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Maspero M, Hull TL. Clinical approach to patients with an ileal pouch. Abdom Radiol (NY) 2023; 48:2918-2929. [PMID: 37005915 DOI: 10.1007/s00261-023-03888-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 04/04/2023]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice to maintain intestinal continuity when a total proctocolectomy is a required. It is a technically challenging operation that may be burdened by several nuanced complications both in the immediate postoperative period and in the long term. Most patients with a pouch and any kind of complication will undergo radiological studies, thus multidisciplinary collaboration between surgeons, gastroenterologists, and radiologists is paramount to their timely and accurate diagnosis. When treating pouch patients, radiologists should be familiar with regular pouch anatomy and its appearance in imaging studies, as well as with the most common complications that can occur in this population. In this review, we examine the clinical decision-making process at each step before and after pouch creation, as well as the most common complications associated with pouch surgery, their diagnosis, and their management.
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Affiliation(s)
- Marianna Maspero
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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2
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Leeds IL, Canner JK, DiBrito SR, Safar B. Do Cost Limitations of Extended Prophylaxis After Surgery Apply to Ulcerative Colitis Patients? Dis Colon Rectum 2022; 65:702-712. [PMID: 34840290 PMCID: PMC8995329 DOI: 10.1097/dcr.0000000000002056] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal surgery patients with ulcerative colitis are at increased risk of postoperative venous thromboembolism. Extended prophylaxis for thromboembolism prevention has been used in colorectal surgery patients, but it has been criticized for its lack of cost-effectiveness. However, the cost-effectiveness of extended prophylaxis for postoperative ulcerative colitis patients may be unique. OBJECTIVE This study aimed to assess the cost-effectiveness of extended prophylaxis in postoperative ulcerative colitis patients. DESIGN A decision analysis compared costs and benefits in postoperative ulcerative colitis patients with and without extended prophylaxis over a lifetime horizon. SETTING Assumptions for decision analysis were identified from available literature for a typical ulcerative colitis patient's risk of thrombosis, age at surgery, type of thrombosis, prophylaxis risk reduction, bleeding complications, and mortality. MAIN OUTCOME MEASURES Costs ($) and benefits (quality-adjusted life year) reflected a societal perspective and were time-discounted at 3%. Costs and benefits were combined to produce the main outcome measure, the incremental cost-effectiveness ratio ($ per quality-adjusted life year). Multivariable probabilistic sensitivity analysis modeled uncertainty in probabilities, costs, and disutilities. RESULTS Using reference parameters, the individual expected societal total cost of care was $957 without and $1775 with prophylaxis (not cost-effective; $257,280 per quality-adjusted life year). Preventing a single mortality with prophylaxis would cost $5 million (number needed to treat: 6134 individuals). Adjusting across a range of scenarios upheld these conclusions 77% of the time. With further sensitivity testing, venous thromboembolism cumulative risk (>1.5%) and ePpx regimen pricing (<$299) were the 2 parameters most sensitive to uncertainty. LIMITATIONS Recommendations of decision analysis methodology are limited to group decision-making, not an individual risk profile. CONCLUSION Routine ePpx in postoperative ulcerative colitis patients is not cost-effective. This finding is sensitive to higher-than-average rates of venous thromboembolism and low-cost prophylaxis opportunities. See Video Abstract at http://links.lww.com/DCR/B818. SE APLICAN LAS LIMITACIONES DE COSTOS DE LA PROFILAXIS PROLONGADA DESPUS DE LA CIRUGA A LOS PACIENTES CON COLITIS ULCEROSA ANTECEDENTES:Los pacientes de cirugía colorrectal con colitis ulcerosa tienen un mayor riesgo de tromboembolismo venoso posoperatorio. La profilaxis extendida para la prevención de la tromboembolia se ha utilizado en pacientes con cirugía colorrectal, aunque ha sido criticada por su falta de rentabilidad. Sin embargo, la rentabilidad de la profilaxis prolongada para los pacientes posoperados con colitis ulcerosa puede ser aceptable.OBJETIVO:Evaluar la rentabilidad de la profilaxis prolongada en pacientes posoperados con colitis ulcerosa.DISEÑO:Un análisis de decisiones comparó los costos y beneficios en pacientes posoperados con colitis ulcerosa con y sin profilaxis prolongada de por vida.AJUSTE:Los supuestos para el análisis de decisiones se identificaron a partir de la literatura disponible para el riesgo de trombosis de un paciente con colitis ulcerosa típica, la edad al momento de la cirugía, el tipo de trombosis, la reducción del riesgo con profilaxis, las complicaciones hemorrágicas y la mortalidad.PRINCIPALES MEDIDAS DE RESULTADO:Los costos ($) y los beneficios (año de vida ajustado por calidad) reflejaron una perspectiva social y se descontaron en el tiempo al 3%. Los costos y los beneficios se combinaron para producir la principal medida de resultado, la relación costo-efectividad incremental ($ por año de vida ajustado por calidad). El análisis de sensibilidad probabilística multivariable modeló la incertidumbre en probabilidades, costos y desutilidades.RESULTADOS:Utilizando parámetros de referencia, el costo total de atención social esperado individual fue de $957 sin profilaxis y $1775 con profilaxis (no rentable; $257,280 por año de vida ajustado por calidad). La prevención de una sola mortalidad con profilaxis costaría $5.0 millones (número necesario a tratar: 6.134 personas). El ajuste en una variedad de escenarios mantuvo estas conclusiones el 77% de las veces. Con más pruebas de sensibilidad, el riesgo acumulado de TEV (>1,5%) y el precio del régimen de ePpx (<$299) fueron los dos parámetros más sensibles a la incertidumbre.LIMITACIONES:Las recomendaciones de la metodología de análisis de decisiones se limitan a la toma de decisiones en grupo, no a un perfil de riesgo individual.CONCLUSIÓN:La profilaxis extendida de rutina en pacientes posoperados con colitis ulcerosa no es rentable. Este hallazgo es sensible a tasas de TEV superiores al promedio y oportunidades de profilaxis de bajo costo. Consulted Video Resumen en http://links.lww.com/DCR/B818. (Traducción-Dr. Felipe Bellolio).
