A review of ischemic colitis: is our clinical recognition and management adequate?

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

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

Uncommon Etiologies of Acute Abdominal Pain: A Case Report on Omental Infarction

Omental infarction is an uncommon cause of abdominal pain. The condition is often misdiagnosed due to its clinical similarity to more common abdominal pathologies like appendicitis and cholecystitis. This report presents the case of a 57-year-old female with a one-week history of left-sided abdominal pain, initially aggravated by eating and defecation. The patient, a long-term smoker with a complex medical history that includes deep vein thrombosis and pulmonary embolism, was hemodynamically stable on presentation. A CT scan revealed a nodular infiltration consistent with an omental infarct. Conservative management was pursued, resulting in symptom resolution by the third day of hospitalization. This case underscores the diagnostic challenges associated with omental infarction, particularly its differentiation from other causes of acute abdominal pain. It highlights the importance of considering rare etiologies in patients with atypical presentations and emphasizes the role of imaging, particularly CT scans, in accurate diagnosis. The patient's successful conservative management aligns with current recommendations, which advocate for non-surgical treatment in most cases. This approach avoids unnecessary surgical interventions and ensures a favorable prognosis with low complication rates in patients with prompt and appropriate management.

An arteriovenous malformation associated ischemic colitis in the setting of acute gastrointestinal clostridium difficile colitis and intestinal amebiasis: A case report

BACKGROUND

There is one reported case of inferior mesenteric arteriovenous malformation presenting as ischemic colitis after an episode of gastrointestinal infection. We documented this case to emphasize the possible association between ischemic colitis and vascular malformations. In addition, this is the number 15th case in the literature about this association.

CASE SUMMARY

A 40 years old male patient presented with abdominal pain and diarrhea of 10 days duration after he was diagnosed and managed as a case of Clostridium Difficile infection and amebiasis. Computed tomography angiography revealed a vascular malformation of the inferior mesenteric artery, repeated colonoscopy showed ulceration and sloughing of the mucosa, he underwent Hartmann's procedure due to colonic ischemia diagnosed by the previous measures. Later on he had a colostomy closure and end to end colorectal anastomosis.

CONCLUSION

There is a possible association between acute gastrointestinal infection and ischemic colitis in the setting of arteriovenous malformation.

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Risk factors and characteristics associated with nonalcoholic fatty liver disease in patients with ischemic colitis

BACKGROUND

Ischemic colitis (IC) was investigated to be associated with dyslipidemia and subcutaneous adipose tissue. Nonalcoholic fatty liver disease (NAFLD) is associated with ischemic diseases such as coronary heart disease, ischemic stroke. But there is a paucity of data regarding the association between NAFLD and IC. NAFLD may be associated with the treatment and prognosis of IC. We investigated risk factors and characteristics associated with NAFLD in patients with IC.

METHODS

Patients with IC (NAFLD: 34 and controls: 81) from Zhongnan Hospital were investigated retrospectively from January 2012 to December 2018. Clinical data were compared by chi-square tests or independent samples T-tests. Binary logistic regressions and Kaplan-Meier analysis were performed to evaluate risk factors and prognosis, respectively.

RESULTS

NAFLD was diagnosed in 28.19% patients with IC. In the logistic regression analysis, hypertension [odds ratio (OR) 3.523; P = 0.019], elevated alanine aminotransferase (ALT) (OR 6.278; P = 0.048), elevated triglyceride (OR 4.667; P = 0.003) and increased weight (OR 1.055; P = 0.039) were risk factors of NAFLD in patients with IC. Patients with NAFLD were more likely to require the vasodilators (P = 0.011) and get a relapse of IC (P = 0.011).

CONCLUSION

NAFLD was found in 28.19% of patients with IC. Hypertension, increased weight, elevated ALT and triglyceride are independent predictors of NAFLD in patients with IC. NAFLD in patients with IC is associated with a greater probability of requiring for the vasodilators. NAFLD in IC and period of bowel rest are risk factors for the recurrence of IC.

