Diagnosis and management of ischemic colitis

Death following cylindrical battery ingestion associated with toxic manganese levels

Cases of battery ingestion are well documented in the scientific literature, especially concerning button cell battery ingestion in children. In this instance, the authors present an atypical case of a young man who voluntarily ingested a cylindrical alkaline battery containing manganese. The patient died approximately a week later, despite not exhibiting any specific symptoms. The battery was found in the cecum during the autopsy, showing deterioration at its positive pole. The cecal mucosa exhibited two ulcerations without perforation. Histological analysis revealed intestinal ischemia in the cecum, with no microscopic lesions in other organs. Toxicology reports indicated high levels of manganese in both cardiac and peripheral blood. Considering all the results from the additional analyses, the experts concluded that the death was likely of multifactorial origin, associated with a toxic blood concentration of manganese. To the best of our knowledge, this is the first recorded death following the ingestion of a cylindrical battery, and the first instance of manganese intoxication resulting from the ingestion of an alkaline battery. The authors will present the case and provide a literature review to assess the extent to which the presence of manganese may have contributed to the fatality.

Development and Validation of a Risk Scoring Model for Early Prediction of Severe Colon Ischemia

BACKGROUND

Colon ischemia (CI) is injury to the intestines secondary to insufficient blood flow. Its clinical severity can range from mild to life-threatening.

AIMS

To investigate predictive risk factors for CI and propose a scoring model for severe outcomes.

METHODS

We retrospectively analyzed the medical records of patients admitted to Chungnam National University Hospital from January 2010 to December 2018. CI was defined as severe when patients required surgery immediately or after initial conservative management, death occurred after hospitalization, or symptoms persisted after 2 weeks. By controlling for possible confounders from the logistic regression analysis, we obtained a new risk scoring model for the early prediction of severe CI. Furthermore, using the area under the receiver operating characteristics curve (AUROC), we assessed the accuracy of the model.

RESULTS

A total of 274 patients endoscopically diagnosed with CI were included, of whom 181 had severe CI. In the multivariate analysis, tachycardia, elevated C-reactive protein, Favier endoscopic classification stage ≥ 2, and history of hypertension were independently and significantly associated with severe CI. The AUROC of the model was 0.749.

CONCLUSIONS

This risk scoring model based on the presence of tachycardia, elevated C-reactive protein level, unfavorable endoscopic findings by Favier's classification, and the history of hypertension could be used to predict severe CI outcomes at an early stage.

Stromal cell-derived factor-1 as a serologic biomarker for the diagnosis of colon ischemia with chronic cardiovascular disease

Colon ischemia (CI) is the most common ischemic disorder of the gastrointestinal tract. Although some markers of CI, such as procalcitonin and alkaline phosphatase, have been reported, few specific serum markers have been identified. We investigated whether serum stromal cell-derived factor-1 (SDF-1) is a specific marker of CI and clarified the relationship between serum SDF-1 level and CI according to a history of combined chronic cardiovascular disease (CVD).We measured SDF-1 level and other serological markers in 84 patients (control, n = 20; CI without chronic CVD, n = 21; chronic CVD without CI, n = 20; CI with chronic CVD, n = 23).Patients with CI were older than those without CI. There were more women in the CI groups than those without CI. At admission, SDF-1 level was significantly higher in patients having CI with chronic CVD (P < .001) than in other groups. SDF-1 level was significantly higher at admission than at discharge in patients having CI with chronic CVD (P < .001) but not in patients having CI without chronic CVD. SDF-1 level did not differ according to symptoms, involved sites, or duration of hospitalization. At a cutoff value of 0.5 pg/mL for the SDF-1 level in patients having CI with chronic CVD, the sensitivity and specificity for SDF-1 were 91.3% and 95%, respectively. The area-under-the-curve (AUC) value was 0.95. In the logistic regression analysis, an elevation of the SDF-1 level to >0.5 pg/mL was a significant indicator of CI with chronic CVD [odds ratio (OR), 114.914; 95% confidence interval, 10.51 to >999.999; P < .001].SDF-1 could be a useful early biomarker for the diagnosis of CI in patients with chronic CVD.

Tolerability of nintedanib-related diarrhea in patients with idiopathic pulmonary fibrosis

BACKGROUND

Nintedanib is an important drug for the treatment of idiopathic pulmonary fibrosis (IPF). However, the drug is discontinued in some patients who present with diarrhea. In this study, we aimed to assess the drug continuation rate in patients who developed diarrhea during nintedanib therapy and to evaluate if antidiarrheal drugs or nintedanib dose reductions improved clinical tolerability and efficacy.

METHODS

Eighty-six patients with IPF were treated in our institution between December 2015 and March 2018. Among them, 50 patients who experienced nintedanib-related diarrhea were analyzed regarding tolerability and persistence rate.

RESULTS

In 50 patients who experienced nintedanib-related diarrhea, 26 (n = 11, without reduction and n = 15, with reduction) continuously received nintedanib. Meanwhile, the drug was discontinued in 24 patients (n = 13, without reduction and n = 11, with reduction). In 9 of 24 patients, the drug was discontinued due to diarrhea. The annual rate of decline in forced vital capacity and the duration of nintedanib administration were not significantly different between groups with and without dosage reduction. Moreover, 23, 13, 8, and 2 patients received 1, 2, 3, and 4 agents, respectively. Clostridium butyricum is a probiotic bacterium most commonly used as an antidiarrheal agent. In this study, it was used in 28 of 46 patients. The total durations of nintedanib administration differed significantly according to the number of antidiarrheal drugs taken: 853 ± 221 days, more than three agents; 424 ± 365 days, without an agent (p = 0.043); and 460 ± 142, one agent (p = 0.0003).

CONCLUSIONS

When diarrhea occurs within a year after using nintedanib, the dose reduction may be acceptable without affecting pulmonary function. Moreover, treatment with multiple antidiarrheals may be a practical option to maintain the use of nintedanib therapy compared with monotherapy and no therapy.

