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

Isolated Cecal Necrosis Mimicking a Colonic Mass

Isolated cecal necrosis (ICN) is a rare form of ischemic colitis that can mimic conditions such as appendicitis, malignancy, or diverticulitis. Most cases of ICN have been identified in patients with significant comorbidities that increase risk of vascular disease. We present a case of ICN mimicking a mass lesion in an elderly patient with few comorbid conditions. Although computed tomography was concerning for colonic mass, diagnostic colonoscopy revealed ischemic colon. The patient underwent right hemicolectomy, and pathology confirmed ICN. It is important to recognize conditions ICN can mimic, understand ICN can present without acute abdomen, and consider ICN in the differential diagnosis even in relatively healthy patients without a history of vascular disease.

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.

Clinical features and risk factors for ischemic colitis in young and middle-aged patients

Background and study aims: Ischemic colitis (IC) is thought to occur more frequently in the elderly, but the incidence in young and middle-aged adults is increasing. This study determined the clinical characteristics of and risk factors for young and middle- aged IC patients. Patients and methods: The medical records of 190 IC patients from 2010-2020 were reviewed. The clinical features of the young and middle-aged IC group (group A, < 60 years [n=70]) were compared to the elderly IC (group B, ≥60 years [n=120]) and age- and gender-matched colon polyp groups (group C, <60 years [n=272]). Independent risk factors for IC in group A were assessed using multivariate logistic regression analysis. Results: There were no significant differences in groups A and B with respect to season of onset, symptoms, signs, treatment, or recurrences. The main symptoms of group A were abdominal pain (98.6%) and hematochezia (98.6%). Lesions commonly involved the left half of the colon (87.1%) and the clinical conditions were generally not severe. The percentage of patients with constipation (11.4% vs. 4.0%, P=0.034) and using a calcium channel antagonist (21.4% vs. 11.4%, P=0.028) was significantly higher in group A than group C. Regression analysis demonstrated that constipation (OR 2.831, P=0.037) and taking a calcium channel antagonist (OR 2.486, P=0.012) were closely associated with the occurrence of IC in group A. Conclusions: Constipation and taking a calcium channel antagonist were independent risk factors for the onset of IC in young and middle-aged adults. Among young and middle-aged adults with abdominal pain and bloody stools who also have constipation or are taking a calcium channel antagonist to treat hypertension, the diagnosis of IC should be considered.

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.

Ischemic colitis. Does right colon location mean worst prognosis?

INTRODUCTION

Most patients with ischemic colitis have a favourable evolution; nevertheless, the location in the right colon has been associated with a worse prognosis. The purpose of this study is to compare the clinical presentation and results of right colon ischemic colitis (CICD) with ischemic colitis of other colonic segments (non-CIDC).

METHODS

Retrospective, observational study of patients admitted to our hospital with ischemic colitis between 1993 and 2014, identified through a computerized search of ICD9 codes. They were divided into 2 groups: CICD and non-CICD. Comorbidities, clinical presentation, need for surgery, and mortality were compared. Multivariate analysis was performed using logistic regression adjusting for age and sex. Statistical significance was established at a value of P < 0.05.

RESULTS

A total of 204 patients were identified, 61 (30%) with CICD; 61% of CICD patients required surgery compared to 22% of non-CICD patients (P < 0.001). Differences in post-surgical mortality (32% vs 55%) and overall mortality (20% vs 15%) were not statistically significant. CICD patients had more commonly unfavourable outcomes than non-CICD patients (61% vs 25%, P < 0.001). The odds ratio (OR) for surgery was 5.28 and 4.47 for unfavourable outcomes for patients with CICD.

CONCLUSIONS

CICD patients have a worse prognosis than non-CICD patients, 5 times more likely to need surgery and 4 times more likely to have unfavourable outcomes.

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.

A postresection perfusion deficit in the right colon is an independent predictor of perioperative outcome after major hepatectomy

BACKGROUND

There is a strong interaction between hepatic hemodynamics and perfusion in the splanchnic system. However, little is known about differences in perfusion in different splanchnic compartments and their changes after hepatectomy.

METHODS

Perfusion in various splanchnic compartments (ie, stomach, small intestine, right and left colon, liver) was assessed pre- and post-hepatectomy by intraoperative laser Doppler flowmetry. Differences of splanchnic perfusion between compartments were evaluated by ANOVA, and risk factors of postoperative complications (graded by the comprehensive complication index [CCI]) were analyzed by univariate and multivariate analyses. A prediction model of postoperative complications was developed.

RESULTS

A total of 50 and 29 patients with major and minor hepatectomy were enrolled. Splanchnic perfusion at baseline varied significantly across different splanchnic compartments with highest values in the small bowel and right colon (P < .001). Major hepatectomy induced a significant perfusion decrease in the stomach (P = .006), right colon (P < .001) and small bowel (P = .035). A postresection perfusion deficit in the right colon with values below 254 perfusion units (PU) was identified as an independent predictor of clinically relevant complications after major hepatectomy (concordance index: 0.79, 95% CI 0.66-0.87, P = .002). Bootstrap validation confirmed internal validity and excellent calibration.

CONCLUSIONS

Major hepatectomy causes significant reduction of splanchnic perfusion. An intraoperative posthepatectomy microcirculatory perfusion deficit of the right colon is a strong and independent predictor of clinically relevant postoperative complications after major hepatectomy.

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.

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.

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.

