A population-based study of incidence, risk factors, clinical spectrum, and outcomes of ischemic colitis

Indigo naturalis‑associated ischemic injury of colorectal mucosa: A case series study

Indigo naturalis, a traditional Chinese herbal medicine characterized by its dark blue hue, is utilized in the treatment of a diverse array of diseases, including ulcerative colitis, psoriasis, oral ulcers, radiation proctitis, chronic myelocytic leukemia and herpes zoster. The common adverse effects associated with indigo naturalis include liver dysfunction, headaches, abdominal pain and nausea. Notably, case reports have documented instances of ischemic injury to the colorectal mucosa attributed to indigo naturalis. The present case series study aimed to elucidate the clinical characteristics of patients that experienced an ischemic injury of the colorectal mucosa due to consuming Chinese patent medicines containing indigo naturalis. The present study included 15 patients (mean age, 61.7±15.1 years; 5 male patients) that were admitted to the Second Affiliated Hospital of Jiaxing University (Jiaxing, China) between March 2013 and February 2016. The patients developed ischemic colonic mucosal injuries after consuming indigo naturalis through Chinese patent medicines, with an incidence rate of 1.3% (15/1,157 patients). Overall, 9/15 patients had idiopathic thrombocytopenic purpura and 6 patients had schistosomal liver fibrosis with hypersplenism but normal myeloproliferative thrombocytopenia. The duration of continuous treatment with indigo naturalis-containing Chinese patent medicines ranged from 12-330 days, with a mean of 98.0±52.3 days. Gastrointestinal symptoms, including abdominal pain, diarrhea and hematochezia, were observed 6-90 days after starting the indigo naturalis-containing Chinese patent medicines, with a mean onset of 28.9±22.2 days. Abdominal computed tomography scans and colonoscopy revealed lesions predominantly in the right hemi-colon and the entire colon, including the rectum. Gastrointestinal symptoms resolved 17.3±12.4 days after discontinuing the treatment with indigo naturalis-containing Chinese patent medicines, and patients had a favorable prognosis and did not experience a recurrence of ischemic colitis. Therefore, individuals taking indigo naturalis orally may be susceptible to developing ischemic injuries of the colorectal mucosa. In cases where colonoscopy indicates a suspected mucosal ischemic injury, it is suggested that endoscopists inquire about the medical history of the patient in order to establish a definitive diagnosis and adjust the dose of the indigo naturalis-containing drug to mitigate the adverse effects.

Precision medicine in intestinal ischemia: the emerging role of biomarkers

Intestinal ischemia (IIs) is a significant gastrointestinal condition characterized by reduced blood flow to the bowel, leading to inflammation and injury. Early diagnosis and management are crucial for preventing severe complications. Under this point of view, circulating biomarkers can enhance patient stratification and guide therapeutic decisions. Fatty acid-binding proteins (FABPs), specifically I-FABP and L-FABP, are small cytosolic proteins released upon enterocyte membrane integrity loss, with elevated plasma levels indicating early intestinal ischemia. Stromal Cell-Derived Factor-1 (SDF-1) regulates stem cell function and shows significantly higher levels in patients with IIs and cardiovascular disease compared to controls. D-Lactate, a bacterial fermentation byproduct, is another significant marker, with higher serum levels observed in intestinal ischemia cases. Alpha-glutathione S-transferase combats intracellular oxidative stress, with significantly elevated levels in acute mesenteric ischemia patients. Additionally, SM22, a small smooth muscle protein, shows higher plasma levels in patients with transmural ischemia compared to those with mucosal ischemic lesions and healthy controls. These biomarkers are promising for their roles in early detection and differentiation of IIs from other gastrointestinal conditions. Therapeutic strategies, including anti-inflammatory therapies, have shown efficacy in managing IIs symptoms and preventing recurrence. This review aims to inform clinicians and researchers about the current advancements in biomarker research and therapeutic approaches for IIs, emphasizing the importance of integrating these biomarkers and treatments into clinical practice to improve the management and prognosis of the disease.

Healthcare professionals' knowledge, attitude and practice towards ischemic bowel disease

BACKGROUND

Ischemic bowel disease (IBD) is a critical condition caused by reduced blood flow to the intestines, leading to tissue damage and potentially severe complications. Early recognition and timely management are essential for improving patient outcomes and reducing morbidity and mortality associated with IBD.

AIM

To evaluate the knowledge, attitude and practice (KAP) of healthcare professionals regarding IBD.

METHODS

This cross-sectional study was conducted among healthcare professionals in China from November 2023 to December 2023 using a self-designed questionnaire.

RESULTS

A total of 315 valid questionnaires were analyzed, with 215 participants (68.25%) being female. The mean KAP scores were 17.55 ± 5.35 (range: 0-24), 27.65 ± 2.77 (range: 8-40), and 18.88 ± 4.23 (range: 6-30), respectively. Multivariate linear regression analysis revealed the following factors to be independently associated with knowledge: Age 26-35 years (β = 2.80, 95%CI: 0.31-5.30, P = 0.028), professional title (β = 2.66, 95%CI: 0.91-4.41, P = 0.003), position (β = -3.78, 95%CI: -5.45 to -2.11, P < 0.001), participation in IBD-related training (β = 3.45, 95%CI: 2.39-4.51, P < 0.001), and admission of more than five IBD cases in the past month (β = 3.25, 95%CI: 1.58-4.92, P < 0.001). Attitude was independently associated with knowledge (β = 0.20, 95%CI: 0.15-0.26, P < 0.001) and being a nurse or nursing supervisor (β = -1.30, 95%CI: -2.16 to -0.40, P = 0.003). Practice was independently associated with knowledge (β = 0.20, 95%CI: 0.10-0.30, P < 0.001) and attitude (β = 0.24, 95%CI: 0.06-0.42, P = 0.007). Structural equation modeling demonstrated direct effects of knowledge on attitude (β = 0.24, P < 0.001) and practice (β = 0.26, P < 0.001), as well as of attitude on practice (β = 0.22, P = 0.012).

CONCLUSION

Healthcare professionals demonstrated adequate knowledge but moderate attitude and inactive practice regarding IBD. Addressing the gaps in attitude and practice through targeted training programs and interventions is essential for improving patient care and outcomes.

Back Up at the Pump? I Have a Gut Feeling About This: A Review of the Gastrointestinal Manifestations From Congestive Heart Failure

Heart failure, which is a clinical syndrome characterized by the heart's inability to maintain adequate cardiac output, is known to affect various organ systems in the body due to its ischemic nature and activation of the systemic immune response, but the resultant complications specifically on the gastrointestinal tract and the liver are not well discussed and poorly understood. Gastrointestinal-related phenomena are common symptoms experienced in patients with heart failure and frequently found to increase morbidity and mortality in these populations. The relationship between the gastrointestinal tract and heart failure are strongly linked and influence each other much so that the bidirectional association of the two is oftentimes referred to as cardiointestinal syndrome. Manifestations include gastrointestinal prodrome, bacterial translocation and protein-losing gastroenteropathy by gut wall edema, cardiac cachexia, hepatic insult and injury, and ischemic colitis. More attention is needed from a cardiology perspective to recognize these common presenting gastrointestinal phenomena that affect much of our patient population with heart failure. In this overview, we describe the association between heart failure and the gastrointestinal tract, the pathophysiology, lab findings, clinical manifestations and complications, and the management involved.

Tirzepatide-Associated Colonic Ischemia

The use of the glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist tirzepatide has markedly increased for the treatment of weight loss and management of diabetes mellitus. Gastrointestinal adverse effects of GLP-1/GIP agonist therapy, including nausea, vomiting, and constipation, are common. We report a case of colonic ischemia in a 62-year-old woman which developed in association with the use of tirzepatide for weight loss. This report highlights a potential risk relationship between GLP-1/GIP agonist therapy and colonic ischemia and identifies risk factors that should be considered before prescribing tirzepatide.

Rapid Endoscopic Diagnosis of Benign Ulcerative Colorectal Diseases With an Artificial Intelligence Contextual Framework

BACKGROUND & AIMS

Benign ulcerative colorectal diseases (UCDs) such as ulcerative colitis, Crohn's disease, ischemic colitis, and intestinal tuberculosis share similar phenotypes with different etiologies and treatment strategies. To accurately diagnose closely related diseases like UCDs, we hypothesize that contextual learning is critical in enhancing the ability of the artificial intelligence models to differentiate the subtle differences in lesions amidst the vastly divergent spatial contexts.