Early Endoscopy Is Associated with Better Clinical Outcomes in Patients Hospitalized with Ischemic Bowel Disease

BACKGROUND AND AIMS

Providing diagnostic and therapeutic interventions, lower gastrointestinal endoscopy is a salient investigative modality for ischemic bowel disease (IB). As studies on the role of endoscopic timing on the outcomes of IB are lacking, we sought to clarify this association.

METHODS

After identifying 18-to-90-year-old patients with a primary diagnosis of IB from the 2012-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, we grouped them based on timing of endoscopy into three: early (n = 9268), late (n = 3515), and no endoscopy (n = 18,452). We explored the determinants of receiving early endoscopy, the impact of endoscopic timing on outcomes (mortality and 13 others), and the impact of the type of endoscopy (colonoscopy vs. sigmoidoscopy) on these outcomes among the early group (SAS 9.4).

RESULTS

Less likely to receive early endoscopy were Blacks compared to Whites (adjusted odds ratio [aOR] 0.81 95% CI [0.70-0.94]), and individuals on Medicaid, Medicare, and uninsured compared to the privately insured group (aOR 0.80 [0.71-0.91], 0.70 [0.58-0.84], and 0.68 [0.56-0.83]). Compared to the late and no endoscopy groups, patients with early endoscopy had less mortality (aOR 0.53 [0.35-0.80] and 0.09 [0.07-0.12]), shorter length of stay (LOS, 4.64 [4.43-4.87] days vs. 8.87 [8.40-9.37] and 6.62 [6.52-7.13] days), lower total hospital cost (THC, $41,055 [$37,995-$44,361] vs. $72,598 [$66,768-$78,937] and $68,737 [$64,028-$73,793]), and better outcomes. Similarly, among those who received early endoscopy, colonoscopy had better outcomes than sigmoidoscopy for mortality, THC, LOS, and adverse events.

CONCLUSION

Early endoscopy, especially colonoscopy, is associated with better clinical outcomes and decreased healthcare utilization in IB. Unfortunately, there are disparities against Blacks, and non-privately insured individuals in receiving early endoscopy.

Colonic Necrosis Following Laparoscopic High Anterior Resection for Sigmoid Colon Cancer: Case Report and Review of the Literature

We report a patient who experienced colonic necrosis after laparoscopic high anterior resection for sigmoid colon cancer, and review the literature to evaluate the clinical features of colonic necrosis following surgery for sigmoid colon and rectal cancer. A 76-year-old man with sigmoid colon cancer underwent laparoscopic high anterior resection. The operation included high ligation of the inferior mesenteric artery and end-to-end anastomosis using circular staples. Pathology findings revealed a pT4N2M0 lesion. Beginning on postoperative day (POD) 1, the patient experienced a high, spiking fever, and gradually developed leukocytosis and high inflammatory condition. The patient complained of abdominal distention, but had no signs of peritonitis. Abdominal computed tomography on POD4 showed wall thickness of the proximal colon from the anastomosis site and ascites with free air. An anastomotic leakage was suspected. Emergency laparotomy revealed a disrupted anastomosis without feces in the abdomen and a gangrenous 15 cm segment of the colon proximal to the anastomosis. The affected area of the colon was excised and Hartmann's procedure was performed. His postoperative period was uneventful. Our review of the literature demonstrates that elderly male patients with cardiovascular and pulmonary complications undergoing laparoscopic sigmoid and rectal cancer surgery with high ligation have high risk of postoperative colonic necrosis. We experienced colonic necrosis following laparoscopic high anterior resection for sigmoid colon cancer and required immediate resection. Elderly male patients with cardiovascular and pulmonary complications undergoing laparoscopic sigmoid and rectal cancer surgery with high ligation should be carefully monitored for postoperative colonic necrosis.

[Side effect management of tyrosine kinase inhibitors in urology : Gastrointestinal side effects]

For approximately one decade, tyrosinkinase inhibitors (TKIs, smart drugs) have dramatically changed and improved the treatment of patients suffering from metastasized renal cell carcinoma. However, the different drugs have substantial side effects. Especially gastrointestinal symptoms may be problematic for patients. These side effects represent a challenge for the physician. On the one hand, dosage modifications and treatment interruption should be avoided to minimize the risk for progression. On the other hand, only mild side effects are tolerable for the patient. Based on a literature review, a clear overview of the incidence of possible side effects for the drugs axitinib, cabozantinib, pazopanib, sorafenib, and sunitinib is provided. Furthermore, we give a practical guide on how to prevent and treat the different gastrointestinal side effects. Finally, it is pointed out when dosage modifications or interruption of treatment are necessary and how to expeditiously re-escalate the treatment after mitigation of side effects.

Colon Stricture After Ischemia Following a Robot-Assisted Ultra-Low Anterior Resection With Coloanal Anastomosis

Four consecutive cases of a colonic stricture following a da Vinci robot-assisted ultra-low anterior resection (LAR) with coloanal anastomosis and diverting ileostomy for the treatment of rectal cancer are reported. The colonic strictures developed after early proximal colonic ischemia without anastomotic site leakage or disruption. All patients were treated with preoperative chemoradiation therapy. During the postoperative recovery period, patients developed colonic ischemia, presenting with a high, spiking fever, but without any symptoms of peritonitis. Patients were treated with conservative management (antibiotic therapy) and discharged after two weeks when in good condition. Several months after discharge, all four patients developed a long-segment colonic stricture from the anastomosis site to the distal colon. Management of the colon strictures, including the anastomotic site, involved colonic dilation with a Hegar dilator in an outpatient clinic for several months. The ileostomies in three patients could not be closed.

The effects of vardenafil and pentoxifylline administration in an animal model of ischemic colitis

OBJECTIVES

Vardenafil enhances dilatation of vascular smooth muscle and inhibits platelet aggregation. The purpose of this study was to evaluate the clinical effects of vardenafil and pentoxifylline administration in an experimental model of ischemic colitis.