Bowel dysfunction after elective spinal surgery: etiology, diagnostics and management based on the medical literature and experience in a university hospital

BACKGROUND

Bowel dysfunction after spinal surgery is often underestimated and if not treated in a timely manner can lead to undesirable surgical interventions or fatal complications. The current medical literature primarily focuses on bowel dysfunction as a result of spinal injury.

OBJECTIVE

The purpose of this review is to explore this topic in evaluating current evidence regarding the causes of acute bowel dysfunction after elective spinal surgery, primarily the thoracolumbar spine. Since available evidence for recommendations of treatment is scarce, an interdisciplinary management approach for treatment of bowel dysfunction following spinal surgery is also formulated.

MATERIAL AND METHODS

An extensive literature search was carried out on PubMed. Keywords that were used in the search included bowel dysfunction, obstruction, postoperative ileus, spinal surgery, spinal fusion, constipation, opioid-induced constipation, colonic pseudo-obstruction, ischemic colitis, immobility-induced bowel changes, epidural anesthesia and diet. Relevant studies were chosen and included in the review. The treatment approach used in the spine center of a university hospital was included.

RESULTS

Current research mainly focuses on investigating the nature and symptomatology of chronic bowel dysfunction after spinal cord injury. Emphasis on the acute phase of bowel dysfunction in patients after elective spinal surgery is lacking. The comorbidities that exacerbate bowel dysfunction postoperatively are well-defined. There has been refinement and expansion of the pharmacological and nonpharmacological treatment that could be implemented. Enough evidence exists to provide sufficient care.

CONCLUSION

Management of acute bowel dysfunction after spinal surgery requires a comprehensive and individualized approach, encompassing comorbidities, behavioral changes, medications and surgery. Close supervision and timely treatment could minimize further complications. Research is required to identify patients who are at a higher risk of developing bowel dysfunction after specific spinal procedures.

A Rare Presentation of Isolated Right Colon Ischemia: The Mass-Forming Variant

Ischemic colitis (IC), the most common gastrointestinal ischemia, remains an enigmatic disease with a wide array of pathogenic mechanisms and injuries along with variable outcomes. Among this group, isolated right colon ischemia (IRCI) appears to be a distinct entity, with its own pathophysiology, clinical presentation, and higher morbidity and mortality compared to left-sided colitis. IRCI is the most common site of mass-forming ischemic colitis. Colonoscopy with biopsy remains the key to diagnosis for this former entity. IRCI management is the same as for other IC and complete resolution of the mass is expected within weeks.

Ischemic colitis. Does right colon location mean worst prognosis?

INTRODUCTION

Most patients with ischemic colitis have a favourable evolution; nevertheless, the location in the right colon has been associated with a worse prognosis. The purpose of this study is to compare the clinical presentation and results of right colon ischemic colitis (CICD) with ischemic colitis of other colonic segments (non-CIDC).

METHODS

Retrospective, observational study of patients admitted to our hospital with ischemic colitis between 1993 and 2014, identified through a computerized search of the ICD9 codes. They were divided into 2groups: CICD and non-CICD. Comorbidities, clinical presentation, need for surgery, and mortality were compared. Multivariate analysis was performed using logistic regression adjusting for age and sex. Statistical significance was established at a value of P <0.05.

RESULTS

A total of 204 patients were identified, 61 (30%) with CICD; 61% of CICD patients required surgery compared to 22% of non-CICD patients (P <0.001). Post-surgical mortality (32 vs. 55%) and overall mortality (20 vs. 15%) differences were not statistically significant. CICD patients had more commonly unfavourable outcomes than non-CICD patients (61 vs. 25%, P <0.001). The odds ratio (OR) for surgery was 5.28 and 4.47 for unfavourable outcomes for patients with CICD.

CONCLUSIONS

CICD patients have a worse prognosis than non-CICD patients, 5 times more likely to need surgery and 4 times more likely to have unfavourable outcomes.

Colon ischemia in patients with severe COVID-19: a single-center retrospective cohort study of 20 patients

PURPOSE

Thromboembolic complications due to COVID-19 are common in patients requiring critical care and are associated with high morbidity and mortality rates. The aim of this study was to evaluate clinical manifestations and postoperative outcomes after colectomy for COVID-19-associated colonic ischemia in the first versus the second wave of the pandemic.

METHODS

A retrospective cohort study of patients with severe COVID-19 at our institution between 1 March 2020 and 31 January 2021 was performed. All patients with severe COVID-19, requiring critical care and surgical treatment of colonic ischemia, were included. The main outcomes were surgical complications and mortality rate.

RESULTS

A total of 190 patients were included of whom 20 (10.5%) patients underwent surgery for colon ischemia. Preoperatively, D-dimer was elevated, especially in the first wave (median 15.24 (interquartile range 6.00-32.00) vs. 2.09 (1.42-4.28) mg/L, p = 0.025). Twelve (60%) patients underwent a (sub)total colectomy, 7 (35%) a right hemicolectomy, and one patient (5%) an ileocecal resection. Grade 3b complications occurred in one of 5 patients (20%) in the first and in 9 of 15 patients (60%) in the second wave. The overall in-hospital mortality was similar in both waves (40% vs. 47%), with death occurring after a median stay of 21 days.

CONCLUSION

In this cohort study of patients with severe COVID-19 and colonic ischemia, clinical presentation and laboratory findings varied. However, the majority of patients required (sub)total colectomy. Despite a lower threshold to surgery in the second wave, mortality remained high.