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Affiliation(s)
- Ira L Leeds
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Naymagon L, Tremblay D, Zubizarreta N, Moshier E, Naymagon S, Mascarenhas J, Schiano T. The Natural History, Treatments, and Outcomes of Portal Vein Thrombosis in Patients With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:215-223. [PMID: 32185400 PMCID: PMC8427727 DOI: 10.1093/ibd/izaa053] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Portal vein thrombosis (PVT) is a poorly described complication of inflammatory bowel disease (IBD). We sought to better characterize presentations, compare treatments, and assess outcomes in IBD-related PVT. METHODS We conducted a retrospective investigation of IBD-related PVT at our institution. Multivariable Cox proportional hazards modeling was used to estimate adjusted hazard ratios across treatments. RESULTS Sixty-three patients with IBD-related PVT (26 with Crohn disease, 37 with ulcerative colitis) were followed for a median 21 months (interquartile ratio [IQR] = 9-52). Major risk factors included intra-abdominal surgery (60%), IBD flare (33%), and intra-abdominal infection (13%). Primary hematologic thrombophilias were rare and did not impact management. Presentations were generally nonspecific, and diagnosis was incidental. Ninety-two percent of patients (58/63) received anticoagulation (AC), including 23 who received direct oral anticoagulants (DOACs), 22 who received warfarin, and 13 who received enoxaparin. All anticoagulated patients started AC within 3 days of diagnosis. Complete radiographic resolution (CRR) of PVT occurred in 71% of patients. We found that DOACs were associated with higher CRR rates (22/23; 96%) relative to warfarin (12/22; 55%): the hazard ratio of DOACs to warfarin was 4.04 (1.83-8.93; P = 0.0006)). Patients receiving DOACs required shorter courses of AC (median 3.9 months; IQR = 2.7-6.1) than those receiving warfarin (median 8.5 months; IQR = 3.9-NA; P = 0.0190). Incidence of gut ischemia (n = 3), symptomatic portal hypertension (n = 3), major bleeding (n = 4), and death (n = 2) were rare, and no patients receiving DOACs experienced these adverse outcomes. CONCLUSIONS We show that early and aggressive use of AC can lead to excellent outcomes in IBD-associated PVT and that DOACs are associated with particularly favorable outcomes in this setting.
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Affiliation(s)
- Leonard Naymagon
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicole Zubizarreta
- Department of Population Health Science and Policy/Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erin Moshier
- Department of Population Health Science and Policy/Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Steven Naymagon
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas Schiano
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Lowenfeld L, Cologne KG. Postoperative Considerations in Inflammatory Bowel Disease. Surg Clin North Am 2019; 99:1095-1109. [PMID: 31676050 DOI: 10.1016/j.suc.2019.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Treatment of inflammatory bowel disease (IBD) is often multidimensional, requiring both medical and surgical therapies at different times throughout the course of the disease. Both medical and surgical treatments may be used in the acute setting, during a flare, or in a more elective maintenance role. These treatments should be planned as complementary and synergistic. Gastroenterologists and colorectal surgeons should collaborate to create a cohesive treatment plan, arranging the sequence and timing of various treatments. This article reviews the anticipated postoperative recovery after surgical treatment of IBD, possible postoperative complications, and considerations of timing surgery with medical therapy.
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Affiliation(s)
- Lea Lowenfeld
- Surgery, Division of Colorectal Surgery, University of Southern California Keck School of Medicine, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA 90033, USA
| | - Kyle G Cologne
- Surgery, Division of Colorectal Surgery, University of Southern California Keck School of Medicine, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA 90033, USA.
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Ng KS, Gonsalves SJ, Sagar PM. Ileal-anal pouches: A review of its history, indications, and complications. World J Gastroenterol 2019; 25:4320-4342. [PMID: 31496616 PMCID: PMC6710180 DOI: 10.3748/wjg.v25.i31.4320] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/12/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023] Open
Abstract
The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.
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Affiliation(s)
- Kheng-Seong Ng
- John Goligher Colorectal Unit, St. James’s University Hospital, Leeds LS9 7TF, United Kingdom
- Institute of Academic Surgery, University of Sydney, Camperdown, New South Wales 2050, Australia
| | - Simon Joseph Gonsalves
- Department of Colorectal Surgery, Huddersfield Royal Infirmary, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield HD3 3EA, United Kingdom
| | - Peter Michael Sagar
- John Goligher Colorectal Unit, St. James’s University Hospital, Leeds LS9 7TF, United Kingdom
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Seo KI, Kang SB. [Hepatobiliary Manifestation of Inflammatory Bowel Disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 73:248-259. [PMID: 31132831 DOI: 10.4166/kjg.2019.73.5.248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/05/2019] [Accepted: 05/12/2019] [Indexed: 12/13/2022]
Abstract
The hepatobiliary system is one of the most common sites of extraintestinal manifestation in patients with inflammatory bowel disease (IBD). The progression of IBD can lead to a primary hepatobiliary manifestation and can occur secondary to multiple drugs or accompanying viral infections. Primary sclerosing cholangitis is the representative hepatobiliary manifestation of IBD, particularly in ulcerative colitis. Although most agents used in the treatment of IBD are potentially hepatotoxic, the risk of serious hepatitis or liver failure is low. The prevalence of HBV and HCV in IBD is similar to the general population, but the clinical concern is HBV reactivation associated with immunosuppressive therapy. Patients undergoing cytotoxic chemotherapy or immunosuppressive therapy with a moderate to high risk of HBV reactivation require prophylactic antiviral therapy. On the other hand, HCV has little risk of reactivation. Patients with IBD are more likely to have nonalcoholic fatty liver disease than the general population and tend to occur at younger ages. IBD and cholelithiasis are closely related, especially in Crohn's disease.
