A Comparison of clinical characteristics between medically-treated patients and surgically-treated patients with ischemic colitis

Congestive ischemic colitis successfully treated with anti-inflammatory therapy: A case report

BACKGROUND

Congestive ischemic colitis is a rare subtype of ischemic colitis with an unknown pathophysiology. Excluding conservative management, such as fasting, no established treatment exists; therefore, surgical intervention should be considered in some cases if symptoms worsen. Current literature suggests that anti-inflammatory agents may effectively treat congestive ischemic colitis.

CASE SUMMARY

We present the case of a 68-year-old female patient who underwent laparoscopic left hemicolectomy for transverse colon cancer 3 years ago. Postoperatively, follow-up included an annual colonoscopy and abdominal computed tomography (CT) at a local clinic. However, progressive erythema and edema of the sigmoid colon were observed 1 year postoperatively. Upon admission to our hospital, she complained of abdominal pain and diarrhea. Abdominal CT showed thickening of the sigmoid colon walls, and colonoscopy revealed erythema, edema, and multiple ulcers with exudate in the sigmoid colon. CT angiography showed engorgement of the sigmoid vasa recta without any vascular abnormalities. The diagnosis was congestive ischemic colitis, and we treated the patient with anti-inflammatory agents. After 2 mo of glucocorticoid therapy (20 mg once daily) and 7 mo of 5-aminosalicylate therapy (1 g twice daily), the ulcers completely healed. She has not experienced any recurrence for 2 years.

CONCLUSION

Anti-inflammatory therapy, specifically glucocorticoids and 5-aminosalicylate, has demonstrated promising efficacy and introduces potential novel treatment options for congestive ischemic colitis.

Clinical impact of inferior mesenteric vein preservation during left hemicolectomy with low ligation of the inferior mesenteric artery for distal transverse and descending colon cancers: A comparative study based on computed tomography

Purpose

Presence of a long remnant sigmoid colon after left hemicolectomy with inferior mesenteric vein (IMV) ligation for distal transverse and descending colon cancers may be a risk factor for venous ischemia. This study aimed to evaluate the clinical impact of IMV preservation in patients who underwent left hemicolectomy with inferior mesenteric artery (IMA) preservation.

Methods

We included 155 patients who underwent left hemicolectomy with IMA preservation for distal transverse and descending colon cancers from 2003 to 2020. Technical success of IMV preservation was determined by assessing pre- and post-operative patency of the IMV on computed tomography (CT) by an abdominal radiologist. Intestinal complications comprising ulceration, stricture, venous engorgement, and colitis in remnant colon were compared between the IMV preservation and ligation groups.

Results

IMV was preserved in 22 (14.2%) and ligated in 133 (85.8%) patients. Surgical time, postoperative recovery outcomes, and number of harvested lymph nodes were similar in both groups. The technical success of IMV preservation was 81.8%. Intestinal complications were less common in the preservation group than in the IMV ligation group (4.5% vs. 23.3%, P=0.048). The complications in the IMV ligation group were anastomotic ulcer (n=2), anastomotic stricture (n=4), venous engorgement of the remnant distal colon (n=4), and colitis in the distal colon (n=21).

Conclusions

IMV preservation may be beneficial after left hemicolectomy with IMA preservation for distal transverse and descending colon cancers. We suggest that IMV preservation might be considered when long remnant sigmoid colon is expected during left hemicolectomy with low ligation of IMA.

Clinical characteristics and long-term outcomes of hospitalised patients with ischemic colitis with different degrees of haematochezia: a retrospective study

BACKGROUND

Based on the literature, haematochezia is associated with a benign clinical course of ischaemic colitis. However, most cases in the literature presented mild haematochezia associated with ischaemic colitis. Therefore, we aimed to investigate the impact of different degrees of haematochezia on the clinical outcomes of ischaemic colitis.

METHODS

Patients were divided into nonhaematochezia, mild-haematochezia, and severe-haematochezia cohorts stratified by the degree of haematochezia. The clinical characteristics and prognoses were retrospectively reviewed.

