Prevalence of electrocardiographic and echocardiographic abnormalities in ambulatory ischemic colitis

Risk factors associated with the development of ischemic colitis

AIM

To ascertain the role of cardiovascular risk factors, cardiovascular diseases, standard treatments and other diseases in the development of ischemic colitis (IC).

METHODS

A retrospective, case-control study was designed, using matched data and covering 161 incident cases of IC who required admission to our hospital from 1998 through 2003. IC was diagnosed on the basis of endoscopic findings and diagnostic or compatible histology. Controls were randomly chosen from a cohort of patients who were admitted in the same period and required a colonoscopy, excluding those with diagnosis of colitis. Cases were matched with controls (ratio 1:2), by age and sex. A conditional logistic regression was performed.

RESULTS

A total of 483 patients (161 cases, 322 controls) were included; mean age 75.67 ± 10.03 years, 55.9% women. The principal indications for colonoscopy in the control group were lower gastrointestinal hemorrhage (35.4%), anemia (33.9%), abdominal pain (19.9%) and diarrhea (9.6%). The endoscopic findings in this group were hemorrhoids (25.5%), diverticular disease (30.4%), polyps (19.9%) and colorectal cancer (10.2%). The following variables were associated with IC in the univariate analysis: arterial hypertension (P = 0.033); dyslipidemia (P < 0.001); diabetes mellitus (P = 0.025); peripheral arterial disease (P = 0.004); heart failure (P = 0.026); treatment with hypotensive drugs (P = 0.023); angiotensin-converting enzyme inhibitors; (P = 0.018); calcium channel antagonists (P = 0.028); and acetylsalicylic acid (ASA) (P < 0.001). Finally, the following variables were independently associated with the development of IC: diabetes mellitus [odds ratio (OR) 1.76, 95% confidence interval (CI): 1.001-3.077, P = 0.046]; dyslipidemia (OR 2.12, 95% CI: 1.26-3.57, P = 0.004); heart failure (OR 3.17, 95% CI: 1.31-7.68, P = 0.01); peripheral arterial disease (OR 4.1, 95% CI: 1.32-12.72, P = 0.015); treatment with digoxin (digitalis) (OR 0.27, 95% CI: 0.084-0.857, P = 0.026); and ASA (OR 1.97, 95% CI: 1.16-3.36, P = 0.012).

CONCLUSION

The development of an episode of IC was independently associated with diabetes, dyslipidemia, presence of heart failure, peripheral arterial disease and treatment with digoxin or ASA.

Ischemic colitis after mesotherapy combined with anti-obesity medications

Mesotherapy and anti-obesity medications are gradually gaining worldwide popularity for purposes of body contouring and weight loss. Their adverse effects are various, but there is a tendency to disregard them. Ischemic colitis is one of the most common diseases associated with non-obstructive blood vessel disorders. However, there have been no case reports about the adverse effects resulting from mesotherapy only or in combination with anti-obesity medications. We report on an interesting case of ischemic colitis after mesotherapy combined with anti-obesity medications in a 39-year-old female who had no risk factors.

Rebamipide enema therapy for left-sided ischemic colitis patients accompanied by ulcers: Open label study

AIM: To attempt rectal administration of rebamipide in the treatment of ischemic colitis patients with ulcers, and evaluate its effects.

METHODS: We compared 9 ischemic colitis patients (2 men, 7 women) with ulcers treated by bowel rest only from 2000 to 2005 (conventional therapy group), with 6 patients (2 men, 4 women) treated by rebamipide enema therapy in 2006 (rebamipide enema therapy group) and analyzed the mean duration of fasting and hospitalization, degree of ulcer healing, and decrease in WBC count for the two groups.

RESULTS: The mean duration of fasting and hospitalization were 2.7 ± 1.8 d and 9.2 ± 1.5 d in the rebamipide group and 7.9 ± 4.1 d and 17.9 ± 6.8 d in the control group, respectively, and significantly reduced in the rebamipide group (t = -2.915; P = 0.0121 and t = -3.054; P = 0.0092). As for the degree of ulcer healing at 7 d after admission, the ulcer score was reduced by 3.5 ± 0.5 (points) in the rebamipide group and 2.8 ± 0.5 (points) in the control group (t = 1.975; P = 0.0797), while the decrease in WBC count was 120.0 ± 55.8 (× 10²/&mgr;L) in the rebamipide group and 85.9 ± 56.8 (× 10²/&mgr;L) in the control group (t = 1.006; P = 0.3360).

CONCLUSION: In left-sided ischemic colitis patients with ulcers, rebamipide enema therapy significantly reduced the duration of fasting and hospitalization, recommending its use as a new and effective therapeutic alternative.