METHODS

Forty female Wistar albino rats weighing 250-300 g were randomized into five experimental groups (each with n = 8) as follows:1) a sham group subjected to a sham surgical procedure and administered only tap water; 2) a control group subjected to a standardized surgical procedure to induce ischemic colitis and administered only tap water; 3) and 4) treatment groups subjected to surgical induction of ischemic colitis followed by the postoperative administration of 5 mg/kg or 10 mg/kg vardenafil, respectively; and 5) a treatment group subjected to surgical induction of ischemic colitis followed by postoperative administration of pentoxifylline at 50 mg/kg/day per day as a single dose for a 3-day period. All animals were sacrificed at 72 h post-surgery and subjected to relaparotomy. We scored the macroscopically visible damage, measured the ischemic area and scored histopathology to determine the severity of ischemia. Tissue malondialdehyde levels were also quantified.

RESULTS

The mean Gomella ischemic areas were 63.3 mm2 in the control group; 3.4 and 9.6 mm2 in the vardenafil 5 and vardenafil 10 groups, respectively; and 3.4 mm2 in the pentoxifylline group (p = 0.0001). The mean malondialdehyde values were 63.7 nmol/g in the control group; 25.3 and 25.6 nmol/g in the vardenafil 5 and vardenafil 10 groups, respectively; and 22.8 nmol/g in the pentoxifylline group (p = 0.0001).

CONCLUSION

Our findings indicate that vardenafil and pentoxifylline are effective treatment options in an animal model of ischemic colitis. The positive clinical effects produced by these drugs are likely due to their influence on the hemodynamics associated with vascular smooth muscle and platelet functions.

Ischemic Colitis, the Great Imitator: A Mass Completely Resolved

Ischemic colitis (IC) is the most common type of intestinal ischemia, with a vast clinical spectrum of injury ranging from mild and transient ischemia to acute fulminant colitis. The pattern of injury is usually segmental, but it is mainly dictated by individual anatomy, duration of ischemia, and degree of re-perfusion injury. Analysis of clinical presentation, early endoscopic evaluation, and biopsy are all essential for prevention of misdiagnosis. We present a unique case of IC with mass-like features on regular imaging, emphasizing the importance of endoscopy and biopsy for accurate diagnosis.

Hyperamylasaemia and ischaemic colitis

INTRODUCTION

Ischaemic colitis is a differential diagnosis to be considered in patients who have a high cardiovascular risk. Presentation of severe ischaemia is usually that of an acute abdomen with passage of fresh blood per rectum, and hyperamylasaemia.

PRESENTATION OF CASE

A 66-year-old gentleman was admitted to A&E with a short history of central abdominal pain, nausea, vomiting and fresh bleeding per rectum. A diagnosis of ischaemic colitis was made by the computed tomography (CT) scan findings of colonic thickening and pneumatosis, in addition to colonoscopy demonstrating sloughy mucosa and ulceration. Symptoms did not resolve with conservative management, therefore laparotomy + Hartmann's procedure was performed. Histology showed extensive areas of both partial and full thickness ischaemia with stricture.

DISCUSSION

Amylase is an indicator of intra-abdominal inflammatory processes. Hyperamylasaemia (normal <100 U/l) is most frequently associated with pancreatitis; however, causation is not exclusive and other differentials including bowel ischaemia must be considered, although amylase is not a specific marker for ischaemic colitis. It is important to distinguish between ischaemic and ulcerative colitis.

CONCLUSION

Intestinal ischaemia is a serious acute abdominal pathology that is associated with hyperamylasaemia, and frequently requires prompt surgical intervention to prevent subsequent mortality.

Ischemic colitis: the ABCs of diagnosis and surgical management

Ischemic colitis (IC) is a rare condition. As ischemia is often transient and clinical symptoms are reversible, its exact incidence is unknown. In current clinical practice, two types of IC are described according to the severity: severe IC, with transmural colonic ischemia and/or multi-organ failure (MOF), and mild IC, without MOF and spontaneous favourable evolution in most cases. Two clinical contexts are encountered: spontaneous IC (SIC) and postoperative IC (POIC), mainly after aortic surgery. As there is no specific clinico-biologic symptom of IC, emergent CT-scan and rectosigmoidoscopy are required for diagnosis confirmation, surgical decision and prognosis analysis. IC surgical treatment is not consensual but can be standardized according to organ function and the degree of ischemia: surgical treatment in case of colonic necrosis with deep ischemia and/or MOF; observation for superficial ischemia without organ dysfunction; systematic medical care. Surgery is required in 20% of cases, and consists in extended colectomy without continuity restoration and prophylactic cholecystectomy. Continuity restoration is feasible in one third of survivors, who are exposed to a high risk of severe cardiovascular events.

Detection of patients at high risk for non-occlusive mesenteric ischemia in hemodialysis

BACKGROUND

Nonocclusive mesenteric ischemia (NOMI) is an emerging condition in hemodialysis (HD) patients not widely studied.

MATERIALS AND METHODS

A retrospective study was conducted between 2003 and 2011. NOMI cases were recorded, and demographic, clinical, biochemical, and HD parameters were collected. This group was compared with a control group (n = 93). Risk factors, prognosis, and survival were analyzed.

RESULTS

There were 57 episodes of NOMI (incidence, 2.29 episodes per 100 patients/y). Cecum was the most frequently affected segment. Nineteen patients (33%) underwent surgery. Twenty-six patients (59%) did not survive the acute episode. Cecal damage was the only protective factor associated with mortality (relative risk [RR], 0.712; P = 0.044). The incidence of NOMI was related to erythropoietin resistance index, diabetes mellitus, and longer time on HD compared with control group (RR, 6.92, P = 0.009; RR, 9.98, P = 0.005; and RR, 1.017, P < 0.001, respectively). Mortality in survival NOMI patients was higher at 4-y follow-up compared with that in the control group (log-rank, 15.5; P < 0.0001).