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Affiliation(s)
- Kwang Il Seo
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sang-Bum Kang
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
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Sheedy SP, Bartlett DJ, Lightner AL, Trenkner SW, Bruining DH, Fidler JL, VanBuren WM, Menias CO, Reber JD, Fletcher JG. Judging the J pouch: a pictorial review. Abdom Radiol (NY) 2019; 44:845-866. [PMID: 30259096 DOI: 10.1007/s00261-018-1786-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Restorative total proctocolectomy with ileal pouch-anal anastomosis is the surgery of choice for patients with medically refractory ulcerative colitis, ulcerative colitis with high-grade dysplasia or multi-focal low-grade dysplasia, and for patients with familial adenomatous polyposis. The natural history of the surgery is favorable, and patients generally experience improved quality of life and acceptable long-term functional outcome. However, some patients experience significant long-term morbidity from early and/or late pouch-related complications. When complications arise, radiologists must understand the advantages and disadvantages of the various imaging modalities that can be used to assess the pouch. Radiologist familiarity with the surgical technique, pouch anatomy, and imaging appearance of the various potential early and late complications will help facilitate appropriate clinical and surgical decision-making. This review provides an anatomic-based imaging review of the pouch and pouch-related complications, including numerous illustrative fluoroscopic and cross-sectional imaging examples.
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Affiliation(s)
- Shannon P Sheedy
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - David J Bartlett
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Amy L Lightner
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Steven W Trenkner
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeff L Fidler
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Wendaline M VanBuren
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Joshua D Reber
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Joel G Fletcher
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Kiely JM, Kiran RP. Leak, fistula, sepsis, sinus, portal vein thrombosis. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1053/j.scrs.2019.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Baker ME, Fletcher JG, Al-Hawary M, Bruining D. Interdisciplinary Updates in Crohn’s Disease Reporting Nomenclature, and Cross-Sectional Disease Monitoring. Radiol Clin North Am 2018; 56:691-707. [DOI: 10.1016/j.rcl.2018.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Ando K, Fujiya M, Nomura Y, Inaba Y, Sugiyama Y, Iwama T, Ijiri M, Takahashi K, Tanaka K, Sakatani A, Ueno N, Kashima S, Moriichi K, Mizukami Y, Okumura T. The incidence and risk factors of venous thromboembolism in Japanese inpatients with inflammatory bowel disease: a retrospective cohort study. Intest Res 2018; 16:416-425. [PMID: 30090041 PMCID: PMC6077312 DOI: 10.5217/ir.2018.16.3.416] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 12/25/2022] Open
Abstract
Background/Aims Venous thromboembolism (VTE) is a major extraintestinal manifestation in inflammatory bowel disease (IBD), regarded as an independent risk factor for VTE according to reports from Western countries. However, the incidence and risk factors of VTE in Asian IBD patients are not fully understood. We aimed to reveal the incidence and risk factors of VTE in Japanese IBD inpatients. Methods The incidence of VTE in inpatients with IBD (n=340), gastrointestinal cancers (n=557), and other gastrointestinal diseases (n=569) treated at our hospital from 2009 to 2013 was retrospectively investigated. The characteristics and laboratory data of IBD inpatients with and without VTE were compared in univariate and multivariate analyses. Clinical courses of VTE in IBD were surveyed. Results VTE was detected in 7.1% of IBD inpatients, significantly higher than in gastrointestinal cancer inpatients (2.5%) and inpatients with other gastrointestinal diseases (0.88%). The incidence of VTE in ulcerative colitis (UC) patients (16.7%) was much higher than that in those with Crohn's disease (3.6%). In the univariate analysis, the risk factors were an older age, central venous catheter, prednisolone, surgery, low serum albumin, high serum C-reactive protein and D-dimer. According to a multivariate analysis, >50 years of age and surgery were the only risk factors. The in-hospital mortality rate of IBD inpatients with VTE was 4.2%. Conclusions The incidence of VTE with IBD, especially UC, was found to be high compared with other digestive disease, which was almost equivalent to that of Western countries. The efficacy of prophylaxis needs to be investigated in Asian IBD patients.
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Affiliation(s)
- Katsuyoshi Ando
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Mikihiro Fujiya
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Yoshiki Nomura
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Yuhei Inaba
- Department of Gastroenterology, Asahikawa City Hospital, Asahikawa, Japan
| | - Yuuya Sugiyama
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Takuya Iwama
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Masami Ijiri
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Keitaro Takahashi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kazuyuki Tanaka
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Aki Sakatani
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Nobuhiro Ueno
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Shin Kashima
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kentaro Moriichi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Yusuke Mizukami
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Toshikatsu Okumura
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
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Factors associated with portomesenteric venous thrombosis after total colectomy with ileorectal anastomosis or end ileostomy. Am J Surg 2018; 215:62-65. [DOI: 10.1016/j.amjsurg.2017.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 05/09/2017] [Accepted: 10/03/2017] [Indexed: 02/06/2023]
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12
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Olpin JD, Sjoberg BP, Stilwill SE, Jensen LE, Rezvani M, Shaaban AM. Beyond the Bowel: Extraintestinal Manifestations of Inflammatory Bowel Disease. Radiographics 2017; 37:1135-1160. [PMID: 28548906 DOI: 10.1148/rg.2017160121] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Inflammatory bowel disease (IBD) is a chronic, relapsing immune-mediated inflammation of the gastrointestinal tract. IBD includes two major disease entities: Crohn disease and ulcerative colitis. Imaging plays an important role in the diagnosis and surveillance of these complex disorders. Computed tomographic and magnetic resonance enterographic techniques have been refined in recent years to provide a superb means of evaluating the gastrointestinal tract for suspected IBD. Although the intestinal imaging manifestations of IBD have been extensively discussed in the radiology literature, extraintestinal imaging manifestations of IBD have received less attention. Multiple extraintestinal manifestations may be seen in IBD, including those of gastrointestinal (hepatobiliary and pancreatic), genitourinary, musculoskeletal, pulmonary, cardiac, ocular, and dermatologic disorders. Although many associations between IBD and extraintestinal organ systems have been well established, other associations have not been fully elucidated. Some extraintestinal disorders may share a common pathogenesis with IBD. Other extraintestinal disorders may occur as a result of unintended treatment-related complications of IBD. Although extraintestinal disorders within the abdomen and pelvis may be well depicted with cross-sectional enterography, other musculoskeletal and thoracic disorders may be less evident with such examinations and may warrant further investigation with additional imaging examinations or may be readily apparent from the findings at physical examination. Radiologists involved in the interpretation of IBD imaging examinations must be aware of potential extraintestinal manifestations, to provide referring clinicians with an accurate and comprehensive profile of patients with these complex disorders. © RSNA, 2017.
