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

Ischemic colitis induced by a platelet-raising capsule: A case report

BACKGROUND

Ischemic colitis (IC) is also known as colon ischemia and is caused by colon vascular occlusion or nonocclusion, which results in a reduced blood supply to the colon and is not significant enough to maintain the metabolic function of cells, leading to intestinal wall ischemia. Its main symptoms include abdominal pain, diarrhea, and bloody stool. In severe cases, intestinal gangrene, peritonitis, intestinal stenosis and even intestinal obstruction may occur. IC induced by long-term use of certain special drugs is relatively rare in clinical practice. This article describes the clinical diagnosis and treatment of a typical case and provides a new treatment idea for the treatment of IC.

CASE SUMMARY

The patient was admitted to the hospital with "abdominal pain for half a month and bloody stool with mucous and pus for 3 d" and was diagnosed with "IC". Symptomatic and supportive treatment, such as antibiotics (levofloxacin), acid inhibition and stomach protection, fluid replenishment, and intravenous nutrition, was given. The patient's colonic ulcers were considered to be related to the oral administration of platelet (PLT)-raising capsules; the patient was asked to stop PLT-raising drugs for selective review via colonoscopy, and antibiotics and mesalazine enteric-coated tablets were stopped. Under the guidance of hematology consultation, 60 mg of methylprednisolone was given in combination with PLT infusion to increase the PLT. After treatment, the patient's condition stabilized, the patient's stool turned yellow, the patient's symptoms improved, and the patient was allowed to leave the hospital.

CONCLUSION

PLT-raising capsules can lead to IC, so clinicians should have a full understanding of the application of these drugs in the treatment of various causes of thrombocytopenia, weigh the advantages and disadvantages, and observe patients closely.

Transarterial Chemoembolization-Induced Ischemic Colitis: A Rare Complication Due to Nontarget Embolization

Nontarget embolization is a rare complication that may occur after a patient undergoes transarterial chemoembolization as a localized treatment of hepatocellular carcinoma. This phenomenon can occur because of variations in arterial blood supply to the liver and ultimately can lead to ischemic complications in unintended locations. We describe a case of nontarget embolization during transarterial chemoembolization causing ischemic colitis because of anatomic variation in the origin of the right hepatic artery. This case highlights the importance of recognizing rare side effects associated with this procedure and the need for comprehensive imaging to assess for anatomical variation to avoid poor outcomes.

The association between irritable bowel syndrome and ischemic colitis: a systematic review and meta-analysis

INTRODUCTION

Studies have suggested an association between ischemic colitis and irritable bowel syndrome (IBS) although the results were inconsistent. This systematic review and meta-analysis were performed to comprehensively examine the association between IBS and ischemic colitis by identifying all available cohort and case-control studies and combining their effect estimates together.

EVIDENCE ACQUISITION

EMBASE, MEDLINE and Google Scholar databases were systematically reviewed up to June 2020. Eligible study had to be either cohort or case-control studies that evaluated whether patients with IBS have a higher risk of ischemic colitis than individuals without IBS. Point estimates and standard errors from each eligible study were combined together using the generic inverse variance method of DerSimonian and Laird.

EVIDENCE SYNTHESIS

The systematic review identified three cohort and eight case-control studies. The pooled analysis found a significantly higher risk of ischemic colitis among patient with IBS with the pooled odds ratio of 2.50 (95% CI, 2.00-3.14; I² 57%). Funnel plot was relatively symmetric and was not suggestive of presence of publication bias.

CONCLUSIONS

A significantly increased risk of ischemic colitis among patients with IBS was observed in this systematic review and meta-analysis.

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.

Development and validation of a composite score to predict severe forms of ischemic colitis

OBJECTIVE

To develop a simple scoring system in order to predict the risk of severe (death and/or surgery) ischemic colitis METHODS: In this retrospective study, 205 patients diagnosed with ischemic colitis in a tertiary hospital were consecutively included over a 6-year period. The study sample was sequentially divided into a training cohort (n = 103) and a validation cohort (n = 102). In the training cohort, multivariable analysis was used to identify clinical, biological, and CT variables associated with poor outcome and to build a risk scoring system. The discriminative ability of the score (sensitivity, specificity, positive predictive value, negative predictive value) was estimated in the two cohorts to externally validate the score, and a receiver operating characteristic curve was established to estimate the area under the curve of the score. Bootstrapping was used to validate the score internally.