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.

Predictors of mortality following emergency open colectomy for ischemic colitis: a single-center experience

Background

Ischemic colitis (IC) is a severe emergency in gastrointestinal surgery. The aim of the present study was to identify the predictors of postoperative mortality after emergent open colectomy for IC treatment. Additionally, we compared postoperative outcomes of patients undergoing emergent colectomy due to aortic surgery-related IC (AS-IC group) vs. other IC etiologies (Other-IC group).

Methods

We analyzed records of consecutive patients who underwent emergency open colectomy for IC between 2008 and 2019. Logistic regression analysis was performed to identify clinical and operative parameters associated with postoperative mortality. The AS-IC and Other-IC groups were compared for mortality, morbidity, ICU stay, hospital stay, and survival.

Results

During the study period, 94 patients (mean age, 67.4 ± 13.7 years) underwent emergent open colectomy for IC. In the majority of cases, IC involved the entire colon (53.2%) and vasopressor agents were required preoperatively (63.8%) and/or intraoperatively (78.8%). Thirty-four patients underwent surgery due to AS-IC, whereas 60 due to Other-IC causes. In the AS-IC group, 9 patients had undergone endovascular aortic repair and 25 open aortic surgery; 61.8% of patients needed aortic surgery for ruptured abdominal aortic aneurism (AAA). Overall, 66 patients (70.2%) died within 90 days from surgery. The AS-IC and Other-IC groups showed similar operative outcomes and postoperative complication rates. However, the duration of the ICU stay (19 days vs. 11 days; p = 0.003) and of the total hospital stay (22 days vs. 16 days; p = 0.016) was significantly longer for the AS-IC group than for the Other-IC group. The rate of intestinal continuity restoration at 1 year after surgery was higher for the Other-IC group than for the AS-IC group (58.8% vs. 22.2%; p = 0.05). In the multivariate model, preoperative increased lactate levels, a delay between signs/symptoms’ onset and surgery > 12 h, and the occurrence of postoperative acute kidney injury were statistically associated with postoperative mortality. Neither IC etiology (aortic surgery vs. other etiology) nor ruptured AAA was associated with postoperative mortality.

Conclusion

Emergency open colectomy for IC is associated with high postoperative mortality, which appears to be unrelated to the IC etiology. Preoperative lactate levels, > 12-h delay to surgery, and postoperative acute kidney injury are independent predictors of postoperative mortality.

Nonocclusive Ischemic Colitis: Analysis of Risk Factors for Severity

The purpose of this study was to identify risk factors predictive of severe nonocclussive ischemic colitis (IC) requiring operation or resulting in mortality. One hundred seventeen patients with nonocclussive IC were identified and divided into two groups: those with severe disease (n = 24) and those with disease that resolved with supportive care (n = 93). Univariate and multivariate logistic regression models were used. The splenic flexure was the most common involved segment (57.3%), whereas the right colon was involved in 17.9 per cent of patients. Multivariate logistic regression identified three independent risk factors for severe disease: leukocytosis greater than 15 3 109/L (odds ratio [OR], 5.7; confidence interval [CI], 1.5 to 21), hematocrit less than 35 per cent (OR, 4.5; CI, 1.1 to 17), and history of atrial fibrillation (OR, 15; CI, 1.3 to 190). Right-sided IC and chronic renal insufficiency did not affect severity. Special attention should be given to patients with the following risk factors for a severe course: atrial fibrillation, elevated white blood cell count, and anemia. These factors might enable earlier identification of patients who may benefit from early operation. Further prospective studies focusing on subgroups of IC (occlusive and nonocclusive) are required.

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

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

A case of stricture-type ischemic colitis from excessive alcohol consumption, with follow-up to rule out colon cancer

A 69-year-old man was admitted to Hanawa Kousei Hospital with acute hepatitis attributed to alcohol consumption. His condition improved with conservative treatment. Computed tomography (CT) showed localized thickening of the colonic wall at the splenic flexure;carcinoembryonic antigen level was slightly elevated to 9.7 ng/mL. Colonoscopy (CS) showed an ulcerative lesion in the colonic splenic flexure. Ischemic colitis (IC) and type 4 colon cancer were suspected, but biopsy was not confirmatory. Malignancy could not be ruled out by contrast-enhanced CT;repeat CS showed circumferential stenosis of the colonic splenic flexure. Ischemic colitis was suspected based on changes between the first and second CS. Biopsy histopathology led us to diagnose stricture-type IC. Constipation, but not intestinal obstruction, occurred. Conservative treatment improved the stenosis. Excessive alcohol consumption may lead to IC;imaging studies may be useful to distinguish IC from colon cancer. Since most cases of ischemic colitis can be improved with conservative treatment, patients with stricture-type ischemic colitis may also be treated without surgery early on, with follow-up that includes careful, periodic imaging.

An unusual cause of bowel ischemia in an intensive care unit patient with herpes simplex virus encephalitis

We present a case of an unexpected cause of bowel ischemia in an intensive care unit patient with herpes simplex virus encephalitis who required an operation. A 79-year-old lady was being worked up and treated for encephalitis with antibiotics and an antiviral. On Day 13, she developed abdominal pain, and an ultrasound showed cholelithiasis but no cholecystitis; thus conservative treatment was advocated. By Day 18, pain localized to the right iliac fossa, and she had an emergency laparotomy that showed bowel ischemia and perforation of the caecum with the cause being a terminal ileal adhesional band. An extended right hemicolectomy and ileostomy was performed. Patients with significant comorbidities who are intensive care unit-dependent may still have unexpected clinical challenges. We advocate an increased clinical vigilance in this cohort for unexpected life-threatening presentations such as bowel ischemia and more specifically the cause of the bowel ischemia.

