‘Thumbprinting’

Abstract

Thumbprinting'i mj_2320 666A 68-year-old man presented with fever, non-bloody diarrhoea and diffuse abdominal pain of 7 days' duration. Two weeks earlier, he had received moxifloxacin for a week for acute sinusitis. He had a history of diabetes and rheumatoid arthritis and was taking methotrexate. On examination, the patient was dehydrated, tachycardic, tachypnoeic and hypotensive. The abdomen was diffusely tender with hyperactive bowel sounds; guarding and rebound tenderness were noted in the left lower quadrant. Laboratory evaluation showed leucocytosis (17.3 ¥ 10 9 /L) and renal failure.An upright abdominal radiograph ( Fig. 1) revealed dilated large and small bowel loops with air-fluid levels. The transverse colon and descending colon showed 'thumbprinting' (arrows). Computed tomography of the abdomen (not shown) showed diffuse wall thickening of the large bowel with pericolonic soft tissue stranding. He was treated for presumed Clostridium difficile colitis with IV metronidazole. Despite supportive measures, including aggressive fluid resuscitation, he developed worsening renal failure and acidosis. He underwent subtotal colectomy and end ileostomy 4 days after hospitalization. Intraoperatively, the bowel mucosa was inflamed and oedematous with pseudomembranes. Toxin assay and pathology confirmed pseudomembranous colitis (PMC) because of C. difficile. His recovery was complicated by partial small bowel obstruction which was managed conservatively. The patient is doing well more than a year after surgery.'Thumbprinting' describes the unusually wide transverse bands of thickened bowel which replace normal haustral folds, secondary to submucosal oedema and hemorrhage from capillary leakage. 'Thumbprinting' is seen in ischaemic colitis, inflammatory diseases of the colon, infectious causes of colitis including PMC and in patients with coagulation disorders. 1,2