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Affiliation(s)
- Jeffrey D Olpin
- From the Department of Diagnostic Radiology (J.D.O., S.E.S., L.E.J., M.R., A.M.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; and the Department of Diagnostic Radiology, University of Wisconsin, Madison, Wis (B.P.S.)
| | - Brett P Sjoberg
- From the Department of Diagnostic Radiology (J.D.O., S.E.S., L.E.J., M.R., A.M.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; and the Department of Diagnostic Radiology, University of Wisconsin, Madison, Wis (B.P.S.)
| | - Sarah E Stilwill
- From the Department of Diagnostic Radiology (J.D.O., S.E.S., L.E.J., M.R., A.M.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; and the Department of Diagnostic Radiology, University of Wisconsin, Madison, Wis (B.P.S.)
| | - Leif E Jensen
- From the Department of Diagnostic Radiology (J.D.O., S.E.S., L.E.J., M.R., A.M.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; and the Department of Diagnostic Radiology, University of Wisconsin, Madison, Wis (B.P.S.)
| | - Maryam Rezvani
- From the Department of Diagnostic Radiology (J.D.O., S.E.S., L.E.J., M.R., A.M.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; and the Department of Diagnostic Radiology, University of Wisconsin, Madison, Wis (B.P.S.)
| | - Akram M Shaaban
- From the Department of Diagnostic Radiology (J.D.O., S.E.S., L.E.J., M.R., A.M.S.), University of Utah, 30 North 1900 East, #1A71, Salt Lake City, UT 84132; and the Department of Diagnostic Radiology, University of Wisconsin, Madison, Wis (B.P.S.)
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Restellini S, Chazouillères O, Frossard JL. Hepatic manifestations of inflammatory bowel diseases. Liver Int 2017; 37:475-489. [PMID: 27712010 DOI: 10.1111/liv.13265] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 09/27/2016] [Indexed: 12/18/2022]
Abstract
Inflammatory bowel diseases are associated with various hepatobiliary disorders, reported both in Crohn's disease and ulcerative colitis. They may occur at any moment in the natural course of the disease. The prevalence of liver dysfunction rises from 3% to 50% accordingly to definitions used in different studies. Fatty liver is considered as the most common hepatobiliary complication in inflammatory bowel diseases while primary sclerosing cholangitis is the most specific one. Less frequently, inflammatory bowel diseases-associated hepatobiliary disorders include: autoimmune hepatitis/ primary sclerosing cholangitis overlap syndrome, IgG4-associated cholangiopathy, primary biliary cholangitis, hepatic amyloidosis, granulomatous hepatitis, cholelithiasis, portal vein thrombosis and liver abscess. The spectrum of these manifestations varies according to the type of inflammatory bowel diseases. Treatments of inflammatory bowel diseases may cause liver toxicity, although incidence of serious complications remains low. However, early diagnosis of drug-induced liver injury is of major importance as it affects future clinical management. When facing abnormal liver tests, clinicians should undertake a full diagnostic work-up in order to determine whether the hepatic abnormalities are related to the inflammatory bowel diseases or not. Management of hepatic manifestations in inflammatory bowel diseases usually involves both hepatologists and gastroenterologists because of the complexity of some situations.
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Affiliation(s)
- Sophie Restellini
- Service de Gastroentérologie et Hépatologie, Hôpitaux Universitaires de Genève, Genève, Suisse
| | - Olivier Chazouillères
- Division d'Hépatologie, Centre de Référence des Maladies Inflammatoires des Voies Biliaires, et Université de Sorbonne, UPMC Univ Paris 06, UMR_S 938, CDR Saint-Antoine, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Jean-Louis Frossard
- Service de Gastroentérologie et Hépatologie, Hôpitaux Universitaires de Genève, Genève, Suisse
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Gu J, Stocchi L, Gorgun E, Remzi FH. Risk factors associated with portomesenteric venous thrombosis in patients undergoing restorative proctocolectomy for medically refractory ulcerative colitis. Colorectal Dis 2016; 18:393-9. [PMID: 26773547 DOI: 10.1111/codi.13275] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 09/05/2015] [Indexed: 02/08/2023]
Abstract
AIM Data on risk factors for portomesenteric venous thrombosis (PMVT) following abdominal surgery for ulcerative colitis (UC) are limited. The aim of this study was to investigate factors associated with PMVT after surgical treatment for UC. METHOD Patients who underwent restorative proctocolectomy (RPC) and ileal pouch-anal anastomosis (IPAA) including diverting ileostomy closure for medically refractory UC were identified from a prospectively maintained database. Patient-related, disease-related and treatment-related variables were collected. Univariable and multivariable analyses were performed to assess factors associated with PMVT. RESULTS Of the 521 patients completing surgical treatment for UC between 2006 and 2012, symptomatic PMVT occurred in 36 (7%), which resulted in a significantly increased hospital stay (P < 0.001). Patients developing PMVT were younger (P = 0.014), had a lower preoperative albumin level (P = 0.037) and were more likely to have been taking steroids within 1 month before surgery (P = 0.006). The combined incidence of PMVT was comparable between patients having a three-stage and two-stage management (6% vs. 8%, P = 0.43), but the relative incidence of PMVT after RPC + IPAA was 8%, significantly higher than the 4% after total abdominal colectomy (TAC) (P = 0.005) and the 2% after subsequent completion proctectomy (CP) + IPAA (P = 0.038). Multivariate analysis confirmed that RPC + IPAA was associated with a significantly greater risk of PMVT than CP + IPAA (OR = 4.9, P = 0.003) or TAC (OR = 3.5, P = 0.011). Preoperative steroid use was an independent factor for PMVT (OR = 5.8, P = 0.006). CONCLUSION Steroid use 1 month before surgery is associated with an increased risk of PMVT. A staged restorative proctocolectomy does not increase the overall incidence of PMVT.