Older patients are significantly more likely to have colon ischaemia-associated conditions that are chronic and complex

BACKGROUND

Colon ischaemia is a common disease which has been associated with various medications and comorbidities.

AIM

To test the hypothesis that there are differences in the frequencies of these associations in older compared with younger patients.

METHODS

A retrospective cohort study was performed of patients hospitalized with colon ischaemia at two major medical centres from 2005-2017. Clinical, colonoscopic and pathologic criteria were used to identify patients admitted with colon ischaemia; patients with other types of colitis were excluded. Demographic and medical data were extracted. Two cohorts were created: patients aged 18-64 years and patients > 65 years. These were compared using SAS 14.3.

RESULTS

A total of 788 patients were included, of which 271 (34.4%) were of ages 18-64 years, and 517 (66.6%) were 65 years old or older. In the older cohort, constipation-inducing medications (83.8% vs 64.1%; P = <0.0001), diuretics (38.1% vs 25.1%; P = <0.001) and nonsteroidal anti-inflammatory drugs (58% vs 41.5%; P = <0.0001) were more common than in the younger cohort. Antipsychotic medication use was more common in the younger cohort (10.4% vs 5.4%; P = 0.01). There was a higher percentage of younger patients with a history of hypercoaguable state (1.9% vs 0.2%; P = 0.03) and dialysis dependence (22.9% vs 8.7%; P = <0.01), while a higher percentage of patients in the older cohort had a history of chronic obstructive pulmonary disease (12% vs 6.3%; P = 0.01) or atrial fibrillation (18.9% vs 10.3%; P = <0.01).

CONCLUSIONS

Our study shows that older patients are more likely to have colon ischaemia-associated conditions that are chronic and complex, while younger patients are more likely to have acute colon ischaemia-associated conditions.

Real-world multicentre experience of the pathological features of colonic ischaemia and their relationship to symptom duration, disease distribution and clinical outcome

AIM

To determine the pathological features of colonic ischaemia (CI) and their relationship to symptom duration, disease distribution and clinical outcome in a real-world, clinical setting.

METHOD

A retrospective, multicentre chart review was performed in patients diagnosed with CI at Montefiore Medical Center (January 2005 to July 2015), and Yale-New Haven Hospital (January 2005 to June 2010). Patients were included if clinical presentation, colonoscopic findings and colonic pathology were all consistent with CI.

RESULTS

Six hundred and sixteen patients with pathologically proven CI were included. Common pathological findings included inflammation (51.1%), ulceration (38.2%), fibrosis (26.0%) and necrosis (20.4%). Infarction and ghost cells were seen in 1.6% and 0.2% of cases, respectively. There was a significant relationship between symptom duration and hyalinization of the lamina propria (P = 0.05) and cryptitis/crypt abscesses (P = 0.01). Patients with isolated right CI (IRCI) were more likely than patients with isolated left CI (ILCI) to exhibit necrosis (P < 0.01), cryptitis/crypt abscess (P < 0.01) and inflammation (P = 0.03). Patients with poor outcomes were more likely to exhibit necrosis (P < 0.01) and capillary fibrin thrombi (P < 0.01) and less likely to exhibit fibrosis (P < 0.01) and epithelial changes (P < 0.01).

CONCLUSION

CI is accompanied by a broad spectrum of pathological findings. The traditional pathognomonic findings of CI are rare and cannot be relied upon to exclude the diagnosis. Patients with IRCI and/or poor outcomes were more likely to have pathological findings of necrosis than patients who had ILCI and/or nonpoor outcomes.

The incidence and outcome of ischemic colitis in a population-based setting

OBJECTIVE

Population-based studies on patients with ischemic colitis (IC) are limited. We aimed to determine the incidence, risk factors and outcome of patients with IC.

METHODS

A retrospective nationwide study was conducted on adult patients with histologically confirmed IC in 2009-2013 in Iceland. IC patients were matched for age and gender with patients hospitalized with lower gastrointestinal bleeding. Data were collected on clinical presentation, comorbidities, smoking habits, management and outcome.

RESULTS

Eighty-nine patients, 61 (69%) females and mean age of 65 years (±17), fulfilled the predetermined criteria. Females were older than males, 68 years (±14) vs. 59 years (±20) (p = .0170). The mean cumulative incidence was 7.3 cases per 100,000 inhabitants. A total of 57 (64%) patients presented with abdominal pain, hematochezia and diarrhea. IC was localized in the left colon in 78 (88%) patients. Overall, 62 (70%) patients had cardiovascular disease vs. 53 (60%) of control group (NS) and 55 (62%) had a history of smoking vs. 53 (60%) in control group (NS). Ten (11%) patients required surgery and/or died within 30-days from hospital admission. At the end of follow-up, 7 (9%) patients had experienced recurrence of IC with an estimated 3-year recurrence rate of 15%.

CONCLUSIONS

IC is a common clinical phenomenon that affects a wide range of age groups, but is most prominent among elderly women. It typically presents with a clinical triad of abdominal pain, hematochezia and diarrhea. Most cases are mild and self-limiting with a good prognosis.

