Atypical Multisegmental Involvement in Suspected Ischemic Colitis: A Case Report

We report a case compatible with ischemic colitis in a 68-year-old man with hypertension, coronary artery disease treated with three stents, peripheral arterial disease, and diabetes mellitus who presented with acute abdominal pain, vomiting, and bloody diarrhea. Initial white blood cell count was 22.2 K/µL, and serum lactate was 0.8 mmol/L. Contrast-enhanced CT demonstrated multisegmental colitis. Colonoscopy showed severe, noncontiguous inflammation involving the rectum, sigmoid colon, hepatic flexure, ascending colon, and cecum, with a normal terminal ileum. Sharply demarcated ulceration and dusky mucosa favored ischemia, although these findings were not diagnostic. The patient remained hemodynamically stable without peritoneal signs and improved with bowel rest, intravenous fluids, ceftriaxone plus metronidazole, surgical consultation, and serial abdominal examinations. No operation was performed. The ischemic mechanism remained indeterminate: dedicated vascular imaging and colonic histopathology were unavailable, stool studies were not obtained, and infectious or other mimics could not be excluded definitively. This case illustrates that suspected ischemic colitis can have atypical rectal and right-sided involvement despite a relatively benign examination and a lactate within the reference range. In this clinically stable patient, close surgical observation supported continued nonoperative treatment despite guideline features of severe disease.