METHODS

White-light colonoscopy datasets of patients with confirmed UCDs and healthy controls were retrospectively collected. We developed a Multiclass Contextual Classification (MCC) model that can differentiate among the mentioned UCDs and healthy controls by incorporating the tissue object contexts surrounding the individual lesion region in a scene and spatial information from other endoscopic frames (video-level) into a unified framework. Internal and external datasets were used to validate the model's performance.

RESULTS

Training datasets included 762 patients, and the internal and external testing cohorts included 257 patients and 293 patients, respectively. Our MCC model provided a rapid reference diagnosis on internal test sets with a high averaged area under the receiver operating characteristic curve (image-level: 0.950 and video-level: 0.973) and balanced accuracy (image-level: 76.1% and video-level: 80.8%), which was superior to junior endoscopists (accuracy: 71.8%, P < .0001) and similar to experts (accuracy: 79.7%, P = .732). The MCC model achieved an area under the receiver operating characteristic curve of 0.988 and balanced accuracy of 85.8% using external testing datasets.

CONCLUSIONS

These results enable this model to fit in the routine endoscopic workflow, and the contextual framework to be adopted for diagnosing other closely related diseases.

Prevalence and predictive value of sarcopenia in hospitalized patients with ischemic colitis

Ischemic colitis (IC) and sarcopenia are associated with aging and multiple comorbidities. We aimed to investigate the prevalence and predictive role of sarcopenia in patients with IC. We retrospectively analyzed 225 hospitalized patients (median age, 72 years; women, 67.1%; severe IC, 34.2%) who were diagnosed with IC between January 2007 and February 2022. Sarcopenia was defined as the skeletal muscle index at the third lumbar vertebra determined by computed tomography. It was present in 49.3% (n = 111) of the patients and was significantly associated with severe IC compared to those without sarcopenia (48.6% vs. 20.2%, P < 0.001). Sarcopenia was associated with extended hospitalization (median: 8 vs. 6 days, P < 0.001) and fasting periods (4 vs. 3 days, P = 0.004), as well as prolonged antibiotic use (9 vs. 7 days, P = 0.039). Sarcopenia was linked to a higher risk of surgery or mortality (9.0% vs. 0%, P = 0.001) and independently predicted this outcome (odds ratio [OR], 11.17; 95% confidence interval [CI], 1.24‒1467.65, P = 0.027). It was prevalent among hospitalized patients with IC, potentially indicating severe IC and a worse prognosis. This underscores the importance of meticulous monitoring, immediate medical intervention, and timely surgical consideration.

Surgical prevalence and outcomes in ischemic colitis: A systematic review and meta-analysis

BACKGROUND/AIM

This study reviews the literature to examine the proportion of patients requiring surgical management in ischemic colitis (IC) and identify surgical outcomes.

METHOD

A systematic review of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials was conducted in accordance with the latest Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. English language studies and adult patients were included. Studies with fewer than 10 patients, and IC post aortic or cardiac surgery was excluded. We present our systematic review and meta-analysis with pooled proportions of right sided IC distribution and prevalence of surgical treatment.

RESULTS

23 studies with a total of 12,844 patients were included in the systematic review, with 19 studies and 12,420 patients included in the meta-analysis. Four studies were excluded from the meta-analysis due to only including specific cohorts of patients-two with cocaine induced colitis, one with phlebosclerotic colitis, and one with IC associated with acute myocardial infarction. The pooled proportion of right sided IC distribution was 15% (CI 14%-17%, p < 0.001), whilst the pooled proportion of surgical management of IC was 15% (CI 13%-16% p < 0.001).

CONCLUSION

Prevalence of surgical management of IC is rare. Right sided IC is associated with higher mortality and higher rates of surgical management. Reporting of surgical outcomes is scant.

Clinical Background and Coronary Artery Lesions Characteristics in Japanese Patients With Acute Coronary Syndrome Suffering Major Bleeding

Background: Although the clinical factors that predict major bleeding in Western patients with acute coronary syndrome (ACS) are becoming elucidated, they have not been fully investigated, especially coronary lesion characteristics, in a Japanese population. Methods and Results: ACS patients (n=1,840) were divided into a "bleeding group" and a "no-bleeding group," according to whether they had major bleeding during the 2-year follow-up period, to investigate the prognostic effect of bleeding and the predictive factors of bleeding. Among them, patients who underwent primary percutaneous coronary intervention with optical coherence tomography (OCT) guidance (n=958) were examined to identify the effect of coronary lesion characteristics on bleeding. Of the 1,840 enrolled patients, 124 (6.7%) experienced major bleeding during the 2-year follow-up period. Incidence of cardiovascular death during the 2-year follow-up period was significantly higher among patients with major bleeding (26.4% vs. 8.5%, P=0.001). OCT examination showed that disrupted fibrous cap (DFC: 68% vs. 48%, P=0.014) and calcified plaque (63% vs. 42%, P=0.011) were more prevalent in the bleeding group. DFC was a predictor of major bleeding in the multivariate Cox proportional hazards analyses (hazard ratio 2.135 [95% confidence interval 1.070-4.263], P<0.001). Conclusions: ACS patients with major bleeding had poorer cardiac outcomes. Advanced atherosclerosis at the culprit lesion influences the higher incidence of major bleeding in ACS patients.

Long-term aspirin use in patients hospitalized with ischemic colitis

Background

Ischemic colitis is a form of mesenteric ischemia that often presents in patients with vascular disease. Long-term aspirin use has been shown to improve the outcomes in patients with cardiovascular or cerebrovascular disease. However, the relationship between aspirin use and ischemic colitis is unclear.

Methods

Patients with a diagnosis of ischemic colitis were identified using the 2020 Nationwide Inpatient Sample. Patients were stratified by long-term aspirin use at the time of hospitalization. Data were collected regarding mortality, bowel perforation, peritonitis, shock, blood transfusion, length of stay in days (LOS), hospital charges, age, sex, race, primary insurance, median income, hospital region, hospital size, and comorbidities. The relationship between aspirin use and outcomes was analyzed using multivariate regression analysis.

Results

A total of 67,685 patients were included. Aspirin users had a mean age of 72.8 years compared to 66.8 years for non-aspirin users. Long-term aspirin use was associated with a lower risk of in-hospital mortality (P<0.001), bowel perforation (P<0.001), peritonitis (P=0.01), shock (P<0.001), and blood transfusion (P<0.001). The mean LOS was 6.1 days in the aspirin group compared to 9.4 days in the non-aspirin group. Ischemic colitis patients taking aspirin had a mean hospitalization charge of $87,123 compared to $161,610 for those not using aspirin.

Conclusions

Our study examined the impact of aspirin use in ischemic colitis patients. Among patients hospitalized with ischemic colitis, we found that long-term aspirin use was associated with a lower risk of in-hospital mortality and adverse events.

Insights into acute mesenteric ischaemia: an up-to-date, evidence-based review from a mesenteric stroke centre unit

Radiologists play a central role in the diagnostic and prognostic evaluation of patients with acute mesenteric ischaemia (AMI). Unfortunately, more than half of AMI patients undergo imaging with no prior suspicion of AMI, making identifying this disease even more difficult. A confirmed diagnosis of AMI is ideally made with dynamic contrast-enhanced CT but the diagnosis may be made on portal-venous phase images in appropriate clinical settings. AMI is diagnosed on CT based on the identification of vascular impairment and bowel ischaemic injury with no other cause. Moreover, radiologists must evaluate the probability of bowel necrosis, which will influence the treatment options.AMI is usually separated into different entities: arterial, venous, non-occlusive and ischaemic colitis. Arterial AMI can be occlusive or stenotic, the dominant causes being atherothrombosis, embolism and isolated superior mesenteric artery (SMA) dissection. The main finding in the bowel is decreased wall enhancement, and necrosis can be suspected when dilatation >25 mm is identified. Venous AMI is related to superior mesenteric vein (SMV) thrombosis as a result of a thrombophilic state (acquired or inherited), local injury (cancer, inflammation or trauma) or underlying SMV insufficiency. The dominant features in the bowel are hypoattenuating wall thickening with submucosal oedema. Decreased enhancement of the involved bowel suggests necrosis. Non-occlusive mesenteric ischaemia (NOMI) is related to impaired SMA flow following global hypoperfusion associated with low-flow states. There are numerous findings in the bowel characterised by diffuse extension. An absence of bowel enhancement and a thin bowel wall suggest necrosis in NOMI. Finally, ischaemic colitis is a sub-entity of arterial AMI and reflects localised colon ischaemia-reperfusion injury. The main CT finding is a thickened colon wall with fat stranding, which seems to be unrelated to SMA or inferior mesenteric artery lesions. A precise identification and description of vascular lesions, bowel involvement and features associated with transmural necrosis is needed to determine patient treatment and outcome.

