High mortality of cocaine-related ischemic colitis: a hybrid cohort/case-control study

Rare Case of Endoscopically Diagnosed Ischemic Colitis Secondary to Chronic Phentermine Use

Phentermine is an amine anorectic that acts as a sympathomimetic agent and undergoes hepatic metabolism predominantly through CYP3A4. It is commonly used as a mediation to facilitate weight loss. Side effects of phentermine can include pulmonary hypertension, valvular heart disease, palpitations, increased heart rate or blood pressure, diarrhea, and cognitive impairment. Very rarely, phentermine usage has been associated with causing ischemic colitis. The mechanism of action for ischemic colitis from phentermine is not well defined but will be discussed in this review. We present a case of a woman who used phentermine daily for weight loss and was endoscopically confirmed to have ischemic colitis after presenting with abdominal pain and bloody diarrhea.

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.

Peritonitis on sigmoidal perforation in a cocaine user: A rare case report

INTRODUCTION AND IMPORTANCE

Cocaine, the second most abused drug in Morocco after cannabis, has been associated with multiple cardiac, pulmonary, neurological, and digestive complications. Colonic perforation following cocaine abuse is relatively lesser-known and requires attention as abuse rates are increasing, and existing evidence is scarce. Only a few cases have been reported in medical literature.

CASE PRESENTATION

We report the case of a 42-year-old male cocaine addict who presented with acute peritonitis. A laparotomy revealed a 3 cm perforation in the sigmoid, The absence of radiological, biological, and pathological evidence confirms the toxic origin of the perforation.

CLINICAL DISCUSSION

Cocaine-induced ischemic colitis is a rare occurrence in a surgeon's clinical experience. This condition is typically confirmed through colonoscopy and often resolves without the need for surgery, although a small number of cases may advance to peritonitis, necessitating surgical intervention.

CONCLUSION

Cocaine's adverse effects should be taken into account in the differential diagnosis of acute ischemic events in young adults. A general understanding of the significant complications associated with cocaine can aid in achieving early diagnosis and prompt treatment.

Cocaine Gut: A Rare Case of Cocaine-Induced Esophageal, Gastric, and Small Bowel Necrosis

Cocaine is an indirect-acting sympathomimetic drug that inhibits norepinephrine and dopamine reuptake in the adrenergic presynaptic cleft. Cocaine use has been associated with strokes, angina, arrhythmias, and agitation. Data on gastrointestinal complications such as mesenteric ischemia, bowel necrosis, ulceration, and perforation are scarce. Here, we present a rare case of cocaine-induced esophageal, gastric, and small bowel necrosis that contributes to the limited literature on this subject. Diagnosis of cocaine-induced gastrointestinal complications involves a combination of imaging studies, laboratory assessments, and histopathological examinations. Timely surgical resection, supported by intravenous fluids, antibiotics, and pain management, is the mainstay of treatment. The prognosis varies but is significantly influenced by the promptness and effectiveness of the intervention, underscoring the importance of vigilant clinical care in such cases.

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.

Does the Route of Cocaine Use Affect the Mortality and Outcomes of Cocaine-Induced Intestinal Ischemia? A Systematic Review

Intestinal ischemia results from diminished perfusion of the colon resulting in tissue hypoxia. Anecdotal reports suggest that cocaine-induced intestinal ischemia has the highest mortality and longer length of stay among the vasoconstrictors. The present study aimed to summarize the available studies in the literature to assess the effect of routes of consumption on the outcomes of cocaine-induced intestinal ischemia. We conducted a systematic search of MEDLINE from inception through October 2019. Studies of cocaine-induced intestinal ischemia were included if data were available on comorbidities, mortality, and hospital length of stay (LOS). The study's primary outcomes were mortality and need for surgery, while secondary outcomes included the hospital length of stay, LACE index, and hospital score. Statistical tests used included linear and binary logistic regression. STATA 2015 was used, and P < 0.05 was statistically significant. Of the 304 studies, 8 case series and 45 case reports (n = 69 patients) met the inclusion criteria. Different routes of cocaine use had similar mortality odds and the need for surgery for intestinal ischemia. Hospital LOS showed significant difference among the subgroups. Readmission scores (LACE and hospital score) were higher for intravenous and smoking than ingestion and intranasal use (P < 0.05). In conclusion, different routes of cocaine use appear to have similar mortality odds for intestinal ischemia, which vary significantly among the different routes of cocaine consumption for the length of stay and readmission scores. Prompt recognition of the route of cocaine use is vital to improve the outcome. Large-scale and well-designed observational studies are needed to investigate this topic further.

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.