CONCLUSIONS

NOMI is associated with erythropoietin resistance index, diabetes mellitus, and longer time on HD. Hypotension must be avoided in these high-risk patients to prevent NOMI.

Ischemic colitis in an endurance runner

A 20-year-old female running the Marine Corps Marathon developed diarrhea at mile 12. After finishing the race she noted that she was covered in bloody stool. A local emergency department suspected ischemic colitis. After discharge, her primary care physician instructed her to discontinue the use of all nonsteroidal anti-inflammatory drugs. Her symptoms resolved and she returned to running without any complications. This paper describes the pathophysiology, diagnostic approach, and management options.

Colonic ischemia following surgery for sigmoid colon and rectal cancer: a study of 10 cases and a review of the literature

PURPOSE

Colonic ischemia following colorectal surgery is an unusual and serious complication. As it has been reported that the incidence of colonic ischemia was higher after laparoscopic surgery, the aim of this report was to document the clinical features of postoperative colonic ischemia following colorectal surgery.

METHODS

Among 1,201 surgeries for sigmoid colon and rectal cancer by a single surgeon from 2006 to 2010, 10 cases of postoperative colonic ischemia were retrospectively identified (0.83%). IMA high ligation was routinely made in all surgeries. The clinical findings and laboratory data of these 10 cases were evaluated.

RESULTS

Of the 10 patients, 9 were male and 1 was female. The mean age was 66.9 years old. The mean BMI was 23.3. Three patients (30%) had a cardiovascular disease other than hypertension. Eight patients (80%) underwent laparoscopic surgery and two patients (20%) underwent open surgery. Intraoperative bleeding occurred in five patients (50%, mean 435 ml). The average day for occurrence of postoperative colonic ischemia was on the 5th day (range 2nd-10th day). A consistent postoperative fever was found in eight patients (80%). Mortality due to postoperative colonic ischemia was 10%.

CONCLUSIONS

Postoperative colonic ischemia may be considered one of the more important complications of colorectal resection.

Ischemic colitis as a cause of severe hematochezia: risk factors and outcomes compared with other colon diagnoses

BACKGROUND

Risk factors and outcomes of severe hematochezia from ischemic colitis compared with other colonic diagnoses have not been well studied.

OBJECTIVE

Our purposes were (1) to compare demographics and outcomes of patients hospitalized with severe hematochezia from ischemic colitis compared with other colonic diagnoses, (2) to compare inpatient and outpatient start of bleeding from ischemic colitis, and (3) to describe potential risk factors.

DESIGN

Prospective cohort study.

SETTING

Tertiary referral academic centers.

PATIENTS

Patients referred for gastroenterology consultation for severe hematochezia.

INTERVENTIONS

Colonoscopic therapy was provided as indicated.

MAIN OUTCOME MEASUREMENTS

Rebleeding, surgery, and length of hospital stay after colonoscopy.

RESULTS

Of 550 patients in the past 12 years with severe hematochezia from colonic sources, the cause in 65 patients (11.8%) was ischemia. Ischemic colitis was found more often in females, in patients taking anticoagulant agents, in patients with severe lung disease, those with higher creatinine levels, those with higher glucose levels, and those with more fresh frozen plasma transfusions. Five patients with focal lesions had colonoscopic hemostasis. Major 30-day outcomes of ischemic colitis patients were significantly worse than patients with other colonic diagnoses. Patients with inpatient (vs outpatient) ischemic colitis had significantly more and more severe comorbidities at baseline and significantly higher rates of rebleeding, surgery, and more days spent in hospital and in the intensive care unit.

LIMITATIONS

Two-center study.

CONCLUSIONS

Major 30-day outcomes in ischemic colitis patients were significantly worse than in patients with other colonic diagnoses. Comparing outpatient and inpatient start of ischemic colitis, inpatients had significantly worse outcomes.

Risk factors for intestinal ischaemia among patients registered in a UK primary care database: a nested case-control study

BACKGROUND

Intestinal ischaemia, including ischaemic colitis and acute mesenteric ischaemia, causes significant morbidity and mortality. Few population-based studies have estimated incidence and potential risk factors for this disease.

AIMS

To estimate the incidence of intestinal ischaemia and identify the associated risk factors in cohorts: (i) patients with irritable bowel syndrome and/or chronic constipation (IBS/CC/both), (ii) individuals free of these conditions.

METHODS

Population-based case-control analysis nested in a cohort of patients with first ever recorded diagnosis of IBS/CC/both and a cohort free of these conditions from general population using the General Practice Research Database.

RESULTS

Of 78 cases of intestinal ischaemia, 71 were from general population, seven from the IBS/CC/both cohort. Incidence rate of intestinal ischaemia in IBS/CC/both patients vs. general population was 4.49:1.09 per 100,000 person-years; age- and gender-adjusted incidence rate ratio (95% CI) was 2.7 (1.2-5.9). Inflammatory bowel disease and heart failure showed an association with ischaemic colitis [OR (95% CI): 4.2 (0.5-38.4) and 5.6 (2.2-14.1)], but none with acute mesenteric ischaemia. Diabetes and prior cardiovascular surgery were associated with higher risk of acute mesenteric ischaemia, but showed no association with ischaemic colitis.

CONCLUSIONS

Results suggest that different risk factors are associated with acute mesenteric ischaemia and ischaemic colitis. However, due to small number of patients, associations should be carefully interpreted.

Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study)

BACKGROUND

There is a lack of prospective studies evaluating the natural history of colonic ischaemia (CI). We performed such a study to evaluate the clinical presentation, outcome, and mortality as well as clinical variables associated with poor prognosis.

METHODS

An open, prospective, and multicentre study was conducted in 24 Spanish hospitals serving a population of 3.5 million people. The study included only patients who met criteria for definitive or probable CI. A website (www.colitisisquemica.org) provided logistical support.