The Impact of COVID-19 on Outcomes of Ischemic Colitis: A Nationwide Retrospective Analysis

Background

Ischemic colitis is the most common presentation of mesenteric ischemia and is associated with significant morbidity and mortality. Coagulopathy has been associated with the development of ischemic colitis. Coronavirus disease 2019 (COVID-19) infection can lead to a variety of pathology and physiological derangements, including coagulopathy. Some case reports have described severe ischemic colitis in patients with COVID-19 infection. Our study aimed to elucidate the impact of COVID-19 infection on ischemic colitis outcomes.

Methods

Patients with a diagnosis of ischemic colitis were identified using the 2020 Nationwide Inpatient Sample (NIS). Patients were stratified based on the presence of COVID-19 infection. Data were collected regarding mortality, shock, blood transfusion, length of stay, hospital charges, age, gender, race, primary insurance, median income, hospital region, hospital bed size, and comorbidities. The relationship between COVID-19 and outcomes was analyzed using multivariate regression analysis.

Results

A total of 67,685 patients were included in the final analysis. COVID-19 was associated with an increased risk of in-hospital mortality (adjusted odds ratio (aOR): 4.006, P < 0.001), shock (aOR: 1.62, P = 0.002), and blood transfusion (aOR: 1.49, P = 0.007). COVID-19 was also associated with an increased length of stay (16.2 days vs. 8.7 days) and higher total hospital charges ($268,884.1 vs. $145,805.9).

Conclusions

Among hospitalized patients with ischemic colitis, COVID-19 infection was associated with worse outcomes and higher resource utilization. Further studies are needed to investigate the mechanisms underlying this association.

The Global Burden of Vascular Intestinal Disorders in 204 Countries and Territories From 1990 to 2019: Global Burden of Diseases Study

Objectives: Assess the prevalence, mortality, and disability-adjusted life years (DALYs) of vascular intestinal disorders (VID) from 1990 to 2019. Methods: This study conducted a secondary data analysis utilizing the Global Burden of Diseases Study 2019. The prevalence, mortality and DALYs of VID were analyzed by sex, age and socio-demographic index (SDI), respectively. Analyses were performed by using R software. Results: Globally, the number of prevalent VID cases increased from 100,158 (95% uncertainty interval: 89,428-114,013) in 1,990-175,740 (157,941-198,969) in 2019. However, the age-standardized rates (ASR) of VID prevalence declined from 2.47 (95% uncertainty interval: 2.24-2.76) per 100,000 population to 2.21 (1.98-2.48) per 100,000 population between 1990 and 2019. Furthermore, the ASR of mortality also decreased from 1990 to 2019. Between 1990 and 2019, the regions with high and high-middle level exhibited the highest diseases burden. Conclusion: Globally, the diseases burden associated with VID demonstrated a decline from 1990 to 2019. However, concerted efforts are still required to enhance measures to combat VID within countries categorized as high and high-middle SDI.

Adult-onset megacolon with focal hypoganglionosis: A detailed phenotyping and prospective cohort study

BACKGROUND

In this prospective cohort study, we evaluated features of "adult-onset megacolon with focal hypoganglionosis."

METHODS

We assessed the radiologic, endoscopic, and histopathologic phenotyping and treatment outcomes of 29 patients between 2017 and 2020. Data from community controls, consisting of 19,948 adults undergoing health screenings, were analyzed to identify risk factors. Experts reviewed clinical features and pathological specimens according to the London Classification for gastrointestinal neuromuscular pathology.

KEY RESULTS

The median age of the patients with adult-onset megacolon with focal hypoganglionosis at symptom onset was 59 years (range, 32.0-74.9 years), with mean symptom onset only 1 year before diagnosis. All patients had focal stenotic regions with proximal bowel dilatation (mean diameter, 78.8 mm; 95% confidence interval [CI], 72-86). The comparison with community controls showed no obvious risk factors. Ten patients underwent surgery, and all exhibited significant hypoganglionosis: 5.4 myenteric ganglion cells/cm (interquartile range [IQR], 3.7-16.4) in the stenotic regions compared to 278 cells/cm (IQR, 190-338) in the proximal and 95 cells/cm (IQR, 45-213) in the distal colon. Hypoganglionosis was associated with CD3+ T cells along the myenteric plexus. Colectomy was associated with significant symptom improvement compared to medical treatment [change in the Global Bowel Satisfaction score, -5.4 points (surgery) vs. -0.3 points (medical treatment); p < 0.001].

CONCLUSIONS AND INFERENCES

Adult-onset megacolon with focal hypoganglionosis has distinct features characterized by hypoganglionosis due to inflammation. Bowel resection appears to benefit these patients.

Prior appendectomy and cerebral infarction as potential risk factors for recurrent ischemic colitis: A retrospective observational study

Background and Aim

Ischemic colitis (IC) is a benign disease associated with acute lower gastrointestinal bleeding and frequent recurrence. While several studies have investigated risk factors for IC onset, few have assessed the risk factors for recurrent IC. This study aimed to identify risk factors for recurrent IC.

Methods

Potential risk factors for recurrence were assessed by examining medical records and laboratory findings in this single-center retrospective study. We extracted the following data from the patients' medical records: patient characteristics, clinical signs and symptoms, laboratory findings, method of treatment, length of hospital stay, disease course, and the frequency of IC morbidities. Patients with IC were selected from a total of 439 312 patients over an 11-year period. Patients were divided into recurrent and nonrecurrent IC groups.

Results

In total, 225 patients met the diagnostic criteria for IC during the specified study period; of these, 204 patients (90.7%) and 21 patients (9.3%) were included in the nonrecurrent and recurrent IC groups, respectively. Univariate and multivariate analyses showed a significant association between IC recurrence and both cerebral infarction (P = 0.008, odds ratio [OR] = 6.3) and history of appendectomy (P = 0.0005, OR = 6.2). The median (interquartile range [IQR]) follow-up time for all patients was 1556 (353-2768) days; this was much longer than the median (IQR) time to recurrence of 291 (64-907) days in the recurrent IC group.

Conclusion

The results of this study suggest that prior cerebral infarction and appendicectomy may be risk factors for IC recurrence.

Contrast-induced ischemic colitis following coronary angiography: A case report

BACKGROUND

Ischemic colitis (IC) is common, rising in incidence and associated with high mortality. Its presentation, disease behavior and severity vary widely, and there is significant heterogeneity in therapeutic strategies and prognosis. The common causes of IC include thromboembolism, hemodynamic insufficiency, iatrogenic factors and drug-induced. However, contrast-induced IC, especially isolated right colon ischemia is rarely reported.

CASE SUMMARY

A 52-year-old man was admitted to the hospital due to intermittent chest distress accompanied by palpitation. Coronary angiography was performed using 60 mL of the iodinated contrast agent iohexol (Omnipaque 300), and revealed moderate stenosis of the left anterior descending artery and right coronary artery. At 3 h post-procedure, he complained of epigastric pain without fever, diarrhea and vomiting. Vital signs remained normal. An iodixanol-enhanced abdominal computed tomography (CT) scan revealed thickening, edema of the ascending and right transverse colonic wall and inflammatory exudate, without thrombus in mesenteric arteries and veins. Following 4 days of treatment with antibiotic and supportive management, the patient had a quick and excellent recovery with disappearance of abdominal pain, normalization of leucocyte count and a significant decrease in C reactive protein. There was no recurrence of abdominal pain during the patient's two-year follow-up.

CONCLUSION

This case emphasizes that contrast-induced IC should be considered in the differential diagnosis of unexplained abdominal pain after a cardiovascular interventional procedure with the administration of contrast media. Timely imaging evaluation by CT and early diagnosis help to improve the prognosis of IC.

