colonic ischemia: what really matters?

Colonic Ischemia: What Colonic Ischemia: What really matters?really matters?Clinical pitfalls in acute managementClinical pitfalls in acute management

Dr. Stewart ChanDr. Stewart Chan

Kwong Wah HospitalKwong Wah Hospital

Case ScenarioCase Scenario

• M/31M/31

• Good past heathGood past heath

• Amateur Marathon runner Amateur Marathon runner

• Sudden onset left-sided Sudden onset left-sided abdominal pain and mild abdominal pain and mild per rectal bleeding after a per rectal bleeding after a Marathon raceMarathon race

• Episodic pain during Episodic pain during training in the preceding 2 training in the preceding 2 monthsmonths

CT: edematous descending colon with pericolic stranding

Diagnosis: MILD Ischemic ColitisDiagnosis: MILD Ischemic Colitis

C Grames and CSB-caban. Case report: Ischemic colitis in an endurance runner. C Grames and CSB-caban. Case report: Ischemic colitis in an endurance runner.

Case Reports in Gastrointestinal Medicine, Vol 2012, Article ID 356895Case Reports in Gastrointestinal Medicine, Vol 2012, Article ID 356895

Colonic Ischemia: Colonic Ischemia: Why does it matterWhy does it matter

• 33rdrd most frequent cause of per-rectal bleeding most frequent cause of per-rectal bleeding

• 15% develops life-threatening gangrenous 15% develops life-threatening gangrenous changeschanges• 60% perioperative mortality60% perioperative mortality

• 30% develops chronic complications30% develops chronic complications• Chronic colitis, ulcers, stricture, recurrenceChronic colitis, ulcers, stricture, recurrence

Brandt LJ et al. Surg Clin North Am. 1992

Colonic ischemia: Colonic ischemia: what really matterswhat really matters

1.1. 20% cases occur in young patients <50 20% cases occur in young patients <50 years oldyears old

2.2. Predisposing factors should be actively Predisposing factors should be actively sought forsought for

3.3. Right colon involvement carries poor Right colon involvement carries poor prognosisprognosis

4.4. Colonoscopy is the gold standard for Colonoscopy is the gold standard for diagnosisdiagnosis

5.5. 20% cases progresses to gangrene formation20% cases progresses to gangrene formation

Predisposing factors should be Predisposing factors should be actively sought foractively sought for

• Common predisposing factorsCommon predisposing factors• Shock from any causesShock from any causes• Colonic obstruction: volvulus, stenotic tumour, Colonic obstruction: volvulus, stenotic tumour,

stricturestricture• Post-operative: e.g. aortic surgeryPost-operative: e.g. aortic surgery

• 2% after endovascular repair; 7% after open repair2% after endovascular repair; 7% after open repair

• Cardiovascular diseases: AF, DM, HT, Cardiovascular diseases: AF, DM, HT, hyperlipidemia, heart failure, chronic renal hyperlipidemia, heart failure, chronic renal failure, peripheral vascular diseasesfailure, peripheral vascular diseases

Hurwitz et al. Surg Gynae Obstet 1960

Brewster et al. Surgery 1991

• 100% predictive of ischemic colitis when 100% predictive of ischemic colitis when symptoms of per rectal bleeding and lower symptoms of per rectal bleeding and lower abdominal pain are associated with 4 or more abdominal pain are associated with 4 or more of the risk factorsof the risk factors• Age >60Age >60• HemodialysisHemodialysis• HypertensionHypertension• DMDM• HypoalbuminemiaHypoalbuminemia• ConstipationConstipation

Park CJ et al. Dis Colon Rectum 2007

• In 10% cases, a predisposing factor is readily In 10% cases, a predisposing factor is readily identifiable on admissionidentifiable on admission

• Go search for predisposing factors when they Go search for predisposing factors when they are apparently absentare apparently absent

• Cardiac workup (ECG, Holter, ECHO)Cardiac workup (ECG, Holter, ECHO)• An embolic source is present in 1/3 cases of An embolic source is present in 1/3 cases of

ischemic colitisischemic colitis

• Young patients: OCPs, cocaine, strenuous Young patients: OCPs, cocaine, strenuous exercises, underlying coagulopathies and exercises, underlying coagulopathies and vasculitidesvasculitides