Assessment of potential risk factors associated with ischaemic colitis

Ischaemic colitis (IC) has been associated with a number of diverse disorders and risk factors, including irritable bowel syndrome (IBS) and constipation. We sought to assess, through a large-scale population study, the potential risk factors associated with IC. Patients with IC and matched controls without IC were identified using the medical and pharmacy claims data from the HealthCore Managed Care Database from 1st January 2000 to 31st May 2005. A multivariate conditional logistic regression model was developed to identify significant risk factors of IC. Interactions of age, sex, prior IBS diagnosis, and prior constipation diagnosis were further evaluated. We identified 1754 patients with IC and 6970 non-IC controls; 64% were women, and mean ages were 63 and 62 years respectively. The final parsimonious model comprised 19 independent variables associated with increased risk for IC including shock, dysentery, bloating, IBS, colon carcinoma, constipation, cardiovascular disease, dyspepsia, abdominal, aortic, or cardiovascular surgery, 12-month laxative, H(2) receptor blocker and oral contraceptive use. A significant interaction was observed between age and prior IBS on risk for IC. In conclusion, multiple risk factors for IC were identified and we confirmed that patients with IBS or constipation are at greater risk for IC.

Kardiovaskuläre Begleiterkrankungen und Komplikationen bei Darmerkrankungen

Vascular diseases are not encountered very often in gastroenterology, though in cases of ischemic colitis a coronary heart disease is often present. In addition, heart diseases such as coronary heart disease, atrial fibrillation, and congestive heart failure are important risk factors for ischemic colitis and should be treated to avoid further ischemic episodes of the gut. The most common extraintestinal manifestations of Crohn's disease and ulcerative colitis are observed in the eye, on the skin, and in the liver region. Involvement of the cardiovascular system does not seem to be very common, though systematic epidemiological data on the significance of these extraintestinal complications--which certainly influence the prognosis--are lacking. Other patients with Crohn's disease or ulcerative colitis suffer from vasculitis, which reflects a further manifestation of inflammatory diseases affecting the cardiovascular system. Another important complication is activation of coagulationfactors, especially during active flare-up of intestinal disease; this can result in thromboembolic events. Systematic studies or investigations on the epidemiology of cardiovascular complications are still lacking, so that an overview of the published data is given. Metastatic tumors of the heart are rare, but there are case reports of cardiac metastases in patients with carcinomas of the colon. Carcinoid heart syndrome, another cardial complication of malignant disease, can prejudice the prognosis of patients with neuroendocrine tumors of the gastrointestinal tract.

Clinical investigation of 41 patients with ischemic colitis accompanied by ulcer

AIM: To investigate the relationship among the presence of ulcer lesions, underlying disease, and clinical course in patients with ischemic colitis.

METHODS: The subjects were 41 patients (10 male and 31 female; mean age 70 years) with ischemic colitis who were admitted to and received treatment in our hospital from 2000 to 2006. We compared their characteristics and analyzed the mean lengths of admission and fasting for 9 patients with ulcer lesions (ulcer group) and 32 without (non-ulcer group).

RESULTS: The groups with presence and absence of ulcer differed significantly only in white blood cell (WBC) count. Lengths of fasting and admission were 7.9 d and 17.9 d for the ulcer group and 4.4 d and 10.7 d for the non-ulcer group, respectively, and significantly longer in the ulcer group (P = 0.0057 and 0.0001). There was no correlation between presence of ulcer and presence of underlying diseases.

CONCLUSION: Lengths of fasting and admission were significantly longer in patients with ischemic colitis with ulcer than for those without ulcer.

Systematic review: the epidemiology of ischaemic colitis

BACKGROUND

Ischaemic colitis has been associated with co-morbid conditions, medications, vascular surgery and advanced age in case reports and case series. Few data exist on the baseline incidence in the general population or on the increased risk imposed by these risk factors.

AIM

To systematically review the literature regarding the incidence, prevalence and risk factors for ischaemic colitis.

METHODS

Searches of bibliographic databases were performed independently by two investigators. Studies were included if they used population-based samples, disease-specific population samples or case-control population-based samples of adults with ischaemic colitis, and reported the incidence, prevalence or risk factors for ischaemic colitis. Eligible articles were reviewed and data were abstracted in a duplicate, independent manner.

RESULTS

Four studies were identified that reported the general population incidence and four that reported the disease-specific population incidence. The incidence of ischaemic colitis in general populations ranged from 4.5 to 44 cases per 100 000 person-years. The risk was increased two- to four-fold by either prevalent irritable bowel syndrome or chronic obstructive pulmonary disease. The risk was also increased in females and in subjects of 65 years and older.

