Natural history of outpatient-onset ischemic colitis compared with other lower gastrointestinal bleeding: a long-term cohort study

Clinical characteristics and long-term outcomes of hospitalised patients with ischemic colitis with different degrees of haematochezia: a retrospective study

BACKGROUND

Based on the literature, haematochezia is associated with a benign clinical course of ischaemic colitis. However, most cases in the literature presented mild haematochezia associated with ischaemic colitis. Therefore, we aimed to investigate the impact of different degrees of haematochezia on the clinical outcomes of ischaemic colitis.

METHODS

Patients were divided into nonhaematochezia, mild-haematochezia, and severe-haematochezia cohorts stratified by the degree of haematochezia. The clinical characteristics and prognoses were retrospectively reviewed.

RESULTS

Haematochezia cohort (n = 89) was associated with a lower rate of severe illness (25% vs. 52%, P = 0.001), lower rate of isolated right colon ischaemia (7% vs. 28%, P = 0.001), lower surgery rates (13% vs. 36%, P = 0.001), and shorter hospital stay (12 vs. 17 days, P < 0.001) compared with nonhaematochezia cohort (n = 50). Severe-haematochezia cohort (n = 11) had a higher frequency of severe illness (73% vs. 18%, P < 0.001), higher surgical intervention rate (55% vs. 6%, P < 0.001), higher nonsurgical complication rate, higher in-hospital mortality (45% vs. 0%, P < 0.001), and longer hospital stay (28 vs. 10  days, P = 0.001), compared with mild-haematochezia cohort (n = 78). Additionally, in-hospital mortality (45% vs. 6%, P = 0.003) and nonsurgical complication rate were higher in the severe-haematochezia than in the nonhaematochezia cohort. However, the three cohorts had comparable prognoses for long-term survival and recurrence.

CONCLUSIONS

Mild haematochezia was related to a benign clinical course of ischaemic colitis, while lack of haematochezia or severe haematochezia was associated with worse hospitalisation outcomes.

Acute lower gastrointestinal bleeding: A population-based five-year follow-up study

Background

Data on the natural history of acute lower gastrointestinal bleeding (ALGIB) are lacking. We evaluated five-year bleeding risk and mortality in ALGIB patients and controls. Furthermore, we aimed to find predictors of rebleeding.

Methods

This was a population-based retrospective case-control study conducted at the National University Hospital of Iceland, and included every individual who underwent endoscopy in 2010-2011. ALGIB was defined as rectal bleeding leading to hospitalisation or occurring in a hospitalised patient. Controls were randomly selected from those who underwent endoscopy in the same time period but who did not have GIB, and were matched for sex and age. Patients were followed up five years after index bleeding. Rebleeding was defined as ALGIB >14 days after index bleeding.

Results

In total, 2294 patients underwent 2602 colonoscopies in 2010-2011. Of those, 319 (14%) had ALGIB. The mean age for cases and controls was 64 and 65 years (±19.3-20.7), respectively, and females accounted for 51-52% of the study population. For ALGIB patients, the five-year risk of a bleeding was 20% (95% confidence interval (CI) 15-24%) compared to 3% (95% CI 1-5%) in controls (log rank < 0.0001; co-morbidity-adjusted hazard ratio (HR) 6.9 (95% CI 3.4-14)). Only 37% of bleeders had the same cause of index bleeding and rebleeding. In ALGIB patients, age and inflammatory bowel disease (IBD) were predictors of rebleeding, with odds ratios per 10 years of 1.3 (95% CI 1.1-1.6) and 4.3 (95% CI 1.5-12), respectively. Bleeders did not have a higher risk of five-year mortality compared to controls (HR = 1.2; 95% CI 0.87-1.6).

Conclusions

One fifth of ALGIB patients had rebleeding during follow-up. Age and IBD were independent predictors of rebleeding. ALGIB was not associated with lower five-year survival.

Lower GI Bleeding: An Update on Incidences and Causes

Bleeding from the lower gastrointestinal tract represents a significant source of morbidity and mortality. The colon represents the vast majority of the location of bleeding with only a much smaller incidence occurring in the small intestine. The major causes of lower gastrointestinal bleeding (LGIB) are from diverticulosis, vascular malformations, and cancer. We discuss the incidence and causes of LGIB.

Initial management for acute lower gastrointestinal bleeding

Acute lower gastrointestinal bleeding (LGIB) is a common indication for hospital admission. Patients with LGIB often experience persistent or recurrent bleeding and require blood transfusions and interventions, such as colonoscopic, radiological, and surgical treatments. Appropriate decision-making is needed to initially manage acute LGIB, including emergency hospitalization, timing of colonoscopy, and medication use. In this literature review, we summarize the evidence for initial management of acute LGIB. Assessing various clinical factors, including comorbidities, medication use, presenting symptoms, vital signs, and laboratory data is useful for risk stratification of severe LGIB, and for discriminating upper gastrointestinal bleeding. Early timing of colonoscopy had the possibility of improving identification of the bleeding source, and the rate of endoscopic intervention, compared with elective colonoscopy. Contrast-enhanced computed tomography before colonoscopy may help identify stigmata of recent hemorrhage on colonoscopy, particularly in patients who can be examined immediately after the last hematochezia. How to deal with nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotic agents after hemostasis should be carefully considered because of the risk of rebleeding and thromboembolic events. In general, aspirin as primary prophylaxis for cardiovascular events and NSAIDs were suggested to be discontinued after LGIB. Managing acute LGIB based on this information would improve clinical outcomes. Further investigations are needed to distinguish patients with LGIB who require early colonoscopy and hemostatic intervention.

Seasonal variation in occurrence of ischemic colitis: a retrospective study

Objectives We aimed to identify the clinical characteristics of ischemic colitis (IC) and to investigate the occurrence of seasonal variation. Methods From January 2008 to December 2014, 368 had IC as the reason for their admission. A total of 364 patients were enrolled in this study. We investigated patient characteristics and seasonal variations in incidence. Results The mean age (±standard deviation) of patients with IC at diagnosis was 66.8 (±16.9) years. Most patients had abdominal pain (341 cases), hematochezia (337 cases), and diarrhea (199 cases) as their chief complaints. The clinical courses of the disease were classified as transient (294 cases), stricture (17 cases), gangrenous (2 cases), and indeterminate types (51 cases). Although IC tended to occur less frequently in winter, the seasonal difference was not significant. Conclusion There is currently no evidence for seasonal variation in hospital admissions for IC.

Colonic ischemia: usual and unusual presentations and their management

PURPOSE OF REVIEW

To provide an update on the epidemiology, pathophysiology, clinical presentation, and management of colonic ischemia.

RECENT FINDINGS

Formerly regarded as a rare cause of lower gastrointestinal hemorrhage, colonic ischemia is now recognized to be the most common manifestation of intestinal vascular compromise. In contrast to ischemic events in the small intestine wherein thrombotic and embolic events predominate, colonic ischemia typically results from a global reduction in blood flow to the colon and no occlusive lesion(s) are evident. Several risk factors for colonic ischemia have been identified and, together with an appropriate clinical presentation and patient demographics, create a context in which the clinician should have a high level of suspicion for its presence. Imaging with computerized tomography, in particular, may be highly supportive of the diagnosis, which where appropriate can be confirmed by colonoscopy and colonic biopsy. For most patients, management is supportive and noninterventional, and the prognosis for recurrence and survival are excellent.

SUMMARY

Colonic ischemia is a common cause of lower abdominal pain and hemorrhage among the elderly typically occurring in the aftermath of an event which led to hypoperfusion of the colon. For most affected individuals the ischemia is reversible and clinical course benign.