Unusual segmental ischemia of the small bowel from cocaine abuse

Cocaine abuse is rising in the young population, triggering uncommon and potentially life-threatening causes of acute abdomen in this age group. The authors present the case of a 30-year-old man with emergency admission due to abdominal pain, with no history of drug abuse. Several signs and symptoms elicited toxicologic blood screening, which disclosed high serum levels of cocaine and its metabolites. Twelve hours after admission, the onset of acute abdomen with signs of diffuse peritonitis prompted surgical exploration through a minimally invasive approach. Two segmental small bowel ischemic loops and diffuse peritonitis, but no bowel perforation, were identified and treated by laparoscopic peritoneal lavage with 5 l of heated saline and intravenous administration of sodium heparin, 10 000 IU. Postoperative course was uneventful with home discharge on postoperative day 5. High index of suspicion is required to establish a prompt diagnosis and treatment of this uncommon cocaine abuse-related disease.

Cocaine-induced mesenteric ischaemia requiring small bowel resection

Cocaine use causes profound vasoconstriction leading to various systemic complications. Gastrointestinal complications such as mesenteric ischaemia are difficult to recognise and may result in serious consequences if not treated promptly. We report on the case of a 47-year-old man presenting with mesenteric ischaemia on a background of acute on chronic cocaine consumption, where diagnosis was not evident until second presentation. He underwent an emergency laparotomy with small bowel resection and jejunostomy formation and made a good recovery with eventual reversal surgery. The literature on cocaine-induced bowel ischaemia shows significant variability in presentation and outcome. Laboratory investigations are non-specific, and early recognition is vital. Given the increasing recreational use of cocaine in the UK, it is imperative to have a high clinical index of suspicion for mesenteric ischaemia in patients presenting with non-specific abdominal pain, and to ensure a detailed social history covering recreational drug use is not forgotten.

Young-Onset Ischemic Colitis: A Condition of Elusive Etiology Frequently Associated With Immune Dysregulation

Ischemic colitis (IC) associates with older age, hypertension, and heart disease, among others. Young-onset IC is rare. We aimed to delineate clinical characteristics of young patients (<40 years) with IC. Cases from 1984 to 2017 were re-reviewed. Of the 60 cases available, 52% (n = 31) had histologic features of IC. Fifty-five percent were female with a mean age of 32 (range = 14-40) years. Fifty-eight percent (n = 18) were resections. The most common presentations were diarrhea and abdominal pain. Three teenagers had IC associated with prior surgery, volvulus, and constipation. In the 21- to 40-year group, 43% (n = 12) lacked clinical associations. A second subset (n = 6, 21%) had histories of immune dysregulation (lupus, dermatomyositis, vasculitis) and poorly controlled HIV/AIDS (n = 5, 18%). Smoking and cocaine were endorsed by 1 and 2 patients, respectively. One patient had premature atherosclerosis while another had HMG Co-A lyase deficiency. Vasculitis was identified in 22% of the resections and in none of the biopsies. Nineteen percent of patients died (n = 6) from complications of IC, all treated surgically, including 1 patient previously misdiagnosed as ulcerative colitis; 2 patients died of unrelated causes. While rare before 20 years of age, IC in teenagers relates to mechanical issues and is rare in children. Associations in young adults include immune dysregulation, cocaine and cigarette use, and premature atherosclerosis. Our retrospective cohort had a surgical mortality rate within the range reported by others, highlighting the importance of accurate diagnosis in young individuals.

Review article: the pharmacological causes of colon ischaemia

BACKGROUND

Colon ischaemia is the most common ischaemic disorder of the gastrointestinal system, can affect any segment of the colon, and may present with a range of symptoms. Diagnosis can be challenging due to symptom overlap with other conditions, varied aetiology, and often rapid and self-resolving course.

AIM

To review comprehensively the literature regarding the pharmacological aetiologies of colonic ischaemia to enhance the understanding of the various mechanisms of disease, presentations, distribution, and outcomes.

METHODS

A PubMed search for "colon ischaemia" and "ischaemic colitis" alone as well as in combination with various known pharmacologic causes was performed. Only the highest quality and relevant literature was included in this review. The quality of the literature for each association was rated by the authors and a consensus was made when discrepancies were encountered. Only associations that were deemed "moderate" or "strong" were included.

RESULTS

The literature considering pharmacologically associated colonic ischaemia is diverse, lacks codification and is characterised by numerous case reports and case series. Constipation-inducing drugs, digoxin, hormonal therapies, illicit drugs, immunomodulators, laxatives, and NSAIDs were strongly associated with colonic ischaemia. Antimicrobials, appetite suppressants, chemotherapies, decongestants, diuretics, ergot alkaloids, serotonin agents, statins, and vasopressor agents were moderately associated.

