Ischemic Colitis in a Woman Associated with Sumatriptan Use

1
Ischemic Colitis in a Woman Associated with
Sumatriptan Use
Mazer, Adrien MS3 Thuc Quyen Nguyen, MD Eashen
Liu, MD James H Lewis, MD
Department of Medicine, Division of
Gastroenterology, Georgetown University Hospital,
Washington, DC
Georgetown University
Introduction
Laboratory and Radiological Findings
Ischemic colitis (IC) is the most common form of
intestinal ischemia, usually resulting from an
acute interruption of colonic blood flow. The
causes are numerous ranging from low flow states
to thromboembolic events1. Several drug classes
have been associated with IC including
antihypertensives, vasoconstrictors, NSAIDs, oral
contraceptives, and serotonin receptor
medications. Sumatriptan is a selective agonist
for 5-HT1D and 5-HT1B receptors and is used in
the treatment of migraine2. These receptors are
located in cerebral and meningeal vessels and
cause vasoconstriction when activated.
Sumatriptan exerts its anti-migraine effects
through this mechanism. Despite this
selectivity, Sumatriptan has been linked with
angina and coronary vasospasm and is therefore
contraindicated in patients with coronary artery
disease3. Sumatriptan has been rarely associated
with ischemic colitis. A MEDLINE search resulted
in the finding of just 2 published reports. The
first article describes 8 cases (7 women, median
age of 46 years, with a time to onset of several
hours to a few weeks) from the FDA's Spontaneous
Reporting System4. The second discusses a single
case report5 (52 year old woman without vascular
or bowel disease who developed IC after several
Sumatriptan doses within a week). These cases
resolved after discontinuation of Sumatriptan. A
search through the raw data of the FDA's Adverse
Event Reporting Program from 2004 - 2007 did not
reveal any significant cases of suspected
Sumatriptan induced ischemic colitis in nearly
1,000 patients with ischemic colitis6. Herein, we
report a case temporally associated with
Sumatriptan, which scored highly using an
ischemic colitis scoring system.
Chem 7 CBC Sodium 133 WBC 16.8 Potassium
3.6 Hb - 14 Chloride 101 HCT 42.8 Bicarbonate
24 Platelets - 282 Creatinine 9 BUN
0.8 Differential Glucose 126 92N, 2L, 5M, 1B
A
B
CT Scan of abdomen/pelvis Diffuse colitis
involving sigmoid colon to hepatic flexure.
C
A
B
D
C
Fig.2 (A-C). A) Low power view of a fragment of
colonic mucosa that shows an area of ulceration
covered by a layer of micropurulent exudate. B)
Higher power view of the same sample. Note the
paucity of the intestinal crypts, the residual
crypts looks atrophic and contain small crypt
abscesses C) Yet another higher power view,
beneath the muscularis mucosa, the small
capillaries plugged with fibrinoid thrombi are
seen (arrows)
History Physical Exam
Figure 1 (A-D) A) Normal Sigmoid Mucosa B)
Stripe sign in the descending colon. C D severe
ischemic colitis changes characterized by
purplish mucosa and exudates and friability, pre
and post biopsy respectively.
Figure C
Discussion
Hospital Course
History and Physical
A colonoscopy was performed the following morning
which revealed a normal rectum and sigmoid. In
the upper descending colon, the stripe sign (an
area of broad exudate) was noted, and there was
severe changes of colitis consistent with
ischemia at the splenic flexure (see figure 1).
The scope was not advanced beyond this point due
to the risk of perforation. Biopsy was obtain
that was consistent with acute IC (see figure
2). An IC scoring system7 (developed for cases
associated with Alosetron) taking into account
presentation, colonscopic findings, radiographic
findings, histopathology and clinic course, with
a score ranging from -6 to 17, gave a score of 15
in this patient, which indicated a very likely
probability of ischemic colitis. She was treated
with anti-inflammatory drugs (pentoxyfylline and
mesalamine), placed on esomeprozole, started on
IV antibiotics (ciprofloxacin and metronidazole)
and hydromorphone for pain. Stool studies sent
for the diarrhea returned as negative for an
infectious etiology. An MRI/MRA on day 6 was
consistent with ischemic colitis demonstrating
edema and colonic wall thickening from the
hepatic flexure to distal sigmoid colon and
indicated no anatomical abnormalities. A 2-D echo
on day 7 demonstrated a normal size and
functioning heart with an ejection fraction of
60 and nothrombus. Over the course of 10 days
the patient's pain and nausea diminished, she was
able to tolerate a regular diet, and her white
blood cells trended down to within the normal
range. She was discharged on day 10. In GI clinic
2 weeks later she reported continued improvement
and had returned to work. Her repeat CBC showed
a white blood cell count of 6,800 and a normal
hemoglobin and hematocrit. A repeat colonoscopy
has been scheduled to assure complete healing.