RESULTS

In the training cohort, four independent variables were associated with unfavorable outcome: hemodynamic instability (2 pts), involvement of the small bowel (1 pt), paper-thin wall pattern (3 pts), no stratified enhancement pattern (1 pt). The score was used to categorize patients into low risk (score: 0, 1), high risk (score: 2-3), and very high risk (score: 4-7) groups with sensitivity and specificity of 97% and 67%, respectively, and a good discriminating capability, with a C-statistic of 0.94. Internal and external validation showed good discrimination capability (C-statistics of 0.9 and 0.84, respectively).

CONCLUSION

A simple risk score can stratify patients into three distinct prognosis groups, which can optimize patient management.

CLINICAL TRIAL NUMBER

NCT04662268 KEY POINTS: • Simple scoring system predicting the risk of severe ischemic colitis • First study to include CT findings to the clinical and biological data used to determine a severity score.

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.

Identification of Acute Mesenteric Ischemia on 18F-FDG PET/CT

ABSTRACT

Acute mesenteric ischemia resulting in bowel necrosis is a surgical emergency. First identification of acute mesenteric ischemia with FDG PET/CT is uncommon, because patients with bowel ischemia are usually diagnosed by other imaging methods such as CT. Nevertheless, prompt imager recognition of the PET/CT findings of mesenteric ischemia and necrosis is critical for proper triage of the patient to potentially lifesaving interventions. We present a 39-year-old woman with portal vein thrombosis who was sent for 18F-FDG PET/CT evaluation of a suspected pancreatic head neoplasm but was unexpectedly found to have ischemic and necrotic small bowel secondary to mesenteric venous infarction.

Gangrenous Ischemic Colitis Due to Acute Promyelocytic Leukaemia, and Myelofibrosis in a 62-year-old Man Suffering from ESRD; Case Report

Introduction and importance

Ischemic colitis, also rare, is the most common ischemic pathology of the digestive system. It usually affects the ageing population and those suffering from end-stage renal disease (ESRD), hypertension, and heart failure. Its incidence varies from 4.5 to 44 cases per 100,000 annually.

Case presentation

We have reported a case of gangrenous colitis in a 62-year-old man suffering from acute promyelocytic leukaemia (APL) and myelofibrosis. He had hypertension and ESRD due to obstructive uropathy from seven years ago in his past medical history. His recurrent constitutional symptoms and persistent leukocytosis of more than 20,000 in μL was always treated as catheter-related infection or sepsis until acute abdomen emerged. The surgical team encountered a vast gangrenous right hemicolon. The leukocytosis did not resolve. Thus, the haematological investigations proved APL with myelofibrosis. The affected colon was free of leukemic infiltration.

Clinical discussion

Hypoperfusion due to ESRD and hemodialysis accompanied with malignancy induced hypercoagulative state provided a context in which small vessels of the bowel were obstructed.

Conclusion

Malignancies are associated with thrombophilia, and colonic involvement is not always related to lymphatic infiltration in leukaemia patients.

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Ischemic colitis, also rare, is the most common ischemic pathology of the digestive system.

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Not every leukocytosis should be viewed as sepsis.

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Although rare, acute promyelocytic leukaemia can be accompanied by myelofibrosis.

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Ischemic colitis may be a result of a hypercoagulable state caused by leukaemias, not necessarily leukaemic invasion.

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The cecum is within a watershed of the colon in which incomplete anastomoses of the marginal arteries make its blood supply poor and vulnerable to ischemia.

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.

Maintaining oxygen delivery is crucial to prevent intestinal ischemia in critical ill patients

Background

Intestinal ischemia is a common complication with obscure pathophysiology in critically ill patients. Since insufficient delivery of oxygen is discussed, we investigated the influence of oxygen delivery, hemoglobin, arterial oxygen saturation, cardiac index and the systemic vascular resistance index on the development of intestinal ischemia. Furthermore, we evaluated the predictive power of elevated lactate levels for the diagnosis of intestinal ischemia.

Methods

In a retrospective case-control study data (mean oxygen delivery, minimum oxygen delivery, systemic vascular resistance index) of critical ill patients from 02/2009–07/2017 were analyzed using a proportional hazard model. General model fit and linearity were tested by likelihood ratio tests. The components of oxygen delivery (hemoglobin, arterial oxygen saturation and cardiac index) were individually tested in models.

