Possible Fruquintinib associated ischemic colitis in a patient with metastatic ampullary adenocarcinoma

Introduction: Ischemic colitis is a severe gastrointestinal condition resulting from compromised colonic perfusion and may occur as a rare adverse effect of anti-angiogenic therapies. Case description: We report a case of severe acute ischemic colitis temporally associated with recent fruquintinib exposure, presenting with large-volume haematochezia in a patient with metastatic ampullary adenocarcinoma. Discussion: Fruquintinib is a highly selective vascular endothelial growth factor receptor tyrosine kinase inhibitor approved for refractory gastrointestinal malignancies and is generally well tolerated. Although gastrointestinal toxicities are well described, ischemic colitis has not been well characterized in association with fruquintinib. LEARNING POINTS: Vascular endothelial growth factor receptor tyrosine kinase inhibitors, including fruquintinib, may predispose to ischemic colitis through microvascular dysfunction, even in the absence of large-vessel occlusion or traditional ischemic risk factors.Ischemic colitis should be considered in patients receiving or recently exposed to anti-angiogenic therapies who present with acute haematochezia and segmental colitis, despite delayed symptom onset after drug discontinuation.Early recognition, exclusion of alternative aetiologies, and prompt withdrawal of the suspected agent with supportive management can lead to favourable outcomes and may prevent progression to perforation or surgical intervention.