CONCLUSIONS

Ischaemic colitis is uncommon in the general population. The effect sizes of the most commonly reported risk factors have not been adequately quantified in population-based studies.

Cardiac sources of embolism should be routinely screened in ischemic colitis

OBJECTIVE

Potential cardiac sources of embolism may promote ischemic colitis. The aim of this study was to evaluate their role in segmental, nongangrenous ischemic colitis and to determine the usefulness of routine cardiac evaluation in patients with this disease.

METHODS

Sixty case and 60 control patients matched for age and gender were included and questioned regarding treatment and prior cardiovascular history or risk factors. Potential cardiac sources of embolism, classified as "proven" or " still debated," were screened using an electrocardiogram, rhythmic Holter monitoring over 24 h, and transthoracic echocardiography.

RESULTS

Sex ratio (male:female) was 1:2, and mean age was 70 +/- 14 yr. Case and control patients had similar drug use, prior cardiovascular history, and risk factors. A potential cardiac source of embolism was found in 26/60 case (43%), compared with 14/60 control patients (23%) (p = 0.02; OR = 2.5, 95% CI = 1.2-5.5). Excluding the "still debated," 21/60 case (35%), compared with 8/60 control patients (13%), had a "proven" cardiac source of embolism (p < 0.01; OR = 3.5, 95% CI = 1.4-8.4). Electrocardiogram alone misdiagnosed 72% of the "proven" cardiac sources of embolism, whereas the combination electrocardiogram plus Holter monitoring detected 71%, and electrocardiogram plus echocardiography 62%. Twelve of 21 case patients with at least one proven cardiac source of embolism, were previously unknown. Anticoagulant therapy was required in 32% of case patients and antiarrhythmic therapy in 25% of cases.

CONCLUSIONS

Potential cardiac sources of embolism were more common in patients with segmental, nongangrenous ischemic colitis than in control patients. Therefore, these patients should undergo a routine electrocardiogram, rhythmic Holter monitoring, and transthoracic echocardiography. Anticoagulant therapy should also be considered for this patient population.

Non-occlusive mesenteric ischaemia: a common disorder in gastroenterology and intensive care

Non-occlusive mesenteric ischaemia is characterized by gastrointestinal ischaemia with normal vessels. In gastroenterology it is recognized as rare disease occasionally causing acute bowel infarction or ischaemic colitis. From intensive care literature this disorder is recognized as an early phenomenon during circulatory stress. This early mucosal ischaemia then leads to increased permeability, bacterial translocation, and further mucosal hypoperfusion. The damage is produced mainly during reperfusion following ischaemia with fresh inflow of oxygen and outflow of waste products into the systemic circulation. The mechanisms underlying non-occlusive mesenteric ischaemia include macrovascular vasoconstriction, hypoperfusion of the tips of the villi and shunting. It is very common in critically ill and perioperative patients, but also occurs in pancreatitis, renal failure and sepsis. Treatment options include aggressive fluid resuscitation and careful choice of vasoactive drugs. Control of reperfusion damage and new endothelin-antagonists are potentially useful new treatment options.

Role of acquired and hereditary thrombotic risk factors in colon ischemia of ambulatory patients

BACKGROUND & AIMS

Hypercoagulable states may play an important role in the pathogenesis of colon ischemia. Aim of this study was to assess this hypothesis investigating the role of acquired and hereditary thrombotic risk factors in patients with definite diagnosis of colon ischemia.

METHODS

We compared the frequency of antiphospholipid antibodies, protein C, protein S, and antithrombin deficiencies, factor V Leiden, prothrombin gene mutation G20210GA, and methylenetetrahydrofolate reductase C677T in 36 patients (23 men, 13 women; mean age, 64.8 years) with colon ischemia, 18 patients with diverticulitis, and 52 healthy controls.

RESULTS

The prevalence of antiphospholipid antibodies was significantly higher in patients with colon ischemia compared with inflammatory and healthy controls (19.4% vs. 0% and 1.9%). Among genetic factors, only factor V Leiden was significantly associated with colon ischemia (22.2% vs. 0% and 3.8%). A combination of thrombophilic disorders was found in 25% of the cases. Overall, one or several prothrombotic abnormalities were present in 26 patients (72%).

CONCLUSIONS

A comprehensive thrombophilic screening in colon ischemia reveals a congenital or acquired thrombophilic state in 72% of patients. Hereditary and acquired thrombotic risk factors may play an important role in the disease pathogenesis.