A Rare Case of Pancolonic Ischemia Complicated by Fusobacterium Necrophorum Bacteremia: A Review of Colonic Ischemia for Internists

The varied clinical presentation and objective findings associated with colonic ischemia (CI) overlap with multiple disease processes. A high index of suspicion is critical for timely diagnosis and prognostication to avoid delays in treatment. We present a case that highlights the challenges of diagnosing CI and the high morbidity associated with severe disease. Case report: A sixty-four-year-old female presented to our community hospital with acute onset abdominal pain, nausea, and diarrhea, complicated by septic shock. She was initially given a diagnosis of infectious colitis until a colonoscopy was performed revealing extensive pancolonic ulcerations. Histopathological features on biopsy were most consistent with colonic ischemia. Blood cultures grew Fusobacterium Necrophorum. Surgery was avoided due to the high morbidity and mortality of performing a total colectomy and ileostomy. The patient continued to struggle with abdominal pain, diarrhea, and hematochezia, consistent with continuous CI, leading to recurrent hospitalizations.

Acute ischemic colitis associated with oral decongestant use: a systematic review

Background and Aim

Acute ischemic colitis (IC) has been linked with the use of oral decongestants. However, clinical evidence on this association remains limited. We aim to evaluate the occurrence and clinical outcomes of acute IC following over-the-counter (OTC) use of pseudoephedrine and phenylephrine.

Methods

We conducted a systematic review of the MEDLINE, Google Scholar, Scopus, and Embase databases between inception and July 20, 2022. Specific search terms were used. The inclusion criteria consisted of English-language articles describing acute IC secondary to pseudoephedrine or phenylephrine.

Results

A total of 18 case reports (level of clinical evidence: IV) fulfilled our inclusion criteria. The mean age of patients was 51.6 ± 15.3 years, with 14 (77.8%) cases reported in women. The clinical presentation was mainly related to abdominal pain 16 (88.9%), hematochezia 15 (83.3%), and/or abdominal tenderness 10 (55.6%). The medical background showed that 5 (27.8%) patients were previously healthy. In the 13 (72.2%) patients with comorbidities, hypertension 6 (46.2%), a history of tobacco use 5 (38.5%), and psychiatric illnesses 4 (30.8%) were commonly reported. Leukocytosis was encountered in 13 (72.2%) patients. Diagnostic investigations included a combination of computed tomography scan and colonoscopy in 10 (55.6%), colonoscopy alone in 6 (33.3%), and flexible sigmoidoscopy in 1 (5.6%) patient. Colonoscopic biopsy was the mainstay of diagnosis in 15 (83.3%) patients. Treatment was based on supportive care in 18 (100%), concurrent antibiotic use in 2 (11.1%), and surgical intervention in 1 (5.6%) patient. Recurrent episodes of IC occurred in 4 (22.2%) patients.

Conclusions

Acute IC secondary to oral decongestants remains a rare but important clinical phenomenon. Clinical suspicion and imaging findings are important for the early diagnosis.

Relevance to Patients

In unexplained cases of IC, clinicians should specifically inquire about oral decongestants since they are OTC and patients commonly fail to reveal their usage. These drugs should be avoided for transient cold symptoms, especially in women.

Discontinuity of marginal artery at splenic flexure and rectosigmoid junction: A systematic review and meta-analysis

AIM

The aim of this study was to provide comprehensive evidence-based assessment of the discontinuity of the marginal artery at the splenic flexure (SF) and the rectosigmoid junction (RSJ).

METHOD

A systematic review was conducted of literature published to 26 December 2022 in the electronic databases PubMed, SCOPUS and Web of Science to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using the Metafor package in R. The primary outcomes were the pooled PPEs of the marginal artery at the SF and the RSJ. The secondary outcome was the size of vascular anastomoses.

RESULTS

A total of 21 studies (n = 2,864 patients) were included. The marginal artery was present at the splenic flexure in 82% (95% CI: 62-95) of patients. Approximately 81% (95% CI: 63-94%) of patients had a large macroscopic anastomosis, while the remainder (19%) had small bridging ramifications forming the vessel. The marginal artery was present at the RSJ in 82% (95% CI: 70-91%) of patients.

CONCLUSION

The marginal artery may be absent at the SF and the RSJ in up to 18% of individuals, which may confer a higher risk of ischaemic colitis. As a result of high interstudy heterogeneity noted in our analysis, further well-powered studies to clarify the prevalence of the marginal artery at the SF and the RSJ, as well as its relationship with other complementary colonic collaterals (intermediate and central mesenteric), are warranted.

A case report of transmural rectosigmoid ischemia in an elderly patient

INTRODUCTION AND IMPORTANCE

While acute colonic ischemia is frequently observed in the elderly, rectal ischemia is a rare occurrence. We presented a case of transmural rectosigmoid ischemia in a patient who had not undergone any significant interventions and had no underlying diseases. Conservative treatment methods were unsuccessful, and surgical resection was necessary to prevent the development of gangrene or sepsis.

CASE PRESENTATION

Upon arrival at our health center, a 69-year-old man reported experiencing left lower quadrant pain and rectorrhagia. The CT scan revealed thickening in the sigmoid and rectum. Subsequent colonoscopy revealed circumferential ulcers, severe edema, erythema, discoloration, and ulcerative mucosa in both the rectum and sigmoid. Due to persistent severe rectorrhagia and worsening pathologic parameters, another colonoscopy was performed three days later.

CLINICAL DISCUSSION

Initially, conservative treatments were administered, but as the tenderness worsened, surgical exploration of the abdomen was necessary. During the procedure, a large ischemia from the sigmoid to the rectal dentate line was observed, and the lesion was resected. A stapler was then inserted into the rectum, followed by the use of the Hartman pouch method to deviate the tract. Finally, colectomy, sigmoidectomy, and rectal resection were performed.

CONCLUSION

Due to the worsening pathological condition of our patient, surgical resection was necessary. It is important to note that rectosigmoid ischemia, although rare, can develop without a known underlying cause. Therefore, it is crucial to consider and evaluate potential causes beyond the most common ones. Furthermore, any pain or rectorragia should be assessed immediately.

[Computed tomography and magnetic resonance imaging of colonic diseases]

BACKGROUND

Early diagnosis of a luminal colonic disease is of essential clinical importance to start timely optimised therapy and detect complications early.

OBJECTIVES

This paper aims to provide an overview of the use of radiological methods in diagnosing neoplastic and inflammatory luminal diseases of the colon. Characteristic morphological features are discussed and compared.

MATERIALS AND METHODS

Based on an extensive literature review, the current state of knowledge regarding the imaging diagnosis of luminal pathologies of the colon and their importance in patient management is presented.

RESULTS

Technological advances in imaging have made the diagnosis of neoplastic and inflammatory colonic diseases using abdominal computed tomography and magnetic resonance imaging the established standard. Imaging is performed as part of the initial diagnosis in clinically symptomatic patients, to exclude complications, as a follow-up assessment under therapy and as an optional screening method in asymptomatic individuals.

CONCLUSIONS

Accurate knowledge of the radiological manifestations of the numerous luminal disease patterns, the typical distribution pattern and characteristic bowel wall changes are essential to improve diagnostic decision-making.

Ischemic Colitis Secondary to Olanzapine and Clonidine Use in a Patient With a History of Laxative Abuse

Ischemic colitis is the most common type of intestinal ischemia and is caused by an acute arterial occlusion, thrombosis, or hypoperfusion of the mesenteric vasculature. This case centers around a 39-year-old female with a past medical history significant for a 20-year history of stimulant laxative abuse, chronic constipation, bipolar disorder, and anxiety that presented with ischemic colitis following 21 days of obstipation. At the time of presentation, the patient was taking olanzapine 15 mg daily for the treatment of bipolar disorder and clonidine 0.2 mg three times daily for anxiety. Over the course of her hospitalization, the patient was found to have a high stool burden, including calcified stool, contributing to ischemic colitis. She was successfully treated with a clonidine taper, multiple enemas, and laxatives. Pharmacological agents that induce constipation have been shown to increase the risk of colonic ischemia by increasing intraluminal pressure in the colon. Atypical antipsychotics block peripheral anticholinergic and anti-serotonergic receptors, limit gastrointestinal muscle contractions, and delay intestinal transit.

Operative management of immune checkpoint colitis following in-transit melanoma: Case report

Immune checkpoint inhibitors are increasingly used as powerful anti-neoplastic therapies in the setting of melanoma. Colitis is a known complication of immune checkpoint inhibitors that if often medically managed. We present a patient with stage IV melanoma with demonstrated in-transit disease undergoing immune checkpoint inhibitor therapy. The patient subsequently developed recalcitrant severe colitis that necessitated operative intervention and bowel resection. The association of immune check point inhibitors and immune related adverse effects are discussed as well as treatments of advanced colitis, including the possibility of surgical management in the setting of severe colitis with complications.