Predictors of severity in ischemic colitis: Usefulness of early ultrasonography

PURPOSE

The main objective was to evaluate the usefulness of early ultrasonography for determining prognosis of patients with ischemic colitis.

MATERIALS AND METHODS

We reviewed the histories of patients with diagnosis of ischemic colitis over a period of 11 years. Two hundred twenty nine patients with ischemic colitis were included. Demographic, clinical, laboratory and sonographic findings were retrospectively analyzed. Patients were divided into two groups according to the outcome: mild (those who improved with conservative treatment) or severe (those who died or required surgery), and the findings of each group were compared. In addition, we developed a predictive model of multivariate logistic regression analysis, and then it was validated in a different population of 58 consecutive patients with ischemic colitis.

RESULTS

The mild ischemic colitis group consisted of 184 patients (age 74,7±8,8years), and the severe group of 45 patients (age 78,6±7,7years). More pancolitis (p=0.005), altered pericolic fat (p=0.032) and free fluid (p=0.013) was observed in the severe ischemic colitis group compared with the mild group. Severe ischemic group had lower wall thickness (p=0.020) and higher resistive index than mild group (p=0.025). Multivariate analysis identified as protective factors to severe ischemic colitis: pain (p=0.026), diarrhea (p=0.034), rectal bleeding (p=0.000), and hypertension (p=0.001). Altered pericolic fat (p=0.008) and pancolitis (p=0.017) were sonographic findings significantly related to severe ischemic colitis. Our model correctly classified 88.4% of the study patients and 89.6% of the population of 58 patients used in validation.

CONCLUSIONS

Sonographic features with clinical findings can predict the outcome of ischemic colitis. Our predictive model could differentiate properly between patients with mild or severe ischemic colitis.

Colon ischemia: Right-sided colon involvement has a different presentation, etiology and worse outcome. A large retrospective cohort study in histology proven patients

BACKGROUND

Colon ischemia (CI), is generally considered a non-occlusive mesenteric ischemia disorder that usually runs a benign course, but right-sided involvement (RCI) has been associated with worse outcome. The poor outcome of RCI has been associated with comorbidity, but more recently also with occlusions of the mesenteric arteries. We performed a retrospective analysis of a large cohort of CI-patients to assess differences in presentation, etiology, and comorbidity between right-sided colon ischemia (RCI) and non-right-sided colon ischemia (NRCI), and their relation to outcome.

METHODS

We performed a retrospective cohort study in two centers from 2000 to 2011 for CI and analyzed clinical presentation, etiology, treatment and outcome. Diagnosis was based on full colonoscopy and/or surgical findings and confirmed by histopathology.

RESULTS

239 patients were included (mean age 69, 52% female). RCI was found in 48% and NRCI in 52%. Patients with NRCI presented more often with rectal bleeding (87% vs. 45%; p<0.001). In RCI more nausea (58% vs. 39%; p=0.013), weight loss (56% vs. 19%; p<0.001), paralytic ileus (32% vs. 18%; p=0.018) and peritoneal signs (27% vs. 7%; p<0.001) was observed compared to NRCI. The cause of CI was more often idiopathic in NRCI (46% vs. 26%; p=0.002); an occlusive cause was seen more often in RCI (26.3 vs 2.4%, p<0.0001). RCI patients had longer hospital stay (15 vs. 8 days, p<0.001), need for surgery (61% vs. 34%, p<0.001), and trend toward higher 30-day in-hospital mortality (20% vs. 12%, p=0.084).

CONCLUSIONS

RCI ischemia has different etiology, presentation, and outcome. The series shows a high proportion of - treatable - vessel occlusion. It reinforces the advice to perform CT angiography in RCI as means to improve its poor outcome.

Seasonal variation in occurrence of ischemic colitis: a retrospective study

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

Colonic ischemia: usual and unusual presentations and their management

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

The predictors of the severity of ischaemic colitis: a systematic review of 2823 patients from 22 studies

AIM

The study reviews the literature related to ischaemic colitis (IC) as the evidence base to identify factors predicting severity.

METHOD

A systematic review of the literature was conducted on the predictors of the severity of IC. Severe IC or adverse outcome of IC was defined as a patient requiring surgery or who died. MEDLINE, Embase and Cochrane Library databases were searched from inception to 15 January 2015. Manual searches of reference lists from potentially relevant papers and meetings were also performed.

RESULTS

In all, 22 studies involving 2823 patients were identified; 19 were case series, two were case-control studies and one was a cohort study. The overall adverse outcome rate was 22.0% (620/2823). The prognostic predictors for surgery or mortality which were most frequently reported included right sided IC, peritonitis, shock or arterial hypotension (< 90 mmHg), male gender, tachycardia and lack of rectal bleeding. Thirteen studies relating to the right colon from which data could be extracted were further analysed. The right colon was involved in 277 cases, with an incidence of adverse outcomes of 48.4% (134/277), while in the non-right colonic involvement group the incidence was significantly lower at 12.1% (142/1175) (P = 0.000).

CONCLUSION

The incidence of adverse outcome in patients with IC remains high. Male gender, tachycardia, lack of rectal bleeding, peritonitis, shock or arterial hypotension (< 90 mmHg) and right sided IC are predictors of poor prognosis. Right-sided IC, shock or arterial hypotension (< 90 mmHg) and signs of peritonitis may be the most significant predictors of severity.