Results

59 out of 874 patients developed intestinal ischemia. A mean oxygen delivery less than 250ml/min/m² (LRT vs. null model: p = 0.018; LRT for non-linearity: p = 0.012) as well as a minimum oxygen delivery less than 400ml/min/m² (LRT vs null model: p = 0.016; LRT for linearity: p = 0.019) were associated with increased risk of the development of intestinal ischemia. We found no significant influence of hemoglobin, arterial oxygen saturation, cardiac index or systemic vascular resistance index. Receiver operating characteristics analysis for elevated lactate levels, pH, CO₂ and central venous saturation was poor with an area under the receiver operating characteristic of 0.5324, 0.52, 0.6017 and 0.6786.

Conclusion

There was a significant correlation for mean and minimum oxygen delivery with the incidence of intestinal ischemia for values below 250ml/min/m² respectively 400ml/min/m². Neither hemoglobin, arterial oxygen saturation, cardiac index, systemic vascular resistance index nor elevated lactate levels could be identified as individual risk factors.

Low-dose aspirin and the severity of ıschemic colitis: A single-center retrospective study

BACKGROUND/AIMS

This retrospective study aimed to evaluate the effect of low-dose aspirin (50-150 mg/d) on the severity of ischemic colitis.

MATERIALS AND METHODS

A total of 244 patients admitted to our hospital for ischemic colitis between 2013 and 2018 were included in the study. Patients were divided into two groups-aspirin and non-aspirin groups-based on their recent history of aspirin use before the onset of ischemic colitis. Clinical performance, biochemical indices, and endoscopic findings were compared.

RESULTS

The average age and the proportion of underlying disease, including hypertension, cerebral infarction, and coronary heart disease in the aspirin group was significantly higher than those in the non-aspirin group (p<0.05). In terms of clinical symptoms, the proportion of diarrhea in the aspirin group was significantly higher than that in the non-aspirin group, while the proportion of abdominal pain was significantly lower in the aspirin group compared with the non-aspirin group. Colonoscopy results showed that the incidence of ulceration was significantly higher in the aspirin group than in the non-aspirin group (p<0.05).

CONCLUSION

The use of low-dose aspirin may aggravate the severity and mask the symptoms of abdominal pain in ischemic colitis.

Are bedside colonoscopies performed in intensive care unit really useful?

PURPOSE

Effectiveness of bedside Colonoscopies in Intensive Care Unit (CICU) might be limited by the poor quality of colonic preparation, and their feasibility. We sought to describe the indications and the profitability of CICU.

METHODS

Retrospective, bicenter observational study (2004-2015) in unselected critically ill patients. We questioned the clinical profitability of CICU, according to its indications and preparation.

RESULTS

One hundred and eleven CICU were performed in 84 patients (sex ratio 1.4, 49 M/35F; age 72.9 years [61.7-84.7]), for lower gastro-intestinal bleeding in 67 patients (LGIB, 60.3%) and for other causes in 44 (39.6%). The profitability was more frequent when CICU was performed for another reason than LGIB (75% vs 28.3%; p < 0.0001). Preparation was good in 47 procedures (42.3%) and allowed 33 complete CICU (29.7%). Fifty-six CICU (50.4%) were performed as a 2nd investigation after a contrast enhanced computed tomography. Three CICU were complicated by 3 hemodynamic and 2 respiratory failures, but none of them were fatal.

CONCLUSIONS

CICU is clinically useful in half of cases, in the diagnostic and the therapeutic management of critically ill patients. Its profitability is close to scheduled colonoscopies and superior in non-lower gastro-intestinal bleeding indications.

Gastrointestinal mucosal damage in patients with COVID-19 undergoing endoscopy: an international multicentre study

BACKGROUND

Although evidence suggests frequent gastrointestinal (GI) involvement during coronavirus disease 2019 (COVID-19), endoscopic findings are scarcely reported.

AIMS

We aimed at registering endoscopic abnormalities and potentially associated risk factors among patients with COVID-19.

METHODS

All consecutive patients with COVID-19 undergoing endoscopy in 16 institutions from high-prevalence regions were enrolled. Mann-Whitney U, χ2 or Fisher's exact test were used to compare patients with major abnormalities to those with negative procedures, and multivariate logistic regression to identify independent predictors.