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Affiliation(s)
- J Gu
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - L Stocchi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - E Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - F H Remzi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Allaix ME, Krane MK, Zoccali M, Umanskiy K, Hurst R, Fichera A. Postoperative portomesenteric venous thrombosis: lessons learned from 1,069 consecutive laparoscopic colorectal resections. World J Surg 2014; 38:976-84. [PMID: 24240673 DOI: 10.1007/s00268-013-2336-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Portomesenteric venous thrombosis (PVT) is a known complication after open and laparoscopic colorectal (LCR) surgery. Risk factors and the prognosis of PVT have been poorly described. METHODS This study is a retrospective analysis of a prospectively collected database. Patients with new-onset postoperative abdominal pain were evaluated with a computed tomography scan of the abdomen. Patients found to have PVT were analyzed. A multivariate analysis was performed to identify predictors of PVT. RESULTS A total of 1,069 patients undergoing LCR surgery for inflammatory bowel disease (IBD) or nonmetastatic cancer between June 2002 and June 2012 were included. Altogether, 37 (3.5 %) patients experienced symptomatic postoperative PVT. On univariate analysis, IBD (p < 0.001), ulcerative colitis (p = 0.016), preoperative therapy with steroids (p = 0.008), operative time ≥220 min (p = 0.004), total proctocolectomy (TPC) (p < 0.001), ileoanal pouch anastomosis (p = 0.006), and postoperative intraabdominal septic complications (p < 0.001) were found to be significant risk factors. By multivariate analysis, TPC (p = 0.026) and postoperative intraabdominal septic complications (p < 0.001) were independent predictors of PVT. In the PVT group, postoperative length of stay was longer (14.8 vs. 7.4 days, p < 0.001). Of the patients evaluated with a hematologic workup, 72.7 % were found to have a hypercoagulable condition. All patients were managed with oral anticoagulation for at least 6 months. No death or complications related to PVT occurred. CONCLUSIONS PVT is a potentially serious complication that is more likely to occur after TPC and in the presence of postoperative intraabdominal septic complications, particularly in patients with a coagulation disorder. Prompt diagnosis and treatment with oral anticoagulation are recommended to avoid long-term sequelae.
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Affiliation(s)
- Marco E Allaix
- Department of Surgery, University of Chicago Medical Center, MC 5095, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA,
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Gizard E, Ford AC, Bronowicki JP, Peyrin-Biroulet L. Systematic review: The epidemiology of the hepatobiliary manifestations in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2014; 40:3-15. [PMID: 24815622 DOI: 10.1111/apt.12794] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 12/31/2013] [Accepted: 04/22/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Extraintestinal manifestations are frequent in inflammatory bowel diseases (IBD). Most studies published so far focused on viral hepatitis and liver toxicity of IBD-related drugs. AIM To conduct a systematic review of hepatobiliary manifestations associated with IBD. We excluded viral hepatitis and liver toxicity of IBD-related drugs. METHODS Studies were identified through the electronic database of MEDLINE, EMBASE and the annual meetings of Digestive Disease Week, the American College of Gastroenterology, the United European Gastroenterology Week and the European Crohn's and Colitis Organization. RESULTS One hundred and forty six articles were included in this systematic review. Cholelithiasis is more frequent in Crohn's disease (CD) than in general population. Prevalence of cholelithiasis in CD ranged from 11% to 34%, whereas it ranges from 5.5% to 15% in non-IBD patients. PSC is more frequent in UC than in CD. Prevalence of PSC ranges from 0.76% to 5.4% in UC and from 1.2% to 3.4% in CD. There is a male predominance when PSC is associated with UC, with a male/female ratio ranging from 65/35 to 70/30. No conclusion can be made on a possible increased risk of gall-bladder carcinoma. Mean prevalence of fatty liver is 23% (range, 1.5-55%). Hepatic amyloidosis occurs in less than 1% of IBD. Liver abscess is encountered mainly in CD. Portal vein thrombosis occurs in 39% to 45% of IBD patients undergoing proctocolectomy. CONCLUSIONS Hepatobiliary manifestations associated with inflammatory bowel diseases are frequent and probably underdiagnosed.