[Computed tomography diagnostics of acute and chronic mesenteric ischemia]

BACKGRAUND

Chronic mesenteric ischemia is more often accompanied by clinical signs characteristic of colitis. Acute mesenteric ischemia, unlike chronic, is accompanied by nonspecific symptoms and is a serious disease that requires urgent diagnosis.

AIMS

The aim of the study was to evaluate the effectiveness of MSCT in the diagnosis of acute and chronic mesenteric ischemia based on our observations.

MATERIALS AND METHODS

The retrospective study included 135 patients with abdominalgia and suspected mesenteric ischemia who underwent multiphase CT of the abdominal cavity with intravenous bolus contrast enhancement. Group 1 included 105 patients with mesenteric ischemia; group 2 included 30, without confirmed mesenteric ischemia, with the presence of a symptom of mesenteric ischemia in the form of abdominalgia.

RESULTS

We studied 135 patients, including 105 patients with mesenteric ischemia, 59 women and 46 men of average age 60±14.9 years. The acute form of ischemia (58%) was determined 1.5 times more often than the chronic one. Occlusive and nonocclusive acute mesenteric ischemia occurred in equal proportions. Mesenteric arterial thrombosis was the cause of acute mesenteric ischemia in 23% of cases. Mesenteric venous thrombosis was the cause of chronic intestinal ischemia in 61%, in 5% - acute form. Mixed arterial-venous genesis of mesenteric ischemia was determined in 4% against the background of strangulation obstruction. Dunbar syndrome as a cause of chronic intestinal ischemia was diagnosed in 16%. Chronic ischemic enterocolitis accounted for 10% of all cases of mesenteric ischemia and 23% of chronic ischemia. Symptoms and symptom complexes characteristic of the studied series of diseases with acute or chronic mesenteric ischemia were delineated. Sensitivity, specificity and prognostic value of CT with intravenous bolus contrast enhancement in diagnostics of diseases accompanied by mesenteric ischemia reached 100%.

CONCLUSIONS

Multiphase CT of the abdominal cavity with bolus contrast enhancement is highly informative in the diagnosis of acute and chronic forms of mesenteric ischemia. Direct CT signs of impaired blood flow in the arteries or veins of the mesentery were indisputable. Indirect signs of mesenteric ischemia were aimed at a thorough analysis of the condition of mesenteric vessels.

The association between irritable bowel syndrome and ischemic colitis: a systematic review and meta-analysis

INTRODUCTION

Studies have suggested an association between ischemic colitis and irritable bowel syndrome (IBS) although the results were inconsistent. This systematic review and meta-analysis were performed to comprehensively examine the association between IBS and ischemic colitis by identifying all available cohort and case-control studies and combining their effect estimates together.

EVIDENCE ACQUISITION

EMBASE, MEDLINE and Google Scholar databases were systematically reviewed up to June 2020. Eligible study had to be either cohort or case-control studies that evaluated whether patients with IBS have a higher risk of ischemic colitis than individuals without IBS. Point estimates and standard errors from each eligible study were combined together using the generic inverse variance method of DerSimonian and Laird.

EVIDENCE SYNTHESIS

The systematic review identified three cohort and eight case-control studies. The pooled analysis found a significantly higher risk of ischemic colitis among patient with IBS with the pooled odds ratio of 2.50 (95% CI, 2.00-3.14; I² 57%). Funnel plot was relatively symmetric and was not suggestive of presence of publication bias.

CONCLUSIONS

A significantly increased risk of ischemic colitis among patients with IBS was observed in this systematic review and meta-analysis.

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.

Risk of Ischemic Bowel Disease in Patients With Atrial Fibrillation Receiving Warfarin or Non-vitamin K Antagonist Oral Anticoagulants

Background

Although atrial fibrillation (AF) is a risk factor for ischemic bowel disease, data regarding the incidence of ischemic bowel disease in patients with anticoagulated AF were limited.

Methods

The present study used the Taiwan NHIRD and included newly diagnosed patients with AF aged ≥ 20 years without ischemic bowel disease from 2012 to 2018. A total of 69,549 patients taking warfarin or non-vitamin K antagonist oral anticoagulants (NOACs) constituted the final study group. We aimed to study the incidence of ischemic bowel disease in patients with AF receiving warfarin or NOACs. Secondary endpoints were also analyzed, including ischemic stroke, systemic embolism, myocardial infarction, mortality, intracranial hemorrhage (ICH), major bleeding, and composite adverse events (ischemic bowel disease or ICH or major bleeding).

Results

There were 43,787 patients taking NOACs and 25,762 patients taking warfarin. The overall incidence rate of ischemic bowel disease was 0.036% per year and increased with the CHA2DS2-VASc scores [0.013% for patients with a CHA2DS2-VASc score of 0 (men) or 1 (women), 0.022% for those with a CHA2DS2-VASc score of 1 (men) or 2 (women), and 0.039% for those with a CHA2DS2-VASc score ≥ 2 (men) or ≥ 3 (women)]. The risk of ischemic bowel disease was similar between NOAC and warfarin groups (0.036%/year vs. 0.037%/year; adjusted hazard ratio 0.802, p = 0.430), whereas the NOAC group had a significantly lower risk of secondary endpoints compared to the warfarin group.

Conclusion

We reported the incidence of ischemic bowel disease in patients with anticoagulated AF from a nationwide cohort database and observed a positive correlation between the increase of CHA2DS2-VASc scores and the incidence rate. Moreover, NOAC was as effective as warfarin for the risk of ischemic bowel disease.

Lactulose-Induced Ischemic Colitis: A Rare Presentation and an Overview of Possible Etiologies of the Disease

Ischemic colitis is one of the most common ischemic pathologies of the gastrointestinal system and can be divided into non-gangrenous and gangrenous forms. The pathophysiology involves restricted blood supply to the colonic mucosa. Several risk factors have been implicated in the development of ischemic colitis. Lactulose, one of the mainstay therapies for the treatment of hepatic encephalopathy in patients with cirrhosis, has been rarely reported as a cause of ischemic colitis. To the best of our knowledge, there has been only one case report associating lactulose use with the development of ischemic colitis. The exact pathophysiology is unknown but might be associated with the fermentation of lactulose by intestinal bacteria, causing gaseous distention and increasing the intraluminal pressure. We present the case of a 77-year-old African American male, a known case of non-alcoholic liver cirrhosis with portal hypertension and esophageal varices, brought in by his family to the emergency department for altered mental status, non-bilious vomiting, abdominal distension, and pain for one day. On physical examination, the patient had upper extremity asterixis and was alert but disoriented to place and person. Diagnostic paracentesis was performed, which revealed leukocytosis, predominantly neutrophils. The patient was admitted for spontaneous bacterial peritonitis and hepatic encephalopathy with decompensated liver cirrhosis. The patient was started lactulose with a goal of three to four bowel movements per day. Despite adequate treatment, the patient continued to develop worsening mental function and abdominal distension. This was later followed by a bloody bowel movement. Laboratory assessment showed an elevated white blood cell count, worsening kidney function, and high anion gap metabolic acidosis. CT scan revealed dilated loops of bowel with air and fluid along with submucosal wall edema, findings suggestive of ischemic colitis. Given the poor prognosis and the patient's condition, colonoscopy was deferred. Lactulose was discontinued, as it was thought to be a contributing cause of the patient's ischemic colitis. His condition continued to deteriorate, and he passed away on Day 18 of admission.

Congestive Heart Failure Is Associated With Worse Outcomes in Patients With Ischemic Colitis: A Nationwide Study

INTRODUCTION

Ischemic colitis (IC) results from compromised blood flow to the colon. Risk factors include atrial fibrillation (A.Fib), peripheral artery disease (PAD), coronary artery disease (CAD), and congestive heart failure (CHF). However, few studies compared the mortality rate and colectomy between patients with IC with CHF and IC alone.

OBJECTIVE

We aim to investigate the possibility of worse outcomes in patients with IC and CHF compared to IC alone.

METHODOLOGY

Using the National Inpatient Sample database from 2016 to 2019, we obtained baseline demographic data, total hospital charge, rate of colectomy, length of hospital stay (LOS), and in-hospital mortality. Data were compared using a t-test and chi-squared. Odds ratios for comorbidities including A.Fib, CAD, PAD, end-stage renal disease, chronic obstructive pulmonary disease, hyperlipidemia, hypertension, diabetes, and cirrhosis were calculated.