Ischemic colitis after enema administration: Incidence, timing, and clinical features

BACKGROUND

Enema administration is a common procedure in the emergency department (ED). However, several published case reports on enema-related ischemic colitis (IC) have raised the concerns regarding the safety of enema agents. Nevertheless, information on its true incidence and characteristics are still lacking.

AIM

To investigate the incidence, timing, and risk factors of IC in patients receiving enema.

METHODS

We consecutively collected the data of all adult patients receiving various enema administrations in the ED from January 2010 to December 2018 and identified patients confirmed with IC following enema. Of 8320 patients receiving glycerin enema, 19 diagnosed of IC were compared with an age-matched control group without IC.

RESULTS

The incidence of IC was 0.23% among 8320 patients receiving glycerin enema; however, there was no occurrence of IC among those who used other enema agents. The mean age ± standard deviation (SD) of patients with glycerin enema-related IC was 70.2 ± 11.7. The mean time interval ± SD from glycerin enema administration to IC occurrence was 5.5 h ± 3.9 h (range 1-15 h). Of the 19 glycerin enema-related IC cases, 15 (79.0%) were diagnosed within 8 h. The independent risk factors for glycerin-related IC were the constipation score [Odds ratio (OR), 2.0; 95% confidence interval (CI): 1.1-3.5, P = 0.017] and leukocytosis (OR, 4.5; 95%CI: 1.4-14.7, P = 0.012).

CONCLUSION

The incidence of glycerin enema-related IC was 0.23% and occurred mostly in the elderly in the early period following enema administration. Glycerin enema-related IC was associated with the constipation score and leukocytosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Management of elderly ulcerative colitis in Japan

Japan has the largest aging society, where many elderly people have intractable diseases including ulcerative colitis (UC). Along with the increasing total number of UC patients, the number of elderly UC patients has also been increasing and will continue to do so in the future. Although the clinical features and natural history of UC in the elderly have many similarities with UC in the non-elderly population, age-specific concerns including comorbidities, immunological dysfunction, and polypharmacy make the diagnosis and management of elderly UC challenging compared to UC in non-elderly patients. Based on increasing data related to elderly UC patients from Japan, as well as other countries, we reviewed the epidemiology, clinical course, differential diagnosis, management of comorbidities, surveillance, medical therapy, and surgery of UC in the elderly.

Therapeutic effects of Ginkgo biloba extract against acute ischemic colitis

Ginkgo biloba extract (GBE) is a plant extract obtained from the leaves of G biloba tree. The aim of this study was to evaluate the clinicopathologic characteristics and therapeutic effects of GBE on ischemic colitis (IC).Forty-seven patients with IC were divided as GBE group (n = 30) and routine group (n = 17). The routine group was given routine therapy, and the GBE group was given routine therapies plus GBE intravenous injection. Clinicopathologic characteristics, endoscopy findings, serum antioxidant enzymes, and inflammatory mediators were evaluated.About 89.3% initial symptom was acute-onset abdominal cramping and abdominal pain followed with hematochezia. The lesions were mainly located in sigmoid colon (80.8%). Serum level of superoxide dismutase (SOD) in patients with IC was significantly decreased (P < .05), while methane dicarboxylic aldehyde (MDA), tumor necrosis factor alpha (TNF-α), and interleukin-6 (IL-6) levels were significantly increased (P < .05). However, serum procalcitonin (PCT) level showed no significant change. Treatment of GBE resulted in quick remittance of abdominal pain and hematochezia, and significant attenuation of colon macroscopic and histologic damage in all patients. Furthermore, the treatment also significantly increased SOD levels, decreased MDA, TNF-α, and IL-6 levels (P < .05).Acute-onset abdominal cramping or abdominal pain followed with hematochezia was the mainly initial symptom of IC, and sigmoid and descending colons were the common vulnerable sites. GBE exerted a beneficial effect on IC with faster symptom relief and better mucosal healing, possibly through scavenging oxidative-free radicals and downregulating inflammatory mediators. GBE may be a promising candidate for protection against IC.