Diagnosis and treatment of ischemic colitis

Ischemic colitis (IC) is a common reason of acute lower gastrointestinal bleeding, and it is frequently seen in elderly people. In recent years, both the incidence and prevalence of IC have been rising. Most episodes of IC are transient and self-limited and only a minority of cases are severe. IC often has missed and delayed diagnosis. This review mainly focuses on the progress in the understanding of the diagnosis and therapy of IC.

Predictive Factors for Severe Outcomes in Ischemic Colitis

Background/Aims

Ischemic colitis includes a wide clinical spectrum ranging from mild to severe forms. This study aimed to determine the factors that are related to the occurrence of severe ischemic colitis.

Methods

This multicenter study was conducted retrospectively in Korea. The patients were divided into mild and severe groups. This study surveyed clinical characteristics, blood tests, endoscopic findings, and imaging studies.

Results

In the comparison of comorbidities, the severe group had a higher ratio of chronic kidney disease than the mild group (p=0.001). In the blood test, the severe group had a reduced number of platelets (p=0.018) and a higher C-reactive protein value (p=0.001). The severe group had a higher ratio of involvement of the right colon (p=0.026). The Eastern Cooperative Oncology Group (ECOG) performance status score of the patients showed that the severe group had higher scores than the mild group (p=0.003). A multivariate analysis showed that chronic kidney disease and high ECOG performance status scores were significant risk factors.

Conclusions

If patients diagnosed with ischemic colitis are also treated for chronic kidney disease or have poor performance status, more attention and early intervention are necessary.

Update on ischemic colitis: from etiopathology to treatment including patients of intensive care unit

Ischemic colitis is the result of colonic hypoperfusion and is regarded as a relatively rare condition. It can be roughly classified as occlusive and non-occlusive. Pathogenesis includes a usually transient compromise in the colonic vasculature, with a parallel activation of an inflammatory cascade caused primarily by reperfusion. Diagnosis of ischemic colitis remains often difficult and requires a combination of diagnostic techniques, whereas clinical signs are occasionally only seen late as complications. Gold standard is considered to be colonoscopy. Clinical presentation and treatment of ischemic colitis vary widely depending on the degree of ischemia. Patients of intensive care unit (ICU) with ischemic colitis are often under-diagnosed, since the parallel co-morbidities and the nonspecific nature of symptoms that mimic almost any abdominal pathology, can mislead the doctor. Moreover, sedated or ventilated patients can mask many of the characteristic features of ischemic colitis and make the diagnosis challenging. Bedside colonoscopy and diagnostic laparoscopy in ICUs are two options, which seem lately to be reliable and promising in diagnosing ischemic colitis in critically ill patients.

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.

Hollow organ abdominal ischemia, part II: clinical features, etiology, imaging findings and management

Acute hollow organ ischemia commonly presents with acute pain prompting radiologic evaluation and almost always requires urgent treatment. Despite different risk factors and anatomic differences, ischemia is commonly due to low flow states but can also be due to arterial and venous occlusion. Radiologic diagnosis is critical as many present with nonspecific symptoms. Contrast-enhanced computed tomography (CT) is the modality of choice. Magnetic resonance imaging (MRI) is preferred in suspected appendicitis in pregnant patients and is superior in biliary necrosis. This article provides a pictorial review of the CT/MRI features of hollow abdominal organ ischemia while highlighting key clinical features, pathogenesis, and management.

[Acute mesenteric ischemia]

BACKGROUND

Acute vascular occlusion within the mesenteric circulation leads to ischemic damage of the corresponding bowel segment, which starts on the mucosal level and progresses transmurally.

OBJECTIVES

Report on pathogenesis, clinical picture and treatment of various forms of intestinal ischemia.

MATERIALS AND METHODS

Analysis of the available literature taking into consideration our own experience.

RESULTS

Frequently, predisposing diseases and risk factors are present (e.g., cardiac diseases, hypercoagulability, status post cardiac surgery, circulatory failure, or administration of vasoconstrictive drugs). Acute small bowel ischemia-caused by either mesenteric embolism, mesenteric artery thrombosis, nonocclusive mesenteric ischemia (NOMI) or mesenteric venous thrombosis-represents an acute emergency. If this condition is suspected clinically, the diagnosis must be established immediately by computed tomography of the abdomen with intravenous administration of contrast medium in order to prevent irreversible damage to the small bowel. Medical treatment is supportive. If possible, occluded vessels may be re-opened either by radiologic intervention or surgically. Irreversibly damaged bowel segments must be surgically removed. Ischemic colitis has a benign course in most cases if limited to reversible mucosal damage. The diagnosis is based mainly on colonoscopy and computed tomography findings, and treatment is symptom oriented. Rarely, severe manifestations with a worse prognosis due to considerable comorbidities occur. In such cases, surgical removal of the ischemic bowel is frequently required.

CONCLUSION

Even today, acute mesenteric ischemia is associated with a poor prognosis. To improve survival and to reduce long-term morbidity, a rapid and systematic diagnostic workup is mandatory.

Right-Side Colon Ischemia: Clinical Features, Large Visceral Artery Occlusion, and Long-Term Follow-Up

CONTEXT

Large visceral artery occlusion (LVAO) could underlie right-side colon ischemia (RSCI) but is little known.

OBJECTIVE

To assess patients with RSCI through long-term follow-up, including features and management of LVAO.