RESULTS

106,705 patients with IC were identified, among which 15,220 patients also had CHF. IC patients with CHF had a longer LOS (6.6 days vs 4.4 days; P<0.0001), higher total hospital charge ($71,359 vs $45,176; P<0.0001), higher mortality rate (8.5% vs 2.9%; P<0.0001), and higher colectomy rate (9.2% vs 5.9%; P<0.0001).

CONCLUSION

CHF is associated with poor outcomes in patients with IC. Our study showed an increased risk of mortality and colectomy compared to patients with IC alone. The findings suggest it may be warranted to have a heightened clinical suspicion of IC in patients with CHF who present with bleeding per rectum.

Factors influencing hospital stay duration for patients with mild ischemic colitis: a retrospective study

Background

Ischemic colitis is the most prevalent ischemic injury of the gastrointestinal tract. The majority of patients with mild ischemic colitis usually achieve complete clinical recovery shortly. However, the predictors of longer hospital stay duration are unclear. This study aimed to evaluate the predictors of hospital stay duration for patients with mild ischemic colitis.

Methods

We retrospectively evaluated 100 patients with mild ischemic colitis between January 2010 and December 2020 at Xiangya Hospital (a tertiary care center). The clinical characteristics and therapeutic drugs of patients who were hospitalized for ≤ 8 days and ≥ 12 days were compared.

Results

Of the 100 patients included, 63 (63%) were hospitalized for ≤ 8 days and 37 (37%) were hospitalized for ≥ 12 days. Patients with cerebrovascular disease (29.7% vs. 11.1%, p = 0.019) and abdominal surgical history (29.7% vs. 7.9%, p = 0.004) were more likely to be hospitalized for ≥ 12 days than for ≤ 8 days. The d-dimer levels [0.78 (0.41–1.82) vs. 0.28 (0.16–0.73), p = 0.001] and positive fecal occult blood test results (86.5% vs. 60.3%, p = 0.006) were higher in patients who were hospitalized for ≥ 12 days than in those who were hospitalized for ≤ 8 days. Probiotic use was greater in patients hospitalized for ≤ 8 days (76.2% vs. 54.1%, p = 0.022). Multivariate analysis indicated that cerebrovascular disease (odds ratio [OR] = 4.585; 95% confidence interval [CI] 1.129–18.624; p = 0.033), abdominal surgical history (OR = 4.551; 95% CI 1.060–19.546; p = 0.042), higher d-dimer levels (OR = 1.928; 95% CI 1.024–3.632; p = 0.042), and higher positive fecal occult blood test results (OR = 7.211; 95% CI 1.929–26.953; p = 0.003) were associated with longer hospital stays.

Conclusion

Cerebrovascular disease, abdominal surgical history, higher d-dimer levels, and higher positive fecal occult blood test results are independent and significant factors that influence longer hospital stays for patients with mild ischemic colitis. Probiotics helped reduce hospital stay in these patients.

An Israeli national survey on ischemic colitis induced by pre-colonoscopy bowel preparation (R1)

BACKGROUND AND STUDY AIMS

Ischemic colitis (IC) may occur as a complication of colonoscopy. The aim of this study was to characterize patients with IC that occurred after exposure to bowel preparation laxatives, prior to an elective colonoscopy.

PATIENTS AND METHODS

A survey among Israeli gastroenterologists. Information was collected regarding individual cases.

RESULTS

Eight patients, who developed IC after bisacodyl ingestion that was taken as part of pre-colonoscopy bowel preparation protocol, were reported. In all patients, severe abdominal pain and/or hematochezia started shortly after the ingestion of the first dose of bisacodyl. IC was found in 7 patients during the planned colonoscopy and in 1 patient using computerized tomography. All patients received supportive treatment and recovered.

CONCLUSIONS

IC induced by bisacodyl is a rare phenomenon. Regardless of being rare, we would advise withholding bisacodyl bowel preparation in elderly subjects with risk factors for IC that are scheduled for a colonoscopy.

Bad blood: ischemic conditions of the large bowel

PURPOSE OF REVIEW

Colon ischemia is the most common form of intestinal ischemic injury and is seen frequently in an elderly population. This disease is usually self-limited, and many causes have been identified. The recent literature has focused on estimates of prognosis, triaging appropriate level of care, and identification of optimal treatments. In this review, we will address our current understanding of colon ischemia including epidemiology, pathophysiology, segmental distribution, presentation, diagnosis, and management.

RECENT FINDINGS

Research has recently been focused on factors associated with poor outcome. The medical comorbidities identified include chronic obstructive pulmonary disease (COPD), hepatic cirrhosis, and chronic aspirin use. Serological markers are noninvasive tools that can triage severity. Recent studies have shown procalcitonin, C-reactive protein, D-dimer, and neutrophil counts can help predict those at greatest risk for poor outcome. The timing of colonoscopy relative to symptomatic onset also can help predict severity. Early colonoscopy allows for quicker identification of ischemic stigmata, reducing the chance of misdiagnosis and potentially unnecessary and harmful treatment. The treatment of colon ischemia has classically been conservative with antimicrobials reserved for those with moderate or severe disease. Recent retrospective analysis calls into question the utility of antibiotics in the treatment of colon ischemia, although the data is not convincing enough to advise against antimicrobial treatment in patients with severe and fulminant disease.

SUMMARY

It is an exciting time for research focused on colon ischemia. With an improved knowledge, awareness of associated risk factors and predictors of severity, clinicians now have enhanced clinical tools to diagnose and triage patients earlier in the disease. This should help institute prompt and appropriate therapies ultimately improving outcomes.

Prediction of severity and outcomes of colon ischaemia using a novel prognostic model: a clinical multicenter study

OBJECTIVE

To identify risk factors of disease severity and between mild and severe colon ischaemia (CI) patients and to improve clinical outcomes, this study aimed to explore a novel scoring model.

METHODS

Retrospective analyses of hospital records between January 2009 and December 2019 were included. Clinical manifestations, mortality, Oakland score, laboratory tests, colonoscopy, and histopathology were collected. Risk factors of severe CI were determined by univariate and multivariate logistic regression and used for the predicting model.

RESULTS

A total of 203 patients with CI were included. Serum C-reactive protein (CRP) and albumin ratio (CAR) were much higher in the severe CI group compared with that of the mild CI group (3.33 ± 1.78 versus 0.68 ± 0.97, p < .001). The Oakland score was much higher in the severe CI group (12.00 ± 3.02 versus 8.77 ± 1.63, p < .001). The histopathological finding of fibrin thrombi was an independent risk factor that predicted poor outcomes (20.00% versus. 1.09%, p < .001). Patients present with CAR ≥3.33, Oakland score ≥12, and histopathological fibrin thrombi were independent risk factors. In addition, the final scoring model was 0.042 × Oakland score + 1.040 × CAR + 3.412 × fibrin thrombi, the area under the curve (AUC) was 0.960 (95% confidence interval:0.930-0.990), and the sensitivity and specificity of the novel scoring model were 95% and 92%, respectively.

CONCLUSIONS

The novel prognostic model was established to predict CI severity and clinical outcomes efficiently.Key messagesIn this article, we discuss the scoring model for clinical outcomes of colon ischaemia patients.In our study, the sensitivity and specificity of a novel scoring model are very high.Thus, laboratory tests (CRP albumin ratio), Oakland score, and histopathological findings (fibrin thrombi) can be assessed efficiently for colon ischaemia outcomes.

Ischemic Colitis Caused by Bowel Preparation for Colonoscopy

Background

Ischemic colitis is an adverse event which may occur during bowel preparation for colonoscopy. This study aims to clarify both the incidence and the risk factors of this complication.

Methods

This was a single-center, retrospective, observational study. All outpatients who were prescribed standardized preparation drugs for colonoscopy at the Kyoto Second Red Cross Hospital between November 2011 and March 2020 were included in the study. A split bowel preparation was carried out as follows; magnesium citrate with or without sodium picosulfate hydrate was/were used as a preparation drug on the day before the colonoscopy, and polyethylene glycol electrolyte solution or sodium phosphate was used on the morning of the endoscopic procedure. Patients were extracted from the electronic medical records and matched with the endoscopy database by examination date and hospital identification number. Following the endoscopic findings, both the incidence and risk factors for ischemic colitis arising after bowel preparation were examined.