Hourmand-Ollivier I et al. Am J Gastroenterol 2003

Right colonic involvement Right colonic involvement carries poor prognosiscarries poor prognosis

• Most cases affect the left colon; 25% cases involves Most cases affect the left colon; 25% cases involves right colon as wellright colon as well

• Right colonic involvement carries 2x higher mortality Right colonic involvement carries 2x higher mortality (23%) and 5x higher risk requiring laparotomy (60%) (23%) and 5x higher risk requiring laparotomy (60%)

• Need to rule out acute mesenteric ischemiaNeed to rule out acute mesenteric ischemia

• Associates with general hypoperfusion state, NSAID Associates with general hypoperfusion state, NSAID useuse

• Red flagsRed flags• Right sided abdominal painRight sided abdominal pain• Absence of per rectal bleedingAbsence of per rectal bleeding• Severe pain out of proportion to the tendernessSevere pain out of proportion to the tenderness

Huguier M, et al. Am J Surg 2006

Sotiriadis J et al. Am J Gastroenterol 2007

Colonoscopy is the Colonoscopy is the gold standard in diagnosisgold standard in diagnosis

• Mild: erythematous and edematous mucosa; Mild: erythematous and edematous mucosa; ecchymosis; petechiae and erosions <1cmecchymosis; petechiae and erosions <1cm

Endoscopic classification and clinical course of ischemic colitis. Toursarkissian & Thompson

• Colonic “single-strip” Colonic “single-strip” signsign• a longitudinal linear a longitudinal linear

ulcer occurring in mild ulcer occurring in mild cases of ischemic cases of ischemic colitis, usually over the colitis, usually over the left colonleft colon

• 75% pathological 75% pathological correlation with correlation with ischemic colitisischemic colitis

Zuckerman GR et al. Am J Gastroenterol. 2003

• Moderate: submucosal hemorrhages, Moderate: submucosal hemorrhages, hemorrhagic nodules, ulcerationshemorrhagic nodules, ulcerations


• Severe: greyish gangrenous changesSevere: greyish gangrenous changes


• Chronic: ulcers with granulation tissue and Chronic: ulcers with granulation tissue and pseudopolyps; stricturespseudopolyps; strictures

• Endoscopic severity positively correlates with Endoscopic severity positively correlates with need for surgery and mortalityneed for surgery and mortality• Need for surgery: mild (5%); moderate (7%); Need for surgery: mild (5%); moderate (7%);

severe (57%)severe (57%)• Mortality: mild (2%); moderate (5%); severe Mortality: mild (2%); moderate (5%); severe

(48%)(48%)

Friedland S et al. Gastrointest Endosc 2007M. Lozano-Maya et al. Rev Esp Enferm Dig 2010

• Early colonoscopy to aid diagnosisEarly colonoscopy to aid diagnosis• mucosal changes dissipate within 48 hoursmucosal changes dissipate within 48 hours• Contraindicated when peritoneal signs are Contraindicated when peritoneal signs are

presentpresent• Serial re-examination required to assess Serial re-examination required to assess

progressionprogression

• Avoid over-inflation / bowel preparationAvoid over-inflation / bowel preparation

• Consider use of CO2 insufflationConsider use of CO2 insufflation

Green BT. South M ed J 2005Baixauli J. Cleve Clin J Med 2003

• CT is usually done at acute presentationCT is usually done at acute presentation

• Highly sensitive (>95%) but not specificHighly sensitive (>95%) but not specific

• Detect complications e.g. pneumatosis coli, Detect complications e.g. pneumatosis coli, perforationperforation

• Delineate the extent of colonic involvementDelineate the extent of colonic involvement• Assess patency of major vesselsAssess patency of major vessels

What really matters What really matters when ordering investigationswhen ordering investigations

• Barium enema not favored Barium enema not favored anymoreanymore• Classical “thumbprint” sign with Classical “thumbprint” sign with

75% sensitivity only75% sensitivity only• ContraindicatedContraindicated in suspected in suspected

gangrene/ perforationgangrene/ perforation

• Mesenteric angiogram rarely Mesenteric angiogram rarely indicatedindicated• Only used in severe cases Only used in severe cases

where acute mesenteric where acute mesenteric ischemia has to be ruled outischemia has to be ruled out