RESULTS

Between February and May 2020, during the first pandemic outbreak with severely restricted endoscopy activity, 114 endoscopies on 106 patients with COVID-19 were performed in 16 institutions (men=70.8%, median age=68 (58-74); 33% admitted in intensive care unit; 44.4% reporting GI symptoms). 66.7% endoscopies were urgent, mainly for overt GI bleeding. 52 (45.6%) patients had major abnormalities, whereas 13 bled from previous conditions. The most prevalent upper GI abnormalities were ulcers (25.3%), erosive/ulcerative gastro-duodenopathy (16.1%) and petechial/haemorrhagic gastropathy (9.2%). Among lower GI endoscopies, 33.3% showed an ischaemic-like colitis.Receiver operating curve analysis identified D-dimers >1850 ng/mL as predicting major abnormalities. Only D-dimers >1850 ng/mL (OR=12.12 (1.69-86.87)) and presence of GI symptoms (OR=6.17 (1.13-33.67)) were independently associated with major abnormalities at multivariate analysis.

CONCLUSION

In this highly selected cohort of hospitalised patients with COVID-19 requiring endoscopy, almost half showed acute mucosal injuries and more than one-third of lower GI endoscopies had features of ischaemic colitis. Among the hospitalisation-related and patient-related variables evaluated in this study, D-dimers above 1850 ng/mL was the most useful at predicting major mucosal abnormalities at endoscopy.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov (ID: NCT04318366).

Case Report: Ischemic Colitis in Severe COVID-19 Pneumonia: An Unforeseen Gastrointestinal Complication

Clinical manifestations and complications of SARS-CoV-2 are still emerging and variant. Gastrointestinal (GI) manifestations and complications are hugely under-recognized. The presence of angiotensin converting enzyme-2 receptors in the intestinal enterocytes, the receptors primarily involved in the pathogenesis of COVID-19 pneumonia, maybe the key factor contributing to the pathogenesis of GI manifestations. Ischemic colitis, although the most common ischemic pathology of the GI tract, is relatively rare, occurring as a result of colonic hypoperfusion. The innumerable causes of colonic ischemia are categorized into occlusive and nonocclusive pathologies. Here, we have discussed a case of severe COVID-19 pneumonia, developing ischemic colitis, as a rare GI complication. The cause of ischemia in COVID-19 pneumonia is multifactorial, including hypercoagulable state, coagulopathy leading to thromboembolic complications, and use of vasopressors in severely ill patients with hemodynamic compromise.

Diagnostic methods and drug therapies in patients with ischemic colitis

PURPOSE

Ischemic colitis (IC) is the most prevalent ischemic injury of thegastrointestinal tract. Clinical features of IC such as acute abdominal pain, hematochezia,and diarrhea are similar to those of acute mesenteric ischemia, inflammatorybowel disease, or infectious bowel disease, and their relative ambiguity candelay diagnosis and treatment. To comprehensively detail the current state ofdiagnostic methods and available drug therapies for detecting and treating IC,this review aims to provide a concise and practical summary of thecorresponding literature.

METHODS

PubMed and Cochrane Library were searched toretrieve all published studies reporting the diagnostic methods and drugtherapies in patients with ischemic colitis. The search strategy of drugtherapy includes human and animal data.

RESULTS

Colonoscopy combined with histopathologicalbiopsy is the standard of diagnosis for the IC. Most patients respond well tothe conservative treatment, and surgical consultation is needed when conservativetreatment is ineffective. Studies of potential drug therapy have beendeveloped, including phosphodiesterase type 5 inhibitors, pentoxifylline,rebamipide, prostaglandin E1, and polydeoxyribonucleotide.

CONCLUSION

Accurate diagnoses and effective treatmentshave helped reduce the mortality rate and improve prognoses for patientsafflicted with IC, and corresponding drug therapies have been constantlyupdated as new research has emerged.

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.