Results

Among the 14,924 patients analyzed, ischemic colitis was observed in 14 patients (0.09%). Multivariate analysis revealed that old age (≥ 75 years old) and strong preparation (magnesium citrate with sodium picosulfate and polyethylene glycol electrolyte solution) for constipated patients were independent risk factors for ischemic colitis (odds ratio: 3.64 (95% confidence interval (CI): 1.36 - 9.77) and 4.27 (95% CI: 1.45 - 12.53), respectively).

Conclusions

The age 75 years and above and strong preparation for patients with constipation were independent risk factors for ischemic colitis prior to colonoscopy. Careful attention should be paid to bowel preparation before colonoscopy for patients aged ≥ 75 years and for those with constipation.

Colonoscopy-related colonic ischemia

Colonoscopy is a risk factor for colon ischemia. The colon is susceptible to ischemia due to its minor blood flow compared to other abdominal organs; the etiology of colon ischemia after colonoscopy is multifactorial. The causative mechanisms include splanchnic circulation impairment, bowel preparation, drugs used for sedation, bowel wall ischemia due to insufflation/barotrauma, and introduction of the endoscope. Gastroenterologists must be aware of this condition and its risk factors for risk minimization, early diagnosis, and proper treatment.

Severe acute ischemic colitis: What is the place of endoscopy in the management strategy?

Background and study aims  Ischemic colitis (IC) is potentially lethal. Clinical and biology information and results of computed tomography (CT) scan and/or colonoscopy are used to assess its severity. However, decision-making about therapy remains a challenge. Patients and methods  This was a retrospective, single-center study between 2006 and 2015. Patients with severe IC who underwent endoscopic evaluation were included. The aims were to determine outcomes depending on endoscopic findings and assess the role of endoscopy in the management. Results  A total of 71 patients were included (men = 48 (68%), mean age = 71 ± 13 years). There was hemodynamic instability in 29 patients (41 %) and severity signs on CT scan in 18 (38 %). Twenty-nine patients (41 %) underwent surgery and 24 (34 %) died. The endoscopic grades were: 15 grade 1 (21 %), 32 grade 2 (45 %), and 24 grade 3 (34%). Regarding patients with grade 3 IC, 55 % had hemodynamic instability, 58 % had severity signs on CT scan, 68 % underwent surgery, and 55 % died. The decision to perform surgery was based on hemodynamic status in 62 % of cases, CT scan data in 14 %, endoscopic findings in 10 %, and other in 14 %. Colectomy was more frequent in patients with grade 3 IC ( P  < 0.05). A mismatch between mucosal aspect (necrosis) and serous (normal) was observed in 13 patients (46 %). Risk factors for colectomy in univariate analysis were aortic aneurysm surgery, hemodynamic instability, no colic enhancement on CT scan, and endoscopic grade 3. Risk factors for mortality in multivariate analysis were hemodynamic instability, colectomy, and Charlson score > 5 ( P  < 0.05). Conclusions  This study suggests a low impact of endoscopy on surgical decision making. Hemodynamic instability was the first indication for colectomy. A discrepancy between endoscopic mucosal (necrosis) and surgical serous (normal) aspects was frequently noted.

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.

Chronic obstructive pulmonary disease is associated with worse outcomes in ischemic colitis: a nationwide retrospective study

BACKGROUND

Ischemic colitis (IC) occurs when the blood supply of the large intestine becomes compromised. Several cardiovascular conditions, such as coronary artery disease, congestive heart failure, and atrial fibrillation, are well-established risk factors for the development of IC. The effects of pulmonary conditions, namely chronic obstructive pulmonary disease (COPD), on IC have not been well studied.

AIMS

Our aim was to elucidate if the presence of COPD worsened outcomes in patients with IC.

METHODS

Retrospective analysis of patients hospitalized with IC in 2016 was evaluated using the National Inpatient Sample database. Baseline demographic data, length of hospital stay (LOS), total hospital cost/charge, rates of colectomy, and in-hospital mortality were extracted from the database. Categorical variables were compared using the chi-square test and continuous variables were compared using the t-test.

RESULTS

A total of 25,035 patients with IC were identified while 4482 of these patients also had COPD. We found that IC patients with COPD had a longer LOS (5.8 days vs 4.4 days; P<0.01), higher total hospital charge ($56,682 vs $42,365; P<0.01), higher total hospital cost ($13,603 vs $10,238; P<0.01), higher mortality rate (6.5% vs 3.1%; P<0.01), and higher colectomy rate (5.1% vs 3.7%; P<0.01).

CONCLUSIONS

The presence of COPD portends poor outcomes in patients with IC. This was evidenced by increased risk of death and increased risk of undergoing colectomy. Given these findings, patients with COPD warrant closer observation. We advocate that COPD be considered as part of the risk assessment of patients with acute IC who need surgical intervention.

Colon ischemia: A comprehensive review

The clinical and endoscopic features of colon ischemia (CI) are non-specific. CI is correctly identified at the time of presentation in only 9% of patients is. The true incidence is likely underestimated because many mild cases resolve spontaneously without medical treatment. Furthermore, since most cases of CI are transient, and no specific cause is detected they are often considered to be "idiopathic". In the setting of severe CI correct diagnosis and prompt recognition and therapy as well as identification of underlying causes are crucial for a favourable outcome. Although less severe, mild cases may present with similar symptoms, the prognosis and management are completely different and managed conservatively rather than with surgery. Unfortunately, data from most studies and current guidelines do not provide recommendations on the long-term management of CI or about the need for endoscopic follow-up to detect the development chronic, recurrent and/or ischemic colonic strictures. In this review, we focus on the definition of CI, its aetiology, and patterns of presentation. We highlight the pharmacological and/or endoscopic management as determined severity of disease that allow for improved outcomes. Prompt recognition and treatment using a multidisciplinary approach are essential for successful management of severe CI because mortality rates are significantly higher when the diagnosis is delayed.

Drug-Induced Colitis

Drug-induced colitis encompasses a wide spectrum of colon disorders that can manifest microscopically or macroscopically. Patients present with new-onset colitis or exacerbations of inflammatory bowel diseases; in some cases, colitis resolves with discontinuation of medication. Mucosal injury can be focal or extensive, involving the entire colonic mucosa, and sometimes involves other parts of the gastrointestinal tract. It has been a challenge to determine the proportion of new-onset colitis caused by medication and there are few data on the overall prevalence. We review the drugs that have been linked with development of drug-induced colitis and strategies for physicians who believe their patients have this disorder-usually discontinuation of the drug believed to cause colitis and treatment with steroids or immune-modulating therapies. Physicians must be aware of medications that can cause colitis.

Ischemic bowel disease in 2021

Ischemic bowel disease (ISBODI) includes colon ischemia, acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Epidemiologically, colon ischemia is the most common type followed by AMI and CMI. There are various risk factors for the development of ISBODI. Abdominal pain is the common presenting symptom of each type. High clinical suspicion is essential in ordering appropriate tests. Imaging studies and colonoscopy with biopsy are the main diagnostic tests. Treatment varies from conservative measures to surgical resection and revascularization. Involvement of multidisciplinary team is essential in managing ISBODI. Although open surgery with revascularization plays an important role, recently there is an increasing interest in percutaneous endovascular treatment.

Colon Ischaemia Induced by Amoxicillin-related Anaphylactic Shock

Colon ischaemia is the most frequent type of ischaemia of the digestive tract. It is more common among the elderly, especially patients with haemodynamic disturbance. In young patients, it is associated with particular drugs such as oral contraceptives and ergotamine derivatives.

Anaphylaxis is characterized by acute onset and skin and mucosal involvement together with cardiovascular involvement. Gastrointestinal symptoms are common in anaphylaxis, but gastrointestinal bleeding and acute colon ischaemia are rarely described. Here, we present the case of a 52-year-old woman with acute ischaemic colitis associated with an anaphylactic reaction to amoxicillin.

Colonic Stricture Secondary to Recurrent Ischemic Colitis

Colonic ischemia is the most common form of gastrointestinal ischemia, which frequently affects the elderly population. The diagnosis and treatment can be challenging since it is prevalent in patients who are debilitated and have multiple comorbidities. However, most cases remain undetected until further complications emerge. Some of these patients will develop prolonged complications like chronic ischemic colitis or stricture requiring surgical intervention. Here we present a case of a colonic stricture secondary to recurrent ischemic colitis in an elderly female patient with multiple medical problems.