20% cases progresses 20% cases progresses to gangrene formationto gangrene formation

• Up to 85% cases are self-limitingUp to 85% cases are self-limiting• Supportive management with bowel rest, fluid Supportive management with bowel rest, fluid

resuscitation and antibioticsresuscitation and antibiotics

• 20% cases progress to gangrenous change which 20% cases progress to gangrenous change which mandates urgent laparotomymandates urgent laparotomy

• Close monitoring of clinical signs and laboratory Close monitoring of clinical signs and laboratory results (WCC, HCO3, lactate)results (WCC, HCO3, lactate)

• Indications for laparotomyIndications for laparotomy• Signs of sepsis, peritonismSigns of sepsis, peritonism• Laboratory / imaging / endoscopic evidence of bowel Laboratory / imaging / endoscopic evidence of bowel

infarction / perforationinfarction / perforation

Gandhi SK et al. Dis Colon Rectum. 1996

• Issues when performing laparotomyIssues when performing laparotomy• Segmental resection of affected bowelSegmental resection of affected bowel• Judicious consideration of primary anastomosisJudicious consideration of primary anastomosis• Use of intra-operative colonoscopy to assess Use of intra-operative colonoscopy to assess

mucosal conditionmucosal condition• Resected segment should be opened up and Resected segment should be opened up and

examined to confirm inclusion of healthy colonic examined to confirm inclusion of healthy colonic marginsmargins

Thank youThank you

• C Grames and CSB-caban. Case report: Ischemic colitis in an endurance runner. Case C Grames and CSB-caban. Case report: Ischemic colitis in an endurance runner. Case Reports in Gastrointestinal Medicine, Vol 2012, Article ID 356895Reports in Gastrointestinal Medicine, Vol 2012, Article ID 356895

• DC Cohen et al. Marathon-induced ischemic colitis: why running is not always good for DC Cohen et al. Marathon-induced ischemic colitis: why running is not always good for you. American Journal of Emergency Medicine (2009) 27, 255.e5-e7you. American Journal of Emergency Medicine (2009) 27, 255.e5-e7

• CJ O’Neill, J Gan. Ischemic colitis in an ironman triathlete: A case report and review of CJ O’Neill, J Gan. Ischemic colitis in an ironman triathlete: A case report and review of the literature. Surgical Practice (2008), 12, 71-72the literature. Surgical Practice (2008), 12, 71-72

• F Paterno, WE Longo. Ischemic colitis: risk factors for eventual surgery. The American F Paterno, WE Longo. Ischemic colitis: risk factors for eventual surgery. The American Journal of Surgery (2010) 200l 646-650Journal of Surgery (2010) 200l 646-650

• C Reissfelder, M Koch et al. Ischemic colitis: Who will survive? Surgery (April 2011) Vol C Reissfelder, M Koch et al. Ischemic colitis: Who will survive? Surgery (April 2011) Vol 149 Number 4149 Number 4

• C Ryan, John RT, et al. Is Ischemic Colitis Ischemic? Diseases of the Colon & Rectum C Ryan, John RT, et al. Is Ischemic Colitis Ischemic? Diseases of the Colon & Rectum (March 2011), Vol 54(3), pp 370-373(March 2011), Vol 54(3), pp 370-373

• PM Glauser, CA Maurer et al. Ischemic Colitis: clinical presentation, localization in PM Glauser, CA Maurer et al. Ischemic Colitis: clinical presentation, localization in relation to risks factors, and long-term results. World J Surg (2011) 35:2549-2554relation to risks factors, and long-term results. World J Surg (2011) 35:2549-2554

• JA Bailey, WE Longo et al. Endovascular Treatment of Segmental Ischemic JA Bailey, WE Longo et al. Endovascular Treatment of Segmental Ischemic Colitis.Digestive Diseases and Sciences (April 2005) Vol 50, Number 4, pp 774-779Colitis.Digestive Diseases and Sciences (April 2005) Vol 50, Number 4, pp 774-779

• T Mohanapriya et al. Ischemic Colitis. Indian J Surg (September-October 2012) 74(5): T Mohanapriya et al. Ischemic Colitis. Indian J Surg (September-October 2012) 74(5): 396-400396-400

colonic ischemia: what really matters?

Documents