucosa with ischemic like changes and a transmural lymphocytic infiltration of the submucosal and subserosal veins. Some veins revealed a fibrinoid necrosis of their wall (Fig. 1). Based on these findings, a diagnosis of enterocolic lymphocytic phlebitis (ELP) was established. The patient did well following surgery, and was asymptomatic at discharge three days later. Three years later he was admitted to the Department of Medicine due to rectal bleeding. Colonoscopy revealed severe diffuse proctitis up to 10 cm from the anus. The histological examination revealed severe chronic active inflammatory changes consistent with inflammatory bowel disease (IBD) colitis. As a result a diagnosis of ulcerative colitis was suggested, and local therapy with hydrocortisone and mesalamine was started. The patient reported excellent symptomatic response, steroids were discontinued, and he continues to use oral mesalamine and to function well.