The Uncertain Effect of Antimicrobial Therapy in the Treatment of Patients with Ischemic Colitis

Although antimicrobial therapy is recommended for patients with moderate or severe ischemic colitis, its beneficial effects are unclear. In the present study, the role of antimicrobial therapy in the treatment of ischemic colitis was investigated. Patients with ischemic colitis were retrospectively identified between January 2004 and June 2019. The characteristics and outcomes of patients who received antibiotics (antibiotics group) and those who did not (no-antibiotics group) were compared. Clinical outcomes included death, surgery, and readmission within 30 days, fasting duration, and hospital stay. Data from 186 patients were analyzed; 122 patients were in the antibiotics group and 64 in the no-antibiotics group. Composite outcome of death, surgery, and readmission within 30 days occurred in 3.3% of patients in the antibiotics group and 3.1% of patients in the no-antibiotics group (p > 0.999). Fasting duration was not significantly different between the two groups (median days, 4.0 vs. 4.0, p = 0.253). However, hospital stays were longer in the antibiotics group than in the no-antibiotics group (median days, 9.0 vs. 7.0, p = 0.043). In patients with ischemic colitis, there was no statistically significant difference in the incidence of death, surgery, and readmission within 30 days between patients who received antibiotics and those who did not receive antibiotics.

Evaluation of characteristics of left-sided colorectal perfusion in elderly patients by angiography

BACKGROUND

Handling of the inferior mesenteric artery (IMA) and maintaining anastomotic perfusion are important in radical resection of left-sided colorectal cancer. However, the branching of this artery and the drainage patterns of this vein vary among individuals, and the characteristics and perfusion region of this artery in elderly patients remain unclear.

AIM

To evaluate the characteristics and perfusion region of the IMA in elderly patients using angiography.

METHODS

We enrolled 154 patients (> 65 years old) who underwent digital subtraction angiography of the IMA. The characteristics, bifurcation, and distribution of the IMA and termination of the anastomotic perfusion of the left colon and rectum were examined using digital subtraction angiography. Collateral arterial arches and the IMA hemoperfusion region were also recorded. Perfusion regions were cross-referenced with clinical and anatomical features by the univariate analysis.

RESULTS

Of 154 patients, 25 (16.2%) had IMA lesions. The left colic artery arose independently from the IMA in 44.2% of patients, shared a trunk with the sigmoid artery in 35.1%, shared an opening with the sigmoid and superior rectal arteries in 16.9%, and was absent in 5.1%. The IMA perfusion region stopped at the splenic flexure in 50 (32.5%) patients. The collateral circulation existed in the colonic perfusion region, including the marginal artery (Drummond’s artery), the ascending branch of the left colonic artery to supply the transverse colon, and the arc of Riolan with a frequency of 100%, 22.7%, and 1.9%, respectively. The IMA perfusion region was independently associated with the comorbidity of atherosclerosis, IMA atherosclerotic lesion, branching pattern, collateral circulation, and marginal artery integrity.

CONCLUSION

The IMA and its branches are prone to arteriosclerosis, and IMA perfusion may be interrupted at the splenic flexure in elderly patients. The applicability and precision of preoperative angiography for evaluating the IMA branching and perfusion patterns could facilitate geriatric laparoscopic left-sided colorectal cancer surgery with suspicion of poor IMA perfusion.

Necrotising enterocolitis in an adult with anorexia nervosa

Necrotising enterocolitis (NEC) is a rare cause of the acute abdomen in adults and carries one of the highest mortality rates in gastroenterology. However, its rarity confines research to small case reports. Both its pathogenesis and aetiology remain enigmatic in adult patients, proving timely diagnosis and management a challenge. This paper reports on one case of NEC in an adult patient with underlying anorexia nervosa, following a seven-day period of starvation. She underwent emergency laparotomy for resection of necrotic bowel and subsequently made a good recovery. To date, there have only been eight reports linking NEC with anorexia nervosa. We review our patient in the context of plausible mechanisms hypothesised in these cases. Successful management depends on prompt diagnosis, resuscitation and surgical intervention.