RESULTS

Haematochezia cohort (n = 89) was associated with a lower rate of severe illness (25% vs. 52%, P = 0.001), lower rate of isolated right colon ischaemia (7% vs. 28%, P = 0.001), lower surgery rates (13% vs. 36%, P = 0.001), and shorter hospital stay (12 vs. 17 days, P < 0.001) compared with nonhaematochezia cohort (n = 50). Severe-haematochezia cohort (n = 11) had a higher frequency of severe illness (73% vs. 18%, P < 0.001), higher surgical intervention rate (55% vs. 6%, P < 0.001), higher nonsurgical complication rate, higher in-hospital mortality (45% vs. 0%, P < 0.001), and longer hospital stay (28 vs. 10  days, P = 0.001), compared with mild-haematochezia cohort (n = 78). Additionally, in-hospital mortality (45% vs. 6%, P = 0.003) and nonsurgical complication rate were higher in the severe-haematochezia than in the nonhaematochezia cohort. However, the three cohorts had comparable prognoses for long-term survival and recurrence.

CONCLUSIONS

Mild haematochezia was related to a benign clinical course of ischaemic colitis, while lack of haematochezia or severe haematochezia was associated with worse hospitalisation outcomes.

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

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

Ischemic colitis. Does right colon location mean worst prognosis?

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development and Validation of a Risk Scoring Model for Early Prediction of Severe Colon Ischemia

BACKGROUND

Colon ischemia (CI) is injury to the intestines secondary to insufficient blood flow. Its clinical severity can range from mild to life-threatening.

AIMS

To investigate predictive risk factors for CI and propose a scoring model for severe outcomes.

METHODS

We retrospectively analyzed the medical records of patients admitted to Chungnam National University Hospital from January 2010 to December 2018. CI was defined as severe when patients required surgery immediately or after initial conservative management, death occurred after hospitalization, or symptoms persisted after 2 weeks. By controlling for possible confounders from the logistic regression analysis, we obtained a new risk scoring model for the early prediction of severe CI. Furthermore, using the area under the receiver operating characteristics curve (AUROC), we assessed the accuracy of the model.

RESULTS

A total of 274 patients endoscopically diagnosed with CI were included, of whom 181 had severe CI. In the multivariate analysis, tachycardia, elevated C-reactive protein, Favier endoscopic classification stage ≥ 2, and history of hypertension were independently and significantly associated with severe CI. The AUROC of the model was 0.749.

CONCLUSIONS

This risk scoring model based on the presence of tachycardia, elevated C-reactive protein level, unfavorable endoscopic findings by Favier's classification, and the history of hypertension could be used to predict severe CI outcomes at an early stage.

Colon ischemia: A comprehensive review

The clinical and endoscopic features of colon ischemia (CI) are non-specific. CI is correctly identified at the time of presentation in only 9% of patients is. The true incidence is likely underestimated because many mild cases resolve spontaneously without medical treatment. Furthermore, since most cases of CI are transient, and no specific cause is detected they are often considered to be "idiopathic". In the setting of severe CI correct diagnosis and prompt recognition and therapy as well as identification of underlying causes are crucial for a favourable outcome. Although less severe, mild cases may present with similar symptoms, the prognosis and management are completely different and managed conservatively rather than with surgery. Unfortunately, data from most studies and current guidelines do not provide recommendations on the long-term management of CI or about the need for endoscopic follow-up to detect the development chronic, recurrent and/or ischemic colonic strictures. In this review, we focus on the definition of CI, its aetiology, and patterns of presentation. We highlight the pharmacological and/or endoscopic management as determined severity of disease that allow for improved outcomes. Prompt recognition and treatment using a multidisciplinary approach are essential for successful management of severe CI because mortality rates are significantly higher when the diagnosis is delayed.

Ischemic colitis. Does right colon location mean worst prognosis?

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Congestive ischemic colitis occurring after resection of left colon cancer: 4 case series

BACKGROUND

Ischemic colitis can occur after colectomy and is sometimes difficult to treat. We report 4 cases of refractory, delayed onset, regional congestive colitis occurring on the anal side of the anastomosis after laparoscopic left hemicolectomy.

