Autoimmune Hemolytic Anemia Occurring After Laparoscopic Total Colectomy With Ileorectal Anastomosis in a Patient With Ulcerative Colitis: A Case report

Background: Postoperative complications that occur in patients with ulcerative colitis (UC) can appear in various features depending on the patient’s illness duration, disease progression, and general condition. Among these complications, they are sometimes difficult to predict and can even be fatal. Methods: A 45-year-old man visited the hospital with abdominal pain. He had been taking mesalazine for 14 years after being diagnosed with UC. On a recent colonoscopy, he was unable to evaluate the proximal colon due to the stricture of the descending colon. On the abdominoperineal computed tomography (A-P CT), multiple pseudopolyps were observed near the ascending colon and hepatic flexure, which were found to be increased in size. Colon cancer was suspected. The patient underwent a Laparoscopic total colectomy with diverting loop ileostomy under the diagnosis of UC with multiple colonic strictures, r/o colon cancer. From postoperative day 8(POD #8), the total and indirect bilirubin levels increased, dropping to serum Hb 8.6g/dL (POD #7) -> 3.0g/dL (POD #8) and showing hypovolemic shock. No active bleeding focus was observed on A-P CT performed during packed RBC and fresh frozen plasma transfusion, and splenomegaly progressed (maximal diameter: 13.2cm (preoperative CT) → 15.7cm (POD 5 days CT) →17.5cm (POD #8)). Based on the suspicion of hemolytic anemia caused by hypersplenism, steroid administration (hydrocortisone 1mg/kg) was started under the consultation of the hematology department (POD #9). A blood test showed positive direct antiglobulin test (DAT) and autoimmune hemolytic anemia was diagnosed, and a steroid was administered with methysol 1mg/kg (POD #11). The Clostridioides difficile infection (CDI) test performed while administering steroids showed positive results, so oral vancomycin was administered. Afterwards, the complete blood count test showed an increase in Hb level, and no additional infections were observed. As the patient was tolerable for diet, he was switched to oral prednisolone 0.5m/kg and discharged at POD #21. Results: He showed negative DAT at POD #1 month, and discontinued oral steroid at POD #2 months. The ileostomy repair was performed at POD #3 months. He is being followed up regularly without any particular problems. Conclusions: AIHA is a fatal complication that occurs very rarely in patients with inflammatory bowel disease, and it must be checked when hyperbilirubinemia and anemia are observed after surgery.