Polydeoxyribonucleotide Exerts Therapeutic Effect by Increasing VEGF and Inhibiting Inflammatory Cytokines in Ischemic Colitis Rats

Ischemic colitis is resulted from an inadequate blood supply to a segment or entire colon. Polydeoxyribonucleotide (PDRN), extracted from salmon sperm, has been reported to exert anti-inflammatory and anti-ischemic effects through the adenosine A_2A receptor (A_2AR). We investigated whether PDRN possesses therapeutic effectiveness on ischemic colitis rats. Ischemic colitis was induced by selective devascularization. The skin temperature on the ischemic colitis-induced region was determined. To assess the colonic damage score and collagen deposition, colonic tissue sections were stained with hematoxylin and eosin (H&E), and Masson trichrome staining was performed. Western blot analysis for A_2AR, vascular endothelial growth factor (VEGF), cyclooxygenase-2 (COX-2), tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and IL-6, Bax, Bcl-2, and extracellular signal-regulated kinase 1/2 (ERK1/2) was performed. Skin temperature was increased and mucosal damage and collagen deposition were observed in the affected colonic tissues in the ischemic colitis rats. Expressions of inflammatory cytokines (TNF-α, IL-1β, and IL-6) and inflammatory mediator (COX-2) were upregulated in the ischemic colitis rats. Apoptosis was increased by decreasing the ratio of Bcl-2 to Bax and by suppressing the phosphorylated form of ERK1/2 expression in the ischemic colitis rats. Treatment with PDRN alleviated mucosal damage reduced the expressions of inflammatory cytokines and COX-2 and inhibited apoptosis in the ischemic colitis rats. PDRN treatment more enhanced the expressions of A_2AR and VEGF in the ischemic colitis rats. PDRN showed therapeutic effectiveness on ischemic colitis by increasing VEGF expression and inhibiting inflammatory cytokines and COX-2 through enhancing A_2AR expression.

Colonoscopic-Guided Pinch Biopsies in Mice as a Useful Model for Evaluating the Roles of Host and Luminal Factors in Colonic Inflammation

Colonic inflammation, a hallmark of inflammatory bowel disease, can be influenced by host intrinsic and extrinsic factors. There continues to be a need for models of colonic inflammation that can both provide insights into disease pathogenesis and be used to investigate potential therapies. Herein, we tested the utility of colonoscopic-guided pinch biopsies in mice for studying colonic inflammation and its treatment. Gene expression profiling of colonic wound beds after injury showed marked changes, including increased expression of genes important for the inflammatory response. Interestingly, many of these gene expression changes mimicked those alterations found in inflammatory bowel disease patients. Biopsy-induced inflammation was associated with increases in neutrophils, macrophages, and natural killer cells. Injury also led to elevated levels of sphingosine-1-phosphate (S1P), a bioactive lipid that is an important mediator of inflammation mainly through its receptor, S1P₁. Genetic deletion of S1P₁ in the endothelium did not alter the inflammatory response but led to increased colonic bleeding. Bacteria invaded into the wound beds, raising the possibility that microbes contributed to the observed changes in mucosal gene expression. In support of this, reducing bacterial abundance markedly attenuated the inflammatory response to wounding. Taken together, this study demonstrates the utility of the pinch biopsy model of colonic injury to elucidate the molecular underpinnings of colonic inflammation and its treatment.

Advents in the Diagnosis and Management of Ischemic Colitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ischemic or toxic injury: A challenging diagnosis and treatment of drug-induced stenosis of the sigmoid colon

A 48-year-old woman was admitted with 15-mo history of abdominal pain, diarrhea and hematochezia, and 5-mo history of defecation difficulty. She had been successively admitted to nine hospitals, with an initial diagnosis of inflammatory bowel disease with stenotic sigmoid colon. Findings from computed tomography virtual colonoscopy, radiography with meglumine diatrizoate, endoscopic balloon dilatation, metallic stent implantation and later overall colonoscopy, coupled with the newfound knowledge of compound Qingdai pill-taking, led to a subsequent diagnosis of ischemic or toxic bowel disease with sigmoid colon stenosis. The patient was successfully treated by laparoscopic sigmoid colectomy, and postoperative pathological examination revealed ischemic or toxic injury of the sigmoid colon, providing a final diagnosis of drug-induced sigmoid colon stenosis. This case highlights that adequate awareness of drug-induced colon stenosis has a decisive role in avoiding misdiagnosis and mistreatment. The diagnostic and therapeutic experiences learnt from this case suggest that endoscopic balloon expansion and colonic metallic stent implantation as bridge treatments were demonstrated as crucial for the differential diagnosis of benign colonic stenosis. Skillful surgical technique and appropriate perioperative management helped to ensure the safety of our patient in subsequent surgery after long-term use of glucocorticoids.

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.