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.

Delayed intestinal stricture following non-resectional treatment for non-occlusive mesenteric ischemia associated with hepatic portal venous gas: a case report

Background

Hepatic portal venous gas associated with non-occlusive mesenteric ischemia is indicative of a serious pathology that leads to bowel necrosis and it has a high mortality rate. Although non-occlusive mesenteric ischemia is acknowledged as a condition that requires early surgical treatment, it has been reported that bowel necrosis and surgical resection of the gangrenous lesion may be avoided if the condition is identified quickly and the cause is detected at an early phase. However, no reports or guidelines have been published that describe the management of patients in whom bowel necrosis and surgical treatment were avoided. We report the case of a patient who presented with non-occlusive mesenteric ischemia who was managed with non-resectional treatment at an early phase and had a delayed small-bowel stricture.

Case presentation

A 24-year-old man presented to the hospital with fever, abdominal pain, and vomiting. Abdominal computed tomography confirmed a diffuse gaseous distention with small-bowel pneumatosis and hepatic portal venous gas. An urgent laparotomy was performed, because septic shock associated with diffuse peritonitis and bowel necrosis was strongly suspected. Although we found purulent ascites and a perforated appendix at the time of surgery, gangrenous and transmural ischemic changes were not evident in the small bowel and colon. We performed an appendectomy without a bowel resection, and the patient was discharged on an oral diet. However, he was re-admitted to hospital, because 4 days after discharge he developed postoperative paralytic ileus. Non-operative management was chosen, but his symptoms did not improve. We decided to perform a laparotomy 40 days after the initial operation, and a considerable adhesion was detected. Therefore, only a synechotomy was performed. On day 57, he experienced symptoms that were associated with bowel obstruction once again. On day 59, a partial resection of the jejunum was performed. Severe luminal strictures were apparent within the jejunum, and marked structural changes were evident.

Conclusion

While non-surgical management can be chosen for selected patients with non-occlusive mesenteric ischemia, continuous observation to evaluate the development of delayed strictures that lead to bowel obstructions is required in patients who undergo non-resectional treatment.

Comparison of clinical characteristics of ischemic colitis between young and elderly patients

AIM: To analyze the clinical characteristics of ischemic colitis (IC) in different age groups.

METHODS: Sixty-eight inpatients diagnosed with IC over the past 6 years were collected. The clinical manifestations, findings on diagnostic colonoscopy, associated medical problems or risk factors, and clinical outcome were reviewed. A comparison between two age groups (≤ 45 and > 45 years old) was conducted.

RESULTS: There were 13 young and 55 elderly patients. No significant difference was found in clinical manifestations between the two groups (P > 0.05). For findings on diagnostic colonoscopy, there were no significant differences in the rates of affected rectum, sigmoid colon, or sigmoid plus descending (P > 0.05), while the rates of affected descending colon, splenic flexure and proximal spleen curve area, and whole intestinal wall, as well as ulcer and pseudotumor appearance in the elderly group were significantly higher than those in the young group (P < 0.05). In the elderly group, the rate of basic diseases associated with vascular/hemodynamic abnormalities was significantly higher than that in the young group (83.6% vs 15.4%, P < 0.01), while the rate of taking oral-contraceptives was significantly higher in the young group (38.5% vs 0%, P < 0.01). There were 66 patients whose clinical symptoms were relieved in 24-72 h after treatment. The relief rates of abdominal pain (69.2% vs 32.7%) and bleeding (76.9% vs 40.0%) in 24 h were significantly higher in the young group (P < 0.05). The mucosal healing rate in 2 wk in the young group was higher than that in the elderly group (100% vs 67.3%, P < 0.05).

CONCLUSION: In IC patients, there is no significant difference in clinical manifestations between young and elderly patients. For younger population, the extent and severity of the involved colon are lower and it took shorter period of time for symptom relief with treatment. Oral contraceptives and vascular/hemodynamic abnormalities may be important risk factors in the age ≤ 45 and >45 groups, respectively.