CONCLUSIONS

Patients presenting with abdominal pain, diarrhoea, or bloody stool need to be evaluated for the possibility of this condition and treated accordingly. Timely diagnosis is necessary to improve patient outcomes. This review aims to increase awareness among clinicians regarding the presentation of pharmacologically induced colonic ischaemia.

Case report: Pentoxifylline treatment in microscopic colitis

RATIONALE

Microscopic colitis is a common cause of diarrhea. Pentoxifylline, a xanthine derivative with anti-tumor necrosis factor-alpha properties, is prescribed for intermittent claudication and other disorders. Our goal was to evaluate the outcomes of patients with microscopic colitis treated with pentoxifylline.

PATIENT CONCERNS

Nine patients with microscopic colitis (8 collagenous colitis and 1 lymphocytic colitis) seen at Mayo Clinic, Rochester, between January 1, 1997 and November 30, 2016, were included. The median age was 56.9 years (range 51.6-60.2), 8 were female (89%), and the median disease duration was 64.8 months (range 60-109). The indications for treatment were budesonide refractoriness in 7 patients, budesonide dependence in 1 patient, and budesonide intolerance in 1 patient.

DIAGNOSES

A histological diagnosis of microscopic colitis was confirmed in all patients.

INTERVENTIONS

Pentoxifylline 400 mg three times a day was used for a median of 3 months (range 2.5-8.3).

OUTCOMES

Complete response occurred in 1 patient (11%) and partial response in 3 patients (33%). The patient who achieved complete response was treated with pentoxifylline due to budesonide intolerance, and completed 43 months of successful maintenance therapy. There were no adverse effects reported.

LESSONS

The majority of budesonide-experienced patients with active microscopic colitis did not respond to pentoxifylline. However, it was well-tolerated, with 1 patient achieving long-term remission and one-third of the cohort having a partial response. Larger controlled studies are required to evaluate the efficacy of pentoxifylline and predictors of response in microscopic colitis. In particular, patients who are not budesonide-refractory may be more likely to respond.

Advents in the Diagnosis and Management of Ischemic Colitis

BACKGROUND

Ischemic colitis (IC) is a common type of ischemic insult, resulting from decreased arterial blood flow to the colon. This disease can be caused from either atherosclerotic occlusive vascular disease or non-occlusive disease. The aim of this study is to present the diagnostic methodology and management of this severe disease based on current literature.

METHODS

A literature search has been done including articles referring to modern diagnosis and management of IC.

RESULTS

IC is usually a transient disease, but it can also cause gangrene of the colon, requiring emergency surgical exploration. Diagnosis is troublesome and is based on imaging examinations, mainly computerized tomography, which in association with colonoscopy can delineate the distribution pattern and severity of disease.

CONCLUSION

The majority of patients with mild disease have usually complete clinical recovery within a short period. The severe forms of the disease carry high morbidity and mortality rates and prompt surgical intervention is the only way to improve the associated severe prognosis.

Colon Ischemia: An Update for Clinicians

Colon ischemia (CI) is an underrecognized entity associated with high morbidity and mortality. Establishing the diagnosis and initiating appropriate and timely treatment is critical for improving outcomes. Colon ischemia is a disease spectrum that requires a full understanding for recognition and treatment. This review outlines the full spectrum of CI management from initial presentation to medical and surgical treatment.

Sonographic and Endoscopic Findings in Cocaine-Induced Ischemic Colitis

Cocaine-induced ischemic colitis is a recognized entity. The diagnosis is based on clinical and endoscopic findings. However, diagnostic imaging is helpful in the evaluation of abdominal symptoms and prior studies have suggested specific sonographic findings in ischemic colitis. We report sonographic and endoscopic images along with abdominal computed tomography in a case of cocaine-induced ischemic colitis.

Ischemic colitis

Most clinicians associate ischemic colitis with elderly patients who have underlying cardiovascular comorbidities. While the majority of cases probably occur in this population, the disease can present in younger patients as a result of different risk factors, making the diagnosis challenging. While a majority of patients respond to medical management, surgery is required in approximately 20% of the cases and is associated with high morbidity and mortality.

Ischemic colitis: A forgotten entity. Results of a retrospective study in 118 patients

OBJECTIVE

The aim of our study was to document our 6-year experiences in identifying the clinical characteristics, laboratory findings, risk factors and the outcomes of patients with ischemic colitis (IC) in a community hospital setting.

METHODS

The medical records of patients who were diagnosed with IC from 2007 to 2013 in two community hospitals were retrospectively reviewed. Their clinical characteristics, laboratory results, radiological, endoscopic and histological evidence, anatomic location of the lesion, comorbidities, concomitant use of drugs, and so on, were collected.

