EP901 - From Heartache to Tummy Ache: Takotsubo Cardiomyopathy as a Rare Etiology of Ischemic Colitis

Purpose/Background: Ischemic colitis is the most common cause of intestinal ischemia, accounting for 50-60% of cases. The colon is most susceptible to ischemia in two watershed regions: the splenic flexure and rectosigmoid junction. The causes of ischemic colitis can broadly be separated into occlusive and non-occlusive disease, both of which lead to decreased mesenteric blood supply to the colon. Severe ischemia will lead to transmural or gangrenous colitis, while damage limited to the mucosa and submucosa in milder cases leads to non-gangrenous colitis. Gangrenous colitis typically necessitates surgical management, whereas nongangrenous colitis may resolve with medical management. Here, we present a rare case of severe ischemic colitis caused by Takotsubo cardiomyopathy requiring right hemicolectomy.

Methods/Interventions: A 69-year-old female, with history of CHF and prior SVT ablation, was found to have hypotension and concerning ST changes in the setting of one day of radiating chest pain and palpitations at rest. Cardiac catheterization demonstrated non-obstructed coronary arteries, reduced ejection fraction (40%), and Takotsubo cardiomyopathy. She received loading doses of aspirin and ticagrelor. One hour later, she developed severe abdominal pain and right-sided tenderness, and computed tomography demonstrated thickening, mucosal enhancement and fat stranding of the ascending and proximal transverse colon as well as portal venous gas concerning for ischemic colitis. It was hypothesized this was secondary to thromboembolism of cardiac intra-cavitary clot given localization of colitis a distance from watershed regions. Bloodwork revealed no leukocytosis and down-trending troponin. Following failure to improve after a brief period of observation on intravenous fluids and antibiotics, the patient underwent an uncomplicated open right hemicolectomy with primary anastomosis, during which a focal area of ischemia was noted near the hepatic flexure.

Results/Outcomes: Final pathology confirmed transmural ischemic change and associated acute transmural inflammation, an incidental tubular adenoma, and no malignancy. The patient progressed appropriately post-operatively and was ultimately discharged on hospital day eight.

Conclusion/Discussion: Takotsubo cardiomyopathy, also known as stress cardiomyopathy, broken heart syndrome or apical ballooning syndrome, is a reversible myocardial injury characterized by transient regional systolic left ventricular dysfunction. Less than 10% of patients with Takutsubo cardiomyopathy have a thromboembolic event, with the most common site of embolus being the cerebral circulation. Embolic sources of colonic ischemia are less likely to follow the distribution of the colonic watershed regions. To our knowledge, there has been only one case reported in the literature describing ischemic colitis in the setting of Takotsubo cardiomyopathy. However, the authors of that paper (Schouver et al, 2016) suggest splanchnic vasoconstriction as the cause of colonic ischemia as their patient had concurrent pheochromocytoma and ischemia was sigmoidal. While rare, intestinal ischemic event should be considered a possible etiology of acute abdominal pain in the setting of Takotsubo cardiomyopathy, regardless of pain distribution. Imaging should be used to identify, and stratify the severity of, bowel ischemia and determine the need for operative intervention.

Image 1 - Takotsubo colitis
Coronal cross section CT abdomen and pelvis with IV contrast demonstrating wall thickening, mucosal enhancement and pericolonic fat stranding of the ascending colon and hepatic flexure, as well as air loculi in the portal vein tributaries