MAIN OUTCOME MEASURES

Mesenteric ischemia and mortality.

DESIGN

Retrospective observational study in an integrated health care system.

RESULTS

Of 49 patients (30 women [61.2%]; mean [standard deviation] age, 69.4 [11.9] years), 19 (38.8%) underwent surgery—that is, 5 (83.3%) of 6 who developed RSCI in hospital following surgical procedures and 14 (32.6%) of 43 who had RSCI before hospitalization (p value = 0.03); overall, 5 (10.2%) died. Among 44 survivors with a median (range) follow-up of 5.19 (0.03-14.26) years, 5 (11.4%), including 3 (20.0%) of 15 operated cases, had symptomatic LVAO and underwent angioplasty and stent placement: 2 for abdominal angina that preceded RSCI, 1 for acute mesenteric ischemia 1 week after resection of RSCI, 1 for RSCI 6 weeks after resection of left-side ischemia, and 1 for abdominal angina that began 3 years after spontaneous recovery from RSCI. None had further mesenteric ischemia until death from nonintestinal disease or the end of follow-up (1.6 to 10.2 years later). Kaplan-Meier survival estimates for all 44 survivors at 1, 3, 5, and 10 years were 88.6%, 72.3%, 57.6%, and 25.9%, respectively. Thirty-one patients (70.4%) died during follow-up, 19 (61.3%) of a known cause; the 39 patients not treated for LVAO lacked mesenteric ischemia.

CONCLUSION

Patients with RSCI may have symptomatic LVAO; therefore, we advise they undergo careful query for symptoms of abdominal angina and routine visceral artery imaging.

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

BACKGROUND & AIMS

Little is known about progression of ischemic colitis (IC) among unselected patients. We aimed to estimate the incidence, risk factors, and natural history of IC in a population-based cohort in Olmsted County, Minnesota.

METHODS

We performed a retrospective population-based cohort and nested case-control study of IC. Each IC case was matched to 2 controls from the same population on the basis of sex, age, and closest registration number. Conditional logistic regression, the Kaplan-Meier method, and proportional hazards regression were used to assess comorbidities, estimate survival, and identify characteristics associated with survival, respectively.

RESULTS

Four hundred forty-five county residents (median age, 71.6 years; 67% female) were diagnosed with IC from 1976 through 2009 and were matched with 890 controls. The age-adjusted and sex-adjusted incidence rates of IC nearly quadrupled from 6.1 cases/100,000 person-years in 1976-1980 to 22.9/100,000 in 2005-2009. The odds for IC were significantly higher among subjects with atherosclerotic diseases; odds ratios ranged from 2.6 for individuals with coronary disease to 7.9 for individuals with peripheral vascular disease. Of IC cases, 59% survived for 5 years (95% confidence interval, 54%-64%), compared with 90% of controls (95% confidence interval, 88%-92%). Age >40 years, male sex, right-sided colon involvement, concomitant small bowel involvement, and chronic obstructive pulmonary disease were all independently associated with mortality (P < .05).

CONCLUSIONS

The incidence of IC increased during the past 3 decades in a population-based cohort in Minnesota. IC typically presents in older patients with multiple comorbidities and is associated with high in-hospital mortality (11.5%) and rates of surgery (17%).

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

PURPOSES

The long-term clinical course of outpatient-onset ischemic colitis remains unknown. Our aims are to elucidate the in- and out-of-hospital clinical outcomes of ischemic colitis and compare them with those of lower gastrointestinal bleeding (LGIB).

METHOD

A cohort of 370 outpatients was hospitalized for ischemic colitis (n = 57) or other LGIB (n = 313). All patients had undergone colonoscopy. During hospitalization, the need for transfusion or interventions, further bleeding, mortality, and length of hospital stay were measured. After discharge, long-term recurrence and mortality were analyzed by the Kaplan-Meier method.

RESULTS

Colonoscopy revealed that 88% of ischemic colitis cases were left sided. Compared with other LGIB, ischemic colitis cases had significantly lower transfusion requirements (p < 0.01), further bleeding (p = 0.02), endoscopic intervention (p < 0.01), and shorter hospital stay (p = 0.03). No significant differences between the groups were noted in the need for surgery, angiographic procedures, or mortality during hospitalization. During a mean follow-up of 22 months, rebleeding was significantly lower (log-rank test; p < 0.01) in ischemic colitis cases (5.3%) than in other LGIB cases (19.4%) after discharge. During the mean follow-up period of 29 months, 1 patient (1.8%) with ischemic colitis and 18 patients (5.8%) with other LGIB died (log-rank test; p = 0.41).

CONCLUSIONS

Outpatient-onset ischemic colitis patients usually had left-sided colitis, recovered with conservative short-term treatment and had lower transfusion requirements and further bleeding compared with other LGIB patients. After discharge, patients with outpatient-onset ischemic colitis had lower recurrence over the long term than other LGIB patients.

Predictors of mortality among patients undergoing colectomy for ischemic colitis: A population-based United States study

BACKGROUND

Ischemic colitis is a potentially life-threatening condition that can require colectomy for management.

OBJECTIVE

To assess independent predictors of mortality following colectomy for ischemic colitis using a nationally representative sample of hospitals in the United States.

METHODS

The Nationwide Inpatient Sample was used to identify all patients with a primary diagnosis of acute vascular insufficiency of the colon (International Classification of Diseases, Ninth Revision codes 557.0 and 557.9) who underwent a colectomy between 1993 and 2008. Incidence and mortality are described; multivariate logistic regression analysis was performed to determine predictors of mortality.