RESULTS

A total of 364 patients met criteria for inclusion. CI was suspected clinically in only 24.2% of cases. The distribution of clinical patterns was as follows: reversible colopathy (26.1%), transient colitis (43.7%), gangrenous colitis (9.9%), fulminant pancolitis (2.5%), and chronic segmental colitis (17.9%). A total of 47 patients (12.9%) had an unfavorable outcome as defined by mortality and/or the need for surgery. Multivariate analysis identified the following signs as independent risk factors for an unfavorable outcome: abdominal pain without rectal bleeding [odds ratio (OR) 3.9; 95% confidence interval (CI) = 1.6-9.3], non-bloody diarrhoea (OR 10; 95% CI = 3.7-27.4), and peritoneal signs (OR 7.3; 95% CI = 2.7-19.6). Unfavorable outcomes also were more frequent in isolated right colon ischaemia (IRCI) compared with non-IRCI (40.9 vs. 10.3%, respectively; p < 0.0001). The overall mortality rate was 7.7%.

CONCLUSIONS

The clinical presentation of CI is very heterogeneous, perhaps explaining why clinical suspicion of this disease is so low. The presence of IRCI, and occurrence of peritoneal signs or onset of CI as severe abdominal pain without bleeding, should alert the physician to a potentially unfavorable course.

Clinical features of ischemic colitis

Ischemic colitis (IC) is the most common form of ischemic injury of the gastrointestinal tract and occurs more frequently in the elderly. It presents either as an occlusive or a non-occlusive form of intestinal ischaemia. The clinical presentation of IC is variable and non-specific. Colonoscopy is the most common diagnostic method and the golden standard for confirmation of IC. Therapy and outcome depend on the severity and complications of the disease. Most cases of the non-gangrenous form show a favorable prognosis after conservative therapy, while high mortality and urgent operative intervention are the hallmarks of gangrenous IC.

Ischemic colitis

Ischemic colitis is the most common form of ischemic enteropathy and occurs more frequently in elderly people. Although the etiology of ischemic colitis is diverse, the most common cause is acute, self-limited disruption of blood supply to the intestine. The typical clinical symptoms of ischemic colitis are minor abdominal pain and mild muscular tension of the affected colon segment. Hematochezia is very common, however, massive hemorrhage that can affect hemodynamics is not frequent. If the lesion is located in the mucous layer or submucosal layer, the disease is often transient and self-limited. Acute ischemic colitis with transmural infarction may lead to colonic necrosis and even death. Colonoscopy and biopsy are the gold standard for diagnosis of the disease. Most patients with ischemic colitis improve after conservative treatment in one or two days. Approximately 20% of patients may deteriorate to develop peritonitis and need surgical treatment.

Development and validation of a novel prognostic scoring model for ischemic colitis

PURPOSE

This study was conducted to identify prognostic factors affecting the course of ischemic colitis and to develop a prognostic scoring model.

METHODS

We analyzed medical records of consecutive patients with ischemic colitis treated between October 2002 and September 2008 at Severance Hospital, Seoul, Republic of Korea. Patients were excluded if results of endoscopy were unavailable. Patients were classified as having severe ischemic colitis on the basis of outcome (improvement delayed for more than 2 weeks, complications requiring surgery, or death). Univariate analyses and multivariate logistic regression analyses with backward stepwise selection were used to identify clinical, endoscopic, and laboratory variables associated with severe ischemic colitis. A novel prognostic scoring model was derived from the data, with probability of severe ischemic colitis and risk index determined for 8 risk groups based on independent risk factors identified by multivariate analyses. Predictive power was tested by means of 10-fold cross-validation, with area under the receiver operating characteristic curve representing discrimination accuracy.

RESULTS

Analyzable data were available for 153 of 173 consecutive patients. Ischemic colitis was classified as severe in 20 patients. Multivariate analyses showed the following significant independent predictors of severe ischemic colitis: tachycardia (adjusted odds ratio = 4.6; 95% CI, 1.4-14.7), shock within 24 hours after admission (adjusted odds ratio = 6.5; 95% CI, 2.0-21.2), and endoscopic evidence of ulceration (adjusted odds ratio = 9.9; 95% CI, 2.0-48.8). Probability of severe ischemic colitis and risk index were 74 times higher for patients with all 3 risk factors (group 8) than for patients with none (group 1). Internal validation showed the area under the receiver operating characteristic curve to be 0.91 (95% confidence interval, 0.86-0.96).

CONCLUSIONS

Endoscopic findings and instability of vital signs were associated with the disease course of ischemic colitis. A novel scoring model based on presence of tachycardia, shock within 24 hours after admission, and endoscopic evidence of ulceration provides a method of assessing patient prognosis and should be further validated.

Male gender and renal dysfunction are predictors of adverse outcome in nonpostoperative ischemic colitis patients

OBJECTIVE

Ischemic colitis (IC) spans a broad spectrum from self-limiting illness to intestinal gangrene and mortality. Prognostic factors specifically for nonpostoperative IC were not fully characterized. We aim to focus on nonpostoperative IC in patients with renal dysfunction and try to identify prognostic factors for adverse outcomes.

METHODS

We conducted a retrospective analysis at a university-affiliated tertiary medical center in Taiwan. From January 2003 to August 2008, 25 men and 52 women (mean age: 66 y) had colonoscopic biopsy-proven IC without prior culprit surgery. We estimated glomerular filtration rate with simplified Modification of Diet in Renal Disease equation. Nine patients with glomerular filtration rate below 30 mL per minute per 1.73 m were classified as renal dysfunction group (including 7 dialysis patients). Adverse outcomes were defined as need for surgery and mortality. Predictors for adverse outcomes were captured by univariate and multivariate analysis. Research ethical committee approved the study protocol.