A Novel Multiparameter Scoring Model for Noninvasive Early Prediction of Ischemic Colitis: A Multicenter, Retrospective, and Real-World Study

INTRODUCTION

Ischemic colitis (IC) is a common gastrointestinal ischemic disease caused by hypoperfusion or reperfusion injury. However, there are few studies on risk factors associated with poor prognoses of the disease. This study aimed to determine the predictors of poor prognoses in patients with IC and establish a prognostic scoring method with good internal and external validity for identifying severe cases in an early stage.

METHODS

We established a prognosis model by conducting a multicenter, retrospective study of patients hospitalized with IC between November 2008 and May 2020. Predictive power was tested using 5-fold internal cross-validation and external validation.

RESULTS

The following 6 factors were included in the prognostic model: neutrophil count, D-dimer level, ischemia of the distal ileum, ischemia of the hepatic flexure, ulceration, and luminal stenosis. The area under the receiver-operating characteristic curve for internal cross-validation of the prediction model was 86%, and that for external validation was 95%. During internal validation, our model correctly identified 88.08% of the patients. It was further found that patients younger than 65 years with a higher neutrophil-to-lymphocyte ratio and higher heart rate had poor prognoses. Patients aged 65 years and older with ischemia of terminal ileum, hepatic flexure, splenic flexure, and intestinal stenosis had poor prognoses.

DISCUSSION

Patients with ischemia in the hepatic flexure and the distal ileum, endoscopic evidence of ulcer or stenosis, higher neutrophil counts, and higher D-dimer levels have worse prognoses. This information could aid in the selection of timely and appropriate treatment.

Large Bowel Ischemia/Infarction: How to Recognize It and Make Differential Diagnosis? A Review

Ischemic colitis represents the most frequent form of intestinal ischemia occurring when there is an acute impairment or chronic reduction in the colonic blood supply, resulting in mucosal ulceration, inflammation, hemorrhage and ischemic necrosis of variable severity. The clinical presentation is variable and nonspecific, so it is often misdiagnosed. The most common etiology is hypoperfusion, almost always associated with generalized atherosclerotic disease. The severity ranges from localized and transient ischemia to transmural necrosis of the bowel wall, becoming a surgical emergency, with significant associated morbidity and mortality. The diagnosis is based on clinical, laboratory suspicion and radiological, endoscopic and histopathological findings. Among the radiological tests, enhanced-CT is the diagnostic investigation of choice. It allows us to make the diagnosis in an appropriate clinical setting, and to define the entity of the ischemia. MR may be adopted in the follow-up in patients with iodine allergy or renal dysfunctions, or younger patients who should avoid radiological exposure. In the majority of cases, supportive therapy is the only required treatment. In this article we review the pathophysiology and the imaging findings of ischemic colitis.

Ischaemic colitis: practical challenges and evidence-based recommendations for management

Ischaemic colitis (IC) is a common condition with rising incidence, and in severe cases a high mortality rate. Its presentation, severity and disease behaviour can vary widely, and there exists significant heterogeneity in treatment strategies and resultant outcomes. In this article we explore practical challenges in the management of IC, and where available make evidence-based recommendations for its management based on a comprehensive review of available literature. An optimal approach to initial management requires early recognition of the diagnosis followed by prompt and appropriate investigation. Ideally, this should involve the input of both gastroenterology and surgery. CT with intravenous contrast is the imaging modality of choice. It can support clinical diagnosis, define the severity and distribution of ischaemia, and has prognostic value. In all but fulminant cases, this should be followed (within 48 hours) by lower gastrointestinal endoscopy to reach the distal-most extent of the disease, providing endoscopic (and histological) confirmation. The mainstay of medical management is conservative/supportive treatment, with bowel rest, fluid resuscitation and antibiotics. Specific laboratory, radiological and endoscopic features are recognised to correlate with more severe disease, higher rates of surgical intervention and ultimately worse outcomes. These factors should be carefully considered when deciding on the need for and timing of surgical intervention.

Leukocytes and creatinine may predict severity and guide management of ischemic colitis

BACKGROUND

Ischemic colitis (IC) is caused by a transient hypo-perfusion of the colon leading to mucosal ulcerations, inflammation, and hemorrhage. The primary aim was to identify predictive factors of endoscopic severity of IC. Secondary endpoints were to show epidemiology, clinical presentation, endoscopic findings, and outcomes of IC.

METHODS

In this single-center retrospective analysis, IC was scored according to endoscopy as: grade 1 (hyperemia, <1 cm erosions and non-confluent ulcers); grade 2 (>1 cm superficial, partially confluent ulcers); and grade 3 (deep or diffuse ulcers or necrosis). Then, IC was grouped into low- (grade 1) and high-grade (grades 2 and 3). Significant (P≤0.1) independent factor of severe IC at univariate analysis were entered into multivariate analysis and considered significant at P<0.05.

RESULTS

227 patients (male:female 60:167; mean age 72.7±16.2 years) were included. IC was scored as grade 1 in 137/227 (60.4%), grade 2 in 62/227 (27.3%), and grade 3 in 28/227 (12.3%) patients. At univariate analysis, age (74.9 vs. 71.3 years; P=0.09), diabetes (14.4% vs. 12.4%; P=0.09), and leukocytosis or creatinine elevation (74.4% vs. 60.6%; P=0.032) were associated with endoscopic high-grade IC. At multivariate analysis, leukocytosis and creatinine levels remained associated with high-grade IC (44.7% vs. 29.9%; odds ratio 1.92, 95% confidence interval 1.07-3.52; P=0.030).

CONCLUSIONS

Although confounding factors cannot be excluded due to study design and patients' characteristics, leukocytosis and/or creatinine elevation at hospital admission were significantly related with endoscopic high-grade IC and might be used to stratify patients for the need of endoscopy.

Ischemic Colitis after Colonoscopy with Bisacodyl Bowel Preparation: A Report of Two Cases

Background

Colonoscopy is widely used for the diagnosis and management of colorectal disease and requires adequate bowel preparation. Ischemic colitis is a form of intestinal ischemia that presents with abdominal pain, diarrhea, and hematochezia. Risk factors include advanced age, cardiovascular disease, and diabetes. Both colonoscopy and bisacodyl bowel preparation have been described as rare causes of ischemic colitis with less than 35 cases collectively in the literature. Our review found that of these cases, there exists significant heterogeneity within individual patient characteristics. The majority of the cases are managed conservatively without complications or sequela. Due to the risk of ischemic colitis, the FDA has withdrawn bisacodyl bowel preparations from use in the USA. Bisacodyl bowel preparations are still used in Canada.

Cases

Here, we present two cases of ischemic colitis in previously healthy women aged 57 and 69 who underwent screening colonoscopy using bisacodyl bowel preparation. Both were treated conservatively without complications.

Conclusion

Thus far, there has been one documented case of ischemic colitis following colonoscopy with bisacodyl bowel preparation; here, we present two additional cases with one case occurring without the presence of known risk factors for ischemic colitis. Our literature review finds that there is limited evidence surrounding bisacodyl as a causative agent of ischemic colitis. Cases often contain confounding variables such as the presence of known risk factors for ischemic colitis. Our report aims to highlight the need for a more comprehensive analysis evaluating the safety of bowel preparations as well as increasing the clinical awareness surrounding the rare risk of colonoscopy-induced ischemic colitis.

Quantifying risk factors for ischemic colitis: A nationwide, retrospective cohort study

BACKGROUND

Despite identifying numerous factors associated with colonic ischemia, the relative risk has been variable and not thoroughly evaluated. Hence, we aimed to quantify the risk of diseases and medications associated with ischemic colitis (IC).

METHODS

A population-based retrospective analysis in International Business Machines (IBM) Explorys (1999-2018), a pooled, de-identified database of 57 million patients in the USA, was performed. Odds ratios (OR) were calculated between IC and other diseases/medications. IC patients were also stratified by age to assess trends of IC in different age groups.

RESULTS

A total of 1560 patients had IC in the database. Hyperlipidemia had the highest association with IC (OR 15.3), consistent with prior reports of atherosclerosis being a major risk factor for IC. Hypertension, congestive heart failure, constipation, prior abdominal surgery, and atrial fibrillation all conferred odds greater than 10, which is consistent with prior reports. Novel findings of our study include that beta blockers (OR 9.6) and pro-inflammatory disease states such as vasculitis, rheumatoid arthritis, and malignancy all increase the risk of IC.

CONCLUSION

Early identification of IC is critical for minimizing morbidity and mortality. Epidemiologic information could be integrated with current clinical algorithms to more rapidly identify patients at risk.