RESULTS

The incidence of colectomy for ischemic colitis was 1.43 cases (95% CI 1.40 cases to 1.47 cases) per 100,000. The incidence of colectomy for ischemic colitis increased by 3.1% per year (95% CI 2.3% to 3.9%) from 1993 to 2003, and stabilized thereafter. The postoperative mortality rate was 21.0% (95% CI 20.2% to 21.8%). After 1997, the mortality rate significantly decreased at an estimated annual rate of 4.5% (95% CI -6.3% to -2.7%). Mortality was associated with older age, 65 to 84 years (OR 5.45 [95% CI 2.91 to 10.22]) versus 18 to 34 years; health insurance, Medicaid (OR 1.69 [95% CI 1.29 to 2.21]) and Medicare (OR 1.33 [95% CI 1.12 to 1.58]) versus private health insurance; and comorbidities such as liver disease (OR 3.54 [95% CI 2.79 to 4.50]). Patients who underwent colonoscopy or sigmoidoscopy (OR 0.78 [95% CI 0.65 to 0.93]) had lower mortality.

CONCLUSIONS

Colectomy for ischemic colitis was associated with considerable mortality. The explanation for the stable incidence and decreasing mortality rates observed in the latter part of the present study should be explored in future studies.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical outcomes and prognostic factors after surgery for non-occlusive mesenteric ischemia: a multicenter study

BACKGROUND

To date, no large-scale study has been undertaken to understand the clinical features of non-occlusive mesenteric ischemia (NOMI) after surgery. We thus performed a multicenter investigation to clarify the clinical outcomes and prognostic factors of NOMI.

PATIENTS AND METHODS

Clinical databases from 22 Japanese facilities were reviewed for evaluation of patients who received surgery for NOMI between 2004 and 2012. NOMI patients (n = 51) were divided into two groups: group I (n = 28) consisted of patients who survived, and group II (n = 23) consisted of patients who did not survived. Prognostic factors were compared between the two groups.

RESULTS

NOMI surgery represented 0.04% of the total number of operations performed in this time period. The overall mortality rate for NOMI surgery was 45%. Hemodialysis was a significant negative prognostic factor (p = 0.027). Preoperative elevation of transaminases, potassium, and white blood cell count, as well as metabolic acidosis and colon ischemia was poor prognostic factors. The mean Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) score of group I versus group II was 54.5 ± 3.6 and 85.2 ± 4.1, respectively (p < 0.001).

CONCLUSIONS

Currently, NOMI surgery has a 45% mortality rate. POSSUM scores can be used to predict the clinical outcome of patients who receive NOMI surgery.

CT findings in acute, subacute, and chronic ischemic colitis: suggestions for diagnosis

Purpose. This paper aims at evaluating CT findings of occlusive and nonocclusive ischemic colitis (IC), in correlation with the etiology and the different phases of the disease. Materials and Methods. CT examination and clinical history of 32 patients with proven IC were retrospectively reviewed. The CT findings were analyzed according to the different phases of the disease (acute, subacute, and chronic). Results. Among the 32 CT examinations performed in the acute phase, 62.5% did not present signs of occlusion of the superior mesenteric artery (SMA) or inferior mesenteric artery (IMA), whereas IMA occlusion was detected in 37.5% of CT examinations. In the acute phase, the presence of pericolic fluid was found in 100% of patients undergoing progressive resorption from acute to subacute phase if an effective reperfusion occurred; the bowel wall thickening was observed in 28.1% patients in acute phase and in 86.4% patients evaluated in subacute phase. The unthickened colonic wall was found in all conditions where ischemia was not followed by effective reperfusion (71.9% of cases), and it was never found in chronic phase, when the colon appeared irregularly thickened. Conclusion. CT allows determining the morphofunctional alterations associated with the IC discriminating the occlusive forms from the nonocclusive forms. CT, furthermore, allows estimating the timing of ischemic damage.

Ischaemic colitis: indications, extent, and results of standardized emergency surgery

BACKGROUND

Acute ischaemic colitis can occur postoperatively, mainly after aortic surgery, or spontaneously. Surgical treatment is debated. Study aim was to describe factors related to ischaemic colitis severity, determine if postoperative and spontaneous ischaemic colitis share similar outcomes, and evaluate results of standardized management.

METHODS

191 consecutive cases of ischaemic colitis observed from 1997 to 2012 were retrospectively analyzed: 119 (62%) after surgery and 72 (38%) spontaneous. Colon resection was performed for endoscopic type 2 colitis with multiple organ failure, and for every type 3. Types 1 and 2 without multiple organ failure were managed nonoperatively.

RESULTS

Seventeen patients (9%) were managed nonoperatively, without mortality. Mortality rate after resection was 48% (84/174), within 9 days (range, 0-152). Multivariate analysis found 2 independent factors associated with postoperative death: age≥75 years and multiple organ failure. The context in which ischaemic colitis occurred was not a risk factor for mortality. Mortality rates were 51% for final type 3 (66% with multiple organ failure, 17% without), 53% for final type 2 with multiple organ failure, and 0% for type 1 or type 2 without multiple organ failure.

CONCLUSION

An aggressive surgical approach in patients with ischaemic colitis seems justified in patients with multiple organ failure and findings of severe form of ischaemia at endoscopy.