A 50 year old Caucasian woman with a past medical
history significant for migraine, hypertension,
and chronic back pain was admitted to the
hospital via the ED at 3pm for evaluation of
acute abdominal pain, nausea, vomiting and bloody
diarrhea. She awoke at 3am experiencing left
lower quadrant pain, diaphoresis and tenesmus,
and subsequently had 6 bowel movements, with each
progressively becoming mixed with small amounts
of blood. The abdominal pain was described as
continuous, crampy, non-radiating from the lower
left quadrant, with a pain score of 8/10,
requiring narcotics in the ED for relief. She
had never experienced GI symptoms like this in
the past. She had traveled to Mexico 3 weeks
prior to this episode, but did not describe any
travelers diarrhea. She denied tobacco or any
drug use and drank 2 glasses of wine with dinner
for the past 5 years. She had a long history of
migraine headaches beginning at puberty and
occurring around her menses. She began using
Sumatriptan tablets about 15 years ago, usually
once every other month. Periodically, she would
use injections. She used 1 injection of 6 mg 8
days prior to the onset of these current
symptoms. She was also taking Olmesartan for
hypertension, Cyclobenzaprine for back spasms and
Naproxen for arthritis. She had no known drug
allergies. T 36.3 P 84 RR 14 BP
125/83 02Sat 100 RA General Well nourished,
alert and conversant, but in considerable pain
and distress HEENT NC/AT, mildly dry mucous
membrane Cards normal rate and regular rhythm,
no murmurs, rubs or gallops Pulm clear to
auscultation bilaterally, no wheezes Abd
tenderness in the LLQ , no guarding, no rebound,
Bowel sounds were hyperactive Ext no clubbing,
cyanosis, or edema Neuro intact sensory, motor,
cerebellar, and reflexes. CN II-XII intact grossly
Any condition that compromises the blood supply
to the colon can potentially cause colonic
ischemia. The area most likely to be affected is
the splenic flexure, known as the watershed
area because the blood supplied to it is by
narrow branches of the SMA. Classic symptoms
include acute onset of crampy abdominal pain and
bloody diarrhea1 in the absence of a history of
inflammatory bowel disease. These symptoms
usually resolve on their own and only supportive
care is necessary. However, in a small
percentage of these patients, the ischemia is
severe, requiring surgical intervention such as
an embolectomy, bypass graft, endarterectomy or
colonic resection. In this case, despite the
fact that this woman has used Sumatriptan for
years, her presentation appears classic for IC
and no other cause were found. With drugs that
can cause IC, it is common that patients can be
on them for months or years prior to developing
symptoms. We have cautioned her against using
Sumatriptan in the future given the severity of
this episode.
References
1Green, B et al. Southern Medical Journal. 2005
Ischemic Colitis A Clinic Review. 2 Katzung,
Bertram. Basic and Clinical Pharmacology. Ninth
edition.2003 3Main, ML et al. Annals of Internal
Medicine. 1998 Cardiac Arrest and Myocardial
Infarction Immediately After Sumitriptan
Injection. 4Knudsen, J et al Arch Internal Med.
1998 Ischemic Colitis and Sumatriptan Use 5Naik,
M et al Dig Dis Sci. 2002Sumatriptan-Associated
Ischemic Colitis 6http//www.fda.gov/cder/aers/def
ault.htm 7Ringle, Yehuda et al. Gastroenterology
2005 Development and Validation of an Ischemic
colitis clinical diagnosis assessment instrument.
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