RESULTS

Patients with renal dysfunction more often had: diabetes mellitus (56% vs. 16%, P=0.02), prolonged symptoms (6.8 d vs. 3.5 d, P=0.01), lower hemoglobin (11.1 g/dL vs. 13.4 g/dL, P=0.01), and more often right colonic involvement (56% vs. 19%, P=0.03). Renal dysfunction patients also had longer hospitalization days (median 15 d vs. 4 d, P=0.045). However, there was no statistical significance in the rate of either surgery or mortality between these 2 groups (P>0.05). Univariate analysis showed that renal dysfunction, sex, emergency department referral, presentation with abdominal pain were significant for adverse outcome (P<0.1). Multivariate analysis revealed that male sex conveyed 9.5-fold risk (P=0.01) and renal dysfunction conveyed 8.5-fold risk (P=0.03) for adverse outcomes.

CONCLUSIONS

Nonpostoperative IC patients with concurrent renal dysfunction had distinct clinical profiles. Multivariate analysis showed that male patients had 9.5-fold and renal dysfunction patients had 8.5-fold increased risk for adverse outcomes. Although IC is often self-limited, our data warrants special attention and aggressive therapy in treating these patients.

Diarrhea and malabsorption in the elderly

Acute and chronic diarrheal disorders are common problems at all ages. It has been estimated that 5% to 7% of the population has an episode of acute diarrhea each year and that 3% to 5% have chronic diarrhea that lasts more than 4 weeks. It is likely that the prevalence of diarrhea is similar in older individuals. This article reviews the impact of diarrhea in the elderly, many of whom are less fit physiologically to withstand the effect of diarrhea on fluid balance and nutritional balance.

Endoscopic findings and clinicopathologic characteristics of ischemic colitis: a report of 85 cases

Ischemic colitis is the most common type of intestinal ischemia and has a clinical spectrum of injury that ranges from mild and transient ischemia to acute fulminant colitis. The aim of this study was to explore endoscopic findings and clinicopathologic characteristics of ischemic colitis and be accurate enough to avoid missed diagnosis or misdiagnosis. A retrospective analysis was undertaken of endoscopy findings and clinicopathologic characteristics of 85 cases of ischemic colitis from March 2005 to April 2008 in the endoscopy center of our hospital. All cases underwent colonoscopy with biopsy within 2 weeks of the onset of symptoms, and all specimens with forceps were stained with hematoxylin-eosin and observed under light microscopy. Of the 85 cases of ischemic colitis (24 men and 61 women, average age 61.36 +/- 14.49 years old, range 29-84), 71 were over 50 years of age. These cases were associated with the basal diseases such as hypertension, cardiovascular disorders, diabetes, and hematological diseases as well as a history of abdominal operation. The clinical features usually presented with sudden onset of abdominal pain, diarrhea, and hematochezia. Ischemic lesions were located mainly in the left colon with segmental form (only descending colon affected 16%, only splenic flexure 14%, and only sigmoid colon 23%). The 85 patients consisted of the non-gangrenous type (82), which were composed of reversible IC (76) and chronic IC (6), and the gangrenous type (3). Endoscopic appearance of the transient ischemic colitis consisted of petechial hemorrhages, edematous and fragile mucosa, segmental erythema, scattered erosion, longitudinal ulcerations, and sharply defined segment of involvement. Ischemic colitis of stricture was characterized by full-thickness mucosa, lumens stricture, and diseased haustrations. The mucosa of gangrenous colitis with cyanotic and pseudopolyps was endoscopically observed as well. Clinicopathologic characteristics showed mucosal inflammation accompanied by erosion, granulation tissue hyperplasia and gland atrophy, lamina propria hemorrhage, and macrophages with hemosiderin pigmentation in submucosa in particular. Although endoscopy findings and clinicopathologic characteristics of ischemic colitis are nonspecific, colonoscopy with biopsy plays a vital role in the early diagnosis of ischemic colitis.

Ischemic colitis: clinical practice in diagnosis and treatment

Ischemic colitis is the most common form of ischemic injury of the gastrointestinal tract and can present either as an occlusive or a non-occlusive form. It accounts for 1 in 1000 hospitalizations but its incidence is underestimated because it often has a mild and transient nature. The etiology of ischemic colitis is multifactorial and the clinical presentation variable. The diagnosis is based on a combination of clinical suspicion, radiographic, endoscopic and histological findings. Therapy and outcome depends on the severity of the disease. Most cases of the non-gangrenous form are transient and resolve spontaneously without complications. On the other hand, high morbidity and mortality and urgent operative intervention are the hallmarks of gangrenous ischemic colitis.

Clinical symptoms of intestinal vascular disorders

Despite advances made in the diagnostic and therapeutic field, acute intestinal ischemia remains a highly lethal condition. This is related to the variability of symptoms and the absence of typical laboratory alterations in early stage.

Spectrum of non-inflammatory bowel disease and non-infectious colitis

A variety of inflammatory diseases of the colon, which can be differentiated from inflammatory bowel disease (IBD) and infectious colitis by their clinical, endoscopic and histological characteristics, are reported as non-IBD and non-infectious colitis. These diseases include microscopic colitis, ischemic colitis, segmental colitis associated with diverticula, radiation colitis, diversion colitis, eosinophilic colitis and Behcet's colitis. The etiopathogenesis of most of these diseases remains obscure and the epidemiological data are rather limited. These conditions are often troublesome for the patient and are associated with diagnostic difficulties for the physician. In many cases the treatment is empirical and there is a need for future research using randomized controlled trials.

Ischemic colitis: Clinical practice in diagnosis and treatment

Ischemic colitis is the most common form of ischemic injury of the gastrointestinal tract and can present either as an occlusive or a non-occlusive form. It accounts for 1 in 1000 hospitalizations but its incidence is underestimated because it often has a mild and transient nature. The etiology of ischemic colitis is multifactorial and the clinical presentation variable. The diagnosis is based on a combination of clinical suspicion, radiographic, endoscopic and histological findings. Therapy and outcome depends on the severity of the disease. Most cases of the non-gangrenous form are transient and resolve spontaneously without complications. On the other hand, high morbidity and mortality and urgent operative intervention are the hallmarks of gangrenous ischemic colitis.