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Affiliation(s)
- E Gizard
- Inserm U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy-Brabois, Université de Lorraine, Vandoeuvre-lès-Nancy, France
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Intra-abdominal venous thrombosis after colectomy in pediatric patients with chronic ulcerative colitis: incidence, treatment, and outcomes. J Pediatr Surg 2014; 49:614-7. [PMID: 24726123 DOI: 10.1016/j.jpedsurg.2013.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 10/08/2013] [Accepted: 10/09/2013] [Indexed: 01/06/2023]
Abstract
PURPOSE Children with chronic ulcerative colitis (CUC) are at increased risk for venous thromboembolism, especially after colectomy procedures. We aim to review our patients with CUC who underwent a colectomy and suffered intra-abdominal thrombosis; moreover we wanted to define thrombotic incidence and outcomes METHODS In this is IRB approved retrospective study, we reviewed our patients who underwent colectomy for CUC from January 1999 to December 2011 for development of intra-abdominal thrombosis. RESULTS Of 366 patients with CUC who underwent colectomy, 15 (4%) were diagnosed with a venous thromboembolism. All patients presented with acute abdominal pain. The locations of thrombus formation varied: 13 (87%) developed thrombi in the portal vein, 4 (27%) in the splenic vein, 2 (13%) in the superior mesenteric vein, 1 (7%) in the hepatic vein, and 1 (7%) in the hepatic artery. The mean number of post-operative days at diagnosis of thrombus was 38.7 days (range 3-180 days). Fourteen patients (93%) underwent anticoagulation for treatment. The mean number of days of anticoagulant therapy until documented resolution of thrombus on imaging was 96.3 days (range 14-364 days). All thrombi resolved with therapy. There was no mortality during follow-up. CONCLUSIONS Four percent of our pediatric patients with chronic ulcerative colitis who underwent colectomy developed symptomatic intra-abdominal venous thromboembolism. 3 to 6 months of anticoagulant therapy is adequate treatment in almost all patients. Practitioners should have a high index of suspicion for intra-abdominal venous thrombus when these patients complain of abdominal pain postoperatively. Based on our experience, prophylactic anticoagulation should be strongly considered peri-operatively in this population.
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Uyeda JW, LeBedis CA, Penn DR, Murakami AM, Ramalingam V, Anderson SW, Soto JA, Gupta A. Ileal pouch-anal anastomosis surgery: anatomy, postoperative complications, and image-guided intervention. Semin Ultrasound CT MR 2014; 34:299-310. [PMID: 23895903 DOI: 10.1053/j.sult.2013.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) surgery has become the surgical procedure of choice for chronic ulcerative colitis and familial adenomatous polyposis. Since its introduction in 1978, the technique of ileal pouch-anal anastomosis has improved and is commonly performed. Although associated with low mortality, postsurgical complications are frequent with which the radiologist should be familiar. An understanding of surgical technique and postsurgical anatomy facilitates the diagnosis of these frequently encountered complications and governs their potential image-guided intervention.
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Affiliation(s)
- Jennifer W Uyeda
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Li C, Hu A, Haacke M, Wang J, Zhao J, Zhou D. Direct portal vein thrombosis visualization with t2*--weighted magnetic resonance imaging. Int J Med Sci 2013; 10:1570-4. [PMID: 24046533 PMCID: PMC3775116 DOI: 10.7150/ijms.6681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 08/12/2013] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND PURPOSE To investigate the feasibility of direct magnetic resonance portal vein thrombosis (PVT) visualization with T2*-weighted imaging (T2*WI) without contrast agent. METHODS Thirty patients with PVT were included in this study. All of them were imaged with contrast-enhanced CT (CE-CT) as well as non-contrast MRI T1, T2 and T2*WI. Imaging data was independently analyzed by two experienced radiologists. T2*WI of all PVT was compared slice-by-slice with each of the comparison sequences (T1WI, T2WI and CE-CT) on the following categories: the location, size, boundary, and conspicuity of thrombus and portal veins. RESULTS The average score of PVT visualization in T2*WI was higher than T1WI and T2WI in location, size, boundary and conspicuity (t = 7.54 - 84.16, P<0.05), and higher than CE-CT in boundary and conspicuity (t = 3.03- 6.98, P<0.05). For portal vein visualization, there was no significant score difference in left, middle and right portal veins between CE-CT and T2*WI (t = -1.76- 1.35, P>0.05). CONCLUSIONS Our results suggest T2*WI can characterize PVT accurately with high quality without the use of intravenous contrast agents.
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Affiliation(s)
- Chuanming Li
- 1. Department of Radiology, Southwest Hospital, Third Military Medical University, 30 Gaotanyan Road, Chongqing 400038, China
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The role of portal vein thrombosis in the clinical course of inflammatory bowel diseases: report on three cases and review of the literature. Gastroenterol Res Pract 2012; 2012:916428. [PMID: 23093957 PMCID: PMC3475311 DOI: 10.1155/2012/916428] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 09/01/2012] [Indexed: 12/13/2022] Open
Abstract
Inflammatory bowel diseases are associated with an increased risk of vascular complications. The most important are arterial and venous thromboembolisms, which are considered as specific extraintestinal manifestations of inflammatory bowel diseases. Among venous thromboembolism events, portal vein thrombosis has been described in inflammatory bowel diseases. We report three cases of portal vein thrombosis occurring in patients with active inflammatory bowel disease. In two of them, hepatic abscess was present. Furthermore, we performed a systematic review based on the clinical literature published on this topic.
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Liver disorders in inflammatory bowel disease. Gastroenterol Res Pract 2012; 2012:642923. [PMID: 22474447 PMCID: PMC3296398 DOI: 10.1155/2012/642923] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Accepted: 11/30/2011] [Indexed: 02/07/2023] Open
Abstract
Disorders of the hepatobiliary system are relatively common extraintestinal manifestations of inflammatory bowel disease (IBD). These disorders are sometimes due to a shared pathogenesis with IBD as seen in primary sclerosing cholangitis (PSC) and small-duct primary sclerosing cholangitis (small-duct PSC). There are also hepatobiliary manifestations such as cholelithiasis and portal vein thrombosis that occur due to the effects of chronic inflammation and the severity of bowel disease. Lastly, medications used in IBD such as sulfasalazine, thiopurines, and methotrexate can adversely affect the liver. It is important to be cognizant of these disorders as some do have serious long-term consequences. The management of these disorders often requires the expertise of multidisciplinary teams to achieve the best outcomes.