RESULTS

A total of 118 patients with IC was identified, most were elderly individuals with a female predominance. The most common symptoms were abdominal pain, rectal bleeding and diarrhea. Hypertension, hyperlipidemia, coronary artery disease and diabetes mellitus were the most common comorbidities. Erythema, edema and erosions/ulcerations were the most common endoscopic findings. Left colon was the most affected location of lesion (84.8%), and there was one case of pancolitis. The descending colon was the most common affected segment, while rectum was the least affected segment. Severe IC occurred in 12.7% of the patients. Death within 30 days from the diagnosis of the disease occurred in 4.2%.

CONCLUSIONS

IC is majorly occurred in elderly with a female predominance. Cardiovascular disease and its associated risk factors are the most common comorbidities. Left colon is the most affected location of the disease and the overall mortality rate was 4.2%. Physicians should make every effort to identify these patients, especially those with high risks.

Oxygen in the regulation of intestinal epithelial transport

The transport of fluid, nutrients and electrolytes to and from the intestinal lumen is a primary function of epithelial cells. Normally, the intestine absorbs approximately 9 l of fluid and 1 kg of nutrients daily, driven by epithelial transport processes that consume large amounts of cellular energy and O2. The epithelium exists at the interface of the richly vascularised mucosa, and the anoxic luminal environment and this steep O2 gradient play a key role in determining the expression pattern of proteins involved in fluid, nutrient and electrolyte transport. However, the dynamic nature of the splanchnic circulation necessitates that the epithelium can evoke co-ordinated responses to fluctuations in O2 availability, which occur either as a part of the normal digestive process or as a consequence of several pathophysiological conditions. While it is known that hypoxia-responsive signals, such as reactive oxygen species, AMP-activated kinase, hypoxia-inducible factors, and prolyl hydroxylases are all important in regulating epithelial responses to altered O2 supply, our understanding of the molecular mechanisms involved is still limited. Here, we aim to review the current literature regarding the role that O2 plays in regulating intestinal transport processes and to highlight areas of research that still need to be addressed.

Is CT Angiogram of the Abdominal Vessels Needed following the Diagnosis of Ischemic Colitis? A Multicenter Community Study

Background. CT angiogram is frequently obtained after diagnosis of ischemic colitis (IC). Aims. To investigate the vascular findings of CT angiogram as compared to contrast-enhanced CT scan and whether this modality changes the management or prognosis of IC. Methods. We conducted a retrospective analysis of patients with IC from 2007 to 2013. Results. CT angiogram was performed in 34 patients (28.81%), whereas contrast-enhanced CT scan was performed in 54 patients (45.76%). In CT angiogram group, 8 patients (23.5%) had atherosclerotic changes. Stenosis was found in 12 patients (35.3%) (9: celiac trunk, 3: SMA). Among this group, one patient underwent colectomy and another underwent angioplasty of the celiac trunk who died within 30 days. Among contrast-enhanced CT scan group, 5 patients (9.3%) had atherosclerotic changes. Stenosis was found in 5 patients (9.3%) (3: celiac trunk, 1: SMA, and 1: IMA). Among this group, 3 patients had colectomy and one died within 30 days. There was no statistical difference between both groups in all vascular findings except the stenosis which was higher in CT angiogram group (P = 0.0025). Neither the need for surgery nor all-cause mortality was different between both groups. Conclusion. CT angiogram did not provide any useful findings that altered the management or the prognosis of IC.

Retrospective analysis of disease association and outcome in histologically confirmed ischemic colitis

OBJECTIVE

To identify risk factors, clinical features and complications in patients with ischemic colitis (IC).

METHODS

All patients diagnosed with biopsy proven IC within a 2-year period were identified; clinical data were retrospectively collected and subsequently analyzed.

RESULTS

In total, 72 IC patients with a mean age of 68 years were included in this study. Among them, 18 (25.0%) were younger than 65 years with a female predominance. One-third of the patients was found to be without vascular risk factors, and 8 patients met the criteria for irritable bowel syndrome. No history of oral contraceptives or hormonal replacement therapy use could be found among the women diagnosed with IC. Over a mean duration of follow-up of 9.5 months (range 0-65 months), the rate of recurrent disease was 16.7%, while only 2 (2.8%) patients developed extra intestinal vascular sequelae. Statistical analysis identified a history of atrial fibrillation and the use of furosemide to be the only significant predictors of a poor outcome, while coronary artery disease and chronic renal failure predicted recurrence and low platelet count predicted stricture formation.

CONCLUSIONS

Although most patients with IC are elderly and have conventional vascular risk factors, it should also be considered in young patients without vascular risk factors, especially in women, who may have an atypical distribution of the disease. Severe complications and extraintestinal vascular sequelae are rare, however, residual gastrointestinal complaints and recurrent disease are relatively common and there are no reliable predictors of the outcome.