Is there a role for Tc-99m (V) DMSA scintigraphy in ischemic colitis?

AIM: To evaluate the role of pentavalent Tc-99m dimercaptosuccinic acid [Tc-99m (V) DMSA] in the diagnosis of ischemic colitis.

METHODS: Fourteen patients with endoscopically and histologically confirmed ischemic colitis were included in the study. Tc-99m (V) DMSA scintigraphy was performed within 2 d after colonoscopy. Images were considered positive when an area of increased activity was observed in the region of interest and negative when no abnormal tracer uptake was detected.

RESULTS: In 3 out of the 14 patients, Tc-99m (V) DMSA images showed moderate activity in the bowel. The scintigraphic results corresponded with the endoscopic findings. In the other 11 patients, no abnormal tracer uptake was detected in the abdomen.

CONCLUSION: Besides the limited number of patients, Tc-99m (V) DMSA could not be considered as a useful imaging modality for the evaluation of ischemic colitis.

Hypoxia inducible factor-1 (HIF-1)-mediated repression of cystic fibrosis transmembrane conductance regulator (CFTR) in the intestinal epithelium

Diarrhea is widespread in intestinal diseases involving ischemia and/or hypoxia. Since hypoxia alters stimulated Cl(-) and water flux, we investigated the influence of such a physiologically and pathophysiologically important signal on expression of the cystic fibrosis transmembrane conductance regulator (CFTR). Located on the apical membrane, this cAMP-activated Cl(-) channel determines salt and fluid transport across mucosal surfaces. Our studies revealed depression of CFTR mRNA, protein, and function in hypoxic epithelia. Chromatin immunoprecipitation identified a previously unappreciated binding site for the hypoxia inducible factor-1 (HIF-1), and promoter studies established its relevance by loss of repression following point mutation. Consequently, HIF-1 overexpressing cells exhibited significantly reduced transport capacity in colorimetric Cl(-) efflux studies, altered short circuit measurements, and changes in transepithelial fluid movement. Whole-body hypoxia in wild-type mice resulted in significantly reduced small intestinal fluid and HCO(3)(-) secretory responses to forskolin. Experiments performed in Cftr(-/-) and Nkcc1(-/-) mice underlined the role of altered CFTR expression for these functional changes, and work in conditional Hif1a mutant mice verified HIF-1-dependent CFTR regulation in vivo. In summary, our study clarifies CFTR regulation and introduces the concept of a HIF-1-orchestrated response designed to regulate ion and fluid movement across hypoxic intestinal epithelia.

The effect of sildenafil on an animal model for ischemic colitis

INTRODUCTION

Sildenafil both enhances vasodilatation by relaxing the smooth muscle in the vessels and inhibits platelet aggregation. We have therefore examined the potential benefits of sildenafil on an animal model for ischemic colitis (IC).

METHODS

Twenty-eight female Wistar albino rats weighing 250-300 g were randomized into three experimental groups as follows: in Group 1, animals were sham operated (n = 8) and received tap water; in Groups 2 and 3, the rats underwent a standardized surgical procedure to induce IC (n = 10 in each group). Group 2 animals served as the controls, receiving only tap water, while Group 3 animals received 10 mg/kg sildenafil per day as a single dose for a 3-day period. All animals were sacrificed 72 h after devascularization. To determine the severity of the ischemia, we scored the macroscopically visible damage, measured the ischemic area and scored the histopathology. Tissue malondialdehyde levels were also evaluated.

RESULTS

The mean area of ischemic changes were 116.80 +/- 189.93 and 0.55 +/- 1.01 mm2 in Group 2 and 3 animals, respectively (p = 0.0001), while the macroscopically mean visible damage score decreased to 0.66 +/- 0.70 (p = 0.0001) for Group 3 animals. The Chiu scores were 0.00, 3.80 +/- 0.91 and 2.66 +/- 1.00 in Group 1, 2 and 3 animals, respectively. There was a statistically significant difference between Group 2 and 3 animals (p = 0.017).

CONCLUSIONS

Our findings support the view that sildenafil leads to a improvement in IC due to its well-known effects on the vascular smooth muscle and on the microcirculatory hemodynamics.

Clinical significance of colonoscopic findings associated with colonic thickening on computed tomography: is colonoscopy warranted when thickening is detected?

GOAL

To determine the utility of colonoscopy in the management of patients with abdominal pain found to have colonic thickening on computed tomography (CT).

BACKGROUND

CT is often used in the investigation of abdominal pain. Clinical guidelines regarding colonoscopy when colonic wall thickening is reported at CT are lacking.

STUDY

From July 2000 to April 2004, the abdominal CT reports of all patients at a major teaching hospital who were investigated for abdominal pain were reviewed. Cases were selected if any colonic wall thickening was reported. Patients were excluded if they had a previously diagnosed gastrointestinal condition, or if they had not undergone colonoscopy within 30 days of the abnormal CT. Clinical, endoscopic, and pathologic data were extracted from the medical records of all eligible patients.

RESULTS

One hundred seven cases were identified. Of these, 8 (7.4%) had colorectal adenocarcinoma. In 10 patients (9.3%), a new diagnosis of inflammatory bowel disease (IBD) was made. Sixteen (15.0%) had findings consistent with infectious colitis, 39 (36.4%) ischemic colitis, and 6 patients (5.6%) had miscellaneous findings possibly responsible for the colonic thickening (diverticulitis, appendicitis, proctitis, and melanosis coli). In 28 patients (26.1%), no abnormality was found that could explain the CT finding. Of those diagnosed with colorectal carcinoma or IBD, only 4 of the 18 patients (28%) presented with evidence of gastrointestinal bleeding or anemia.

CONCLUSIONS

On the basis of the rate of new diagnoses of colorectal carcinoma and IBD, we recommend colonoscopy be performed after clinical evaluation in patients with abdominal pain and colonic thickening on CT.