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Abstract
One of typical examples of liver-gut cross talk is the interaction and impact of inflammatory bowel disease (IBD) and hepatobiliary (HB) abnormalities on each other's disease course. There are several layers of association between IBD and HB diseases: (i) HB diseases and IBD share pathogenetic mechanisms; (ii) HB diseases parallel structural and pathophysiological changes seen with IBD; and (iii) hepatic toxicity is associated with medical therapy for IBD. Interdisciplinary approach, involving gastroenterologists, hepatologists and, in advanced cases, general, colorectal, and liver transplant surgeons, is advocated.
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Affiliation(s)
- Preethi Gk Venkatesh
- Department of Gastroenterology/Hepatology, Digestive Disease Institute, the Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Navaneethan U, Venkatesh PGK, Shen B. Risks and benefits of ileal pouch–anal anastomosis for ulcerative colitis. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/thy.10.87] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Navaneethan U, Shen B. Hepatopancreatobiliary manifestations and complications associated with inflammatory bowel disease. Inflamm Bowel Dis 2010; 16:1598-619. [PMID: 20198712 DOI: 10.1002/ibd.21219] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diseases involving the hepatopancreatobiliary (HPB) system are frequently encountered in patients with inflammatory bowel disease (IBD). Hepatobiliary manifestations constitute some of the most common extraintestinal manifestations of IBD. They appear to occur with similar frequency in patients with Crohn's disease or ulcerative colitis. HPB manifestations may occur in following settings: 1) disease possibly associated with a shared pathogenetic mechanism with IBD including primary sclerosing cholangitis (PSC), small-duct PSC/pericholangitis and PSC/autoimmune hepatitis overlap, acute and chronic pancreatitis related to IBD; 2) diseases which parallel structural and physiological changes seen with IBD, including cholelithiasis, portal vein thrombosis, and hepatic abscess; and 3) diseases related to adverse effects associated with treatment of IBD, including drug-induced hepatitis, pancreatitis (purine-based agents), or liver cirrhosis (methotrexate), and reactivation of hepatitis B, and biologic agent-associated hepatosplenic lymphoma. Less common HPB manifestations that have been described in association with IBD include autoimmune pancreatitis (AIP), IgG4-associated cholangitis (IAC), primary biliary cirrhosis (PBC), fatty liver, granulomatous hepatitis, and amyloidosis. PSC is the most significant hepatobiliary manifestation associated with IBD and poses substantial challenges in management requiring a multidisciplinary approach. The natural disease course of PSC may progress to cirrhosis and ultimately require liver transplantation in spite of total proctocolectomy with ileal-pouch anal anastomosis. The association between AIP, IAC, and elevated serum IgG4 in patients with PSC is intriguing. The recently reported association between IAC and IBD may open the door to investigate these complex disorders. Further studies are warranted to help understand the pathogenesis of HPB manifestations associated with IBD, which would help clinicians better manage these patients. An interdisciplinary approach, involving gastroenterologists, hepatologists, and, in advanced cases, general, colorectal, and transplant surgeons is advocated.
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Ibele AR, Kennedy GD, Lund DP, Nichol PF. Portal vein thrombus after pediatric proctocolectomy with ileoanal anastomosis. J Pediatr Surg 2010; 45:1026-9. [PMID: 20438948 DOI: 10.1016/j.jpedsurg.2010.02.063] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 02/14/2010] [Accepted: 02/15/2010] [Indexed: 11/24/2022]
Abstract
In adults, mesenteric venous thrombosis with extension into the portal system is a known complication of total proctocolectomy with pouch ileoanal anastomosis. Although frequently reported in adults, this complication is rare in pediatric patients undergoing this operation. We report 2 cases of adolescent patients with ulcerative colitis who experienced portal vein thrombosis after this procedure. Both were treated with systemic anticoagulation therapy with complete resolution of their clots. We recommend that mesenteric/portal venous thrombosis be considered in the differential diagnosis in any child presenting with fever, abdominal pain, and leukocytosis after restorative proctocolectomy with ileal pouch anastomosis and that imaging obtained to evaluate abdominal complaints in this population be directed toward ruling out this complication.
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Affiliation(s)
- Anna R Ibele
- Department of General Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI 53792, USA.
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Broder JC, Tkacz JN, Anderson SW, Soto JA, Gupta A. Ileal Pouch–Anal Anastomosis Surgery: Imaging and Intervention for Post-operative Complications. Radiographics 2010; 30:221-33. [DOI: 10.1148/rg.301095084] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Wang L, Li ZS, Lu JP, Wang F, Liu Q, Tian JM. Cavernous transformation of the portal vein: three-dimensional dynamic contrast-enhanced MR angiography. ACTA ACUST UNITED AC 2008; 33:463-8. [PMID: 17703273 DOI: 10.1007/s00261-007-9292-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND To investigate characteristic features of three-dimensional dynamic contrast-enhanced MR angiography (3D DCE-MRA) and validate its clinical significance for the diagnosis of cavernous transformation of the portal vein (CTPV). METHODS 3D DCE-MRA, along with subsequent data processing using three-dimensional reconstruction, was performed in 33 CTPV patients. We observed 33 emboli in the portal vein, 29 in the left and/or right portal branches, 18 in the superior mesenteric vein, and nine emboli in the splenic vein. RESULTS The main presentation of CTPV on 3D DCE-MRA was the replacement of the normal configuration of the portal vein by numerous distorted hepatopetal collateral vessels, the presence of arterio-portal venous shunts, and the appearance of hepatofugal collateral vessels in the abdominal cavity and wall. CONCLUSION 3D DCE-MRA can be used to simultaneously characterize the portal system and collateral vessels, and can improve the diagnosis and clinical treatment of CTPV.
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Affiliation(s)
- Li Wang
- Department of Radiology, Changhai Hospital, Shanghai, 200433, China
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Shen B, Remzi FH, Lavery IC, Lashner BA, Fazio VW. A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy. Clin Gastroenterol Hepatol 2008; 6:145-58; quiz 124. [PMID: 18237865 DOI: 10.1016/j.cgh.2007.11.006] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.
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Affiliation(s)
- Bo Shen
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
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Millan M, Hull TL, Hammel J, Remzi F. Portal vein thrombi after restorative proctocolectomy: serious complication without long-term sequelae. Dis Colon Rectum 2007; 50:1540-4. [PMID: 17701370 DOI: 10.1007/s10350-007-0297-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Portal vein thrombi have been observed after restorative proctocolectomy and ileal pouch-anal anastomosis, and present as a clinical spectrum of abdominal pain, fever, and leukocytosis. Anticoagulation treatment is usually associated with resolution of symptoms. However, the long-term consequences and effect on pouch function are not known. The purpose of this study was to analyze the long-term functional outcome of patients with confirmed portal vein thrombi after restorative proctocolectomy. METHODS A retrospective study of all patients undergoing restorative proctocolectomy from January 1997 to 2000 was performed. A case-control study was designed that matched 37 patients with confirmed portal vein thrombi in this period with 133 patients without portal vein thrombi; the groups were compared with respect to pouch function and quality of life by using the Global Cleveland Clinic Quality of Life Questionnaire for pelvic pouch patients. RESULTS The mean follow-up was 4.73 (range, 4.21-7.28) years. The percentage of male patients was 58.8. The most common diagnosis was ulcerative colitis (62.4 percent). There were no significant differences between portal vein thrombi patients and controls with respect to pouch function (number of bowel movements, urgency, incontinence), episodes of pouchitis, or quality of life. CONCLUSIONS Portal vein thrombi can be a serious complication after restorative proctocolectomy that usually resolves with anticoagulation therapy. Long-term pouch function and quality of life are not affected.
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Affiliation(s)
- M Millan
- Colorectal Surgery Unit, Department of Surgery, Bellvitge University Hospital, L' Hospitalet de Llobregat, Barcelona, Spain
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Ball CG, MacLean AR, Buie WD, Smith DF, Raber EL. Portal vein thrombi after ileal pouch-anal anastomosis: its incidence and association with pouchitis. Surg Today 2007; 37:552-7. [PMID: 17593473 DOI: 10.1007/s00595-006-3470-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Accepted: 11/30/2006] [Indexed: 12/15/2022]
Abstract
PURPOSE Portal vein thrombi (PVT) have recently been linked to ileal pouch-anal anastomosis (IPAA). We assessed the rate of PVT in patients who underwent IPAA and attempted to identify the associated features. METHODS We reviewed all patients who underwent IPAA at our hospital between 1997 and 2002, noting demographic, operative, and clinical data. Computed tomography (CT) scans were independently re-reviewed by two radiologists blinded to patient data. Scans were designated as positive, negative, or indeterminate for PVT. RESULTS A total of 112 patients underwent IPAA for ulcerative colitis, 28 (25%) of whom had a CT scan done within 8 weeks postoperatively. The indications for CT included prolonged ileus (32.1%), abdominal pain (28.6%), and fever (17.9%). On examining the CT scans, 39% were positive, 14% were indeterminate, and 46% were negative for PVT. There was no association between PVT and pelvic sepsis. Within a mean follow-up of 36.2 months, 15.4% patients without PVT had suffered pouchitis compared with 25% of those with indeterminate scans and 45.5% of those with PVT. CONCLUSIONS Portal vein thrombi are a common finding in the subset of patients who require a CT scan after IPAA. Patients who suffer PVT have a higher incidence of postoperative pouchitis. Thus a prospective evaluation of the risk of PVT and its association with pouchitis is warranted.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, Foothills Medical Centre, University of Calgary, 1403-29 Street N.W., Calgary, AB, T2N 2T9, Canada
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Scheirey CD, Scholz FJ. Radiographic Evaluation of the Ileal-Pouch Anal Anastomosis. SEMINARS IN COLON AND RECTAL SURGERY 2007. [DOI: 10.1053/j.scrs.2007.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Choi SH, Lee JM, Lee KH, Kim SH, Kim YJ, An SK, Han JK, Choi BI. Relationship Between Various Patterns of Transient Increased Hepatic Attenuation on CT and Portal Vein Thrombosis Related to Acute Cholecystitis. AJR Am J Roentgenol 2004; 183:437-42. [PMID: 15269038 DOI: 10.2214/ajr.183.2.1830437] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We sought to investigate the prevalence of portal vein thrombosis in patients with acute cholecystitis and the relationship between portal vein thrombosis and the various patterns of transient increased hepatic attenuation on CT. MATERIALS AND METHODS We studied 72 of 107 patients with acute cholecystitis who, during a 3-year period, underwent dual-phase contrast-enhanced CT before percutaneous cholecystostomy or cholecystectomy. CT scans were retrospectively reviewed for the presence of portal vein thrombosis and location of the thrombi and for patterns of transient increased hepatic attenuation, which were classified as either pericholecystic, segmental, or mixed. RESULTS Portal vein thrombi (two in hepatic segment IV, three in the left portal vein, and one in the right posterior portal vein) were found in six (8.3%) of 72 patients, and in those patients, transient increased attenuation with a segmental (five patients) or mixed (one patient) pattern was seen on CT. The pattern of transient increased attenuation in the 54 patients without portal vein thrombosis was pericholecystic in 41 (75.9%) and mixed in 13 (24.1%). Nineteen patients had segmental distribution (segmental or mixed pattern) that in 31.6% (6/19) of the patients was associated with portal vein thrombosis. Segmental distribution was more frequently found in those patients who had acute cholecystitis with portal vein thrombosis than in those who had only acute cholecystitis (p = 0.001). CONCLUSION In patients with acute cholecystitis, portal vein thrombosis is not uncommon. Patterns of transient increased hepatic attenuation were found to vary, depending on the presence or absence of portal vein thrombosis.
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Affiliation(s)
- Seung Hong Choi
- Department of Radiology and Institute of Radiation Medicine, Seoul National University Hospital, 28, Yongon-dong, Chongno-gu, Seoul 110-744, South Korea
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