Ischemic colitis has a worse prognosis when isolated to the right side of the colon

BACKGROUND

In general, ischemic colitis has a very good prognosis, but there is concern that when ischemia affects the right side of the colon in an isolated fashion, the prognosis may not be so favorable.

OBJECTIVE

The aim of this study was to compare the clinical features and outcomes of ischemia isolated to the right side of the colon with those of ischemia involving other areas of the colon.

METHODS

A retrospective study was undertaken of patients with colon ischemia hospitalized at the Moses and Weiler Divisions of the Montefiore Medical Center during the interval 1998-2005. Patients were identified using computerized searches of ICD-9 codes for colon ischemia and were divided into two groups: those with isolated right colon ischemia (IRCI) and those with colon ischemia not involving the right colon in an isolated fashion (non-IRCI). Only patients with biopsy-proven ischemic colitis were entered into our study.

RESULTS

A total of 273 cases of biopsy-proven ischemic colitis were identified, of which 71 (26.0%) were isolated to the right side. Of these IRCI cases, 59.2% had an unfavorable outcome compared with 17.3% of cases of non-ICRI: 54.9% of IRCI patients required surgery compared with 10.9% of non-IRCI patients; mortality in patients with IRCI was 22.5% compared with 11.9% in patients with non-IRCI.

CONCLUSIONS

A total of 273 cases of biopsy-proven ischemic colitis were identified of which 71 (26.0%) involved only the right side. Patients with IRCI had a worse outcome than those with colon ischemia involving other colon regions, including a fivefold need for surgery and a twofold mortality.

[Diagnostic approach to ischemic colitis]

Ischemic colitis is the most frequent form of intestinal ischemia and arises when the colon is temporarily deprived of blood supply. Diagnosis of this entity requires a high index of clinical suspicion. To achieve this, the chronology of the symptoms (abdominal pain followed by defecatory urgency and rectorrhagia) and the clinical context in which these symptoms appear (> 90% affect persons especially at risk for vascular accidents) must be taken into account. Although diagnosis requires early colonoscopy (< 48 h), this procedure should not be performed if peritonitis is present. In severe forms, other imaging techniques, such as Doppler ultrasound or abdominal computed tomography, provide information with diagnostic -and even prognostic- value. Angiography is reserved for patients in whom there is doubt about the presence of acute mesenteric ischemia. Thrombophilia should be investigated in persons aged less than 60 years old.

Severe chronic abdominal pain in the absence of adhesions

Management of the patient with chronic severe abdominal pain in the absence of adhesions remains one of the major challenges of the gastroenterologist. Given that extensive investigation will inevitably take place of such individual, the role of the gastroenterologist who is asked to review such a problem, is to identify unusual manifestations of common disorders from new, previously-unidentified causes, and to assess the degree to which somatisation and psychological overlay are exacerbating the problem. Investigations must be targeted against clinically-generated hypotheses rather than to repeat a non-systematic approach. Therapy in the absence of a newly-identified disorder is generally targeted at alleviating rather than removing symptoms, addressing an individual's personal pain and management needs, and avoiding ever more complex and invasive investigations.

Protective effects of relaxin in ischemia/reperfusion-induced intestinal injury due to splanchnic artery occlusion

1. Splanchnic artery occlusion (SAO) followed by reperfusion causes endothelial injury and inflammation which contribute to the pathophysiology of shock. We investigated the effects of relaxin (RLX), known to afford protection against the deleterious effects of cardiac ischemia/reperfusion, given to rats subjected to splanchnic artery occlusion and reperfusion (SAO/R)-induced splanchnic injury. 2. RLX (30 ng kg(-1), 15 min. before reperfusion) significantly reduced the drop of blood pressure and high mortality rate caused by SAO/R. RLX also reduced histopathological changes, leukocyte infiltration (myeloperoxidase) and expression of endothelial cell adhesion molecules in the ileum. RLX counteracted free radical-mediated tissue injury, as judged by significant decrease in the tissue levels of peroxidation and nitration products (malondialdehyde, nitrotyrosine), DNA damage markers (8-hydroxy-2'-deoxyguanosine, poly-ADP-ribosylated DNA) and consumption of tissue antioxidant enzymes (superoxide dismutase). As a result, RLX led to a reduction of ileal cell apoptosis (caspase 3, terminal deoxynucleotidyltransferase-mediated UTP end labeling). The effects of RLX appear specific, as inactivated RLX substituted for the bioactive hormone had no effects. 3. In conclusion, these results show that RLX exerts a clear-cut protective effect in SAO/R-induced splanchnic injury, likely due to endothelial protection, decreased leukocyte recruitment and hindrance of free radical-mediated tissue injury leading to cell death, lethal complications and high mortality rate. Thus, RLX could be used therapeutically in intestinal ischemia.

Transcriptional repression of Na-K-2Cl cotransporter NKCC1 by hypoxia-inducible factor-1

Tissue edema is commonly associated with hypoxia. Generally, such episodes of fluid accumulation are self-limiting. At present, little is known about mechanisms to compensate excessive fluid transport. Here we describe an adaptive mechanism to dampen fluid loss during hypoxia. Initial studies confirmed previous observations of attenuated electrogenic Cl- secretion after epithelial hypoxia. A screen of known ion transporters in Cl- -secreting epithelia revealed selective downregulation of Na-K-2Cl cotransporter NKCC1 mRNA, protein, and function. Subsequent studies identified transcriptional repression of NKCC1 mediated by hypoxia-inducible factor (HIF). Chromatin immunoprecipitation analysis identified a functional HIF binding site oriented on the antisense strand of genomic DNA downstream of the transcription start site corresponding to the NKCC1 5'-untranslated region. Additional in vivo studies using conditional Hif1a-null mice revealed that the loss of HIF-1alpha in Cl- -secreting epithelia results in a loss of NKCC1 repression. These studies describe a novel regulatory pathway for NKCC1 transcriptional repression by hypoxia. These results suggest that HIF-dependent repression of epithelial NKCC1 may provide a compensatory mechanism to prevent excessive fluid loss during hypoxia.