CASE PRESENTATION

A total of 191 patients underwent surgery for left colon cancer (transverse, descending, and sigmoid colon cancer) at our hospital from January 2012 to December 2017. During the procedures, the left colic artery (LCA) or sigmoid colic artery (SA) was dissected, the superior rectal artery (SRA) was preserved, and the inferior mesenteric vein (IMV) was dissected at the inferior margin of the pancreas. Congestive ischemic colitis due to venous return dysfunction occurred in 4 cases (2.1%), 5 to 34 months postoperatively. The patients had diarrhea and blood in the stool. On computed tomography (CT), the patients exhibited continuous intestinal edema and high-density adipose tissue from the anastomosis site to the rectum. Contrast enhancement showed dilation of the vasa recti and arteries from the inferior mesenteric artery (IMA) to the SRA. Three patients improved with long-term intestinal rest; in 1 case, the stenosis did not improve and required colorectal resection.

CONCLUSION

Diagnoses were easy in these cases, but treatment was prolonged and surgery was necessary in 1 case. While this condition is rare, caution is warranted as it is difficult to treat.

Ischaemic colitis: uncertainty in diagnosis, pathophysiology and management

Ischaemic colitis is the most common form of gastrointestinal ischaemia, but may be confused with acute mesenteric ischaemia, inflammatory bowel disease or infectious colitis. This review article outlines the current classification, epidemiology and risk factors, as well as approaches about diagnosis and management to guide clinical practice. It also identifies areas for further research.

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.

Predisposing Factors of Ischemic Colitis: Data from 14 Years of Experience in a Single Center

BACKGROUND AND AIMS

While several case reports on ischemic colitis (IC) suggest the presence of predisposing causative factors, a few studies have investigated the predisposing factors in IC. This study aimed to identify the characteristics of patients with IC, particularly focusing on the predisposing factors.

METHODS

We conducted a single-center, retrospective analysis of 159 patients with IC. Clinical characteristics, laboratory data, endoscopic findings, and medical records were reviewed. Data were compared between groups of patients defined according to the predisposing factors. The predisposing factors are defined as temporary states or episodic events occurring within a week before the development of IC such as colonoscopy, enema, use of laxatives, heavy drinking, pancreatitis, shock, and burn.

RESULTS

Compared to the group of patients without predisposing factors of IC, the group of patients with predisposing factors was characterized by a relatively higher prevalence of male sex (56.9% versus 33.3%, p = 0.005), younger age (60.9 ± 15.4 versus 67.2 ± 13.4 years, p = 0.010), lower incidence of hypertension (43.1% versus 60.2%, p = 0.044), and fewer risk factors (1.24 ± 1.18 versus 1.82 ± 1.22, p = 0.005).

CONCLUSIONS

Among men with predisposing factors, IC may develop even at a relatively younger age and in the absence of multiple risk factors, suggesting that predisposing factors may be involved in the pathogenesis of IC.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Efficacy of pentoxifylline and tadalafil in rat model of ischemic colitis

OBJECTIVE

The aim of this study is to investigate the efficacy of tadalafil against pentoxifylline in rat model of ischemic colitis (IC).

MATERIAL-METHODS

Thirty-two Wistar albino rats were subjected to laparotomy and left colon devascularization to create an IC model and then randomly placed into four groups. Group-1 (sham group) was administered 0.9% NaCl following laparotomy, group 2 (control group) was administered 0.9% NaCl following induced IC, group 3 was given pentoxifylline (n = 8), and group 4 was given tadalafil. On the third day; macroscopic findings, Gomella's ischemic area and Wallace scoring, histopathological analysis, and Chiu scoring were performed, and malondialdehyde (MDA) measurement in ischemic colon tissue was carried out through chemical analysis.

RESULTS

Significant differences were observed in acidic fluid, bowel dilatation, and serosal change (p < .05). The ischemic area measured 63.3 mm(2) in the control group, 2.8 mm(2) in the pentoxifylline group (p = .0001), and 2.4 mm(2) (p = .0001) in the tadalafil group. A significant difference was seen between the sham group and the control and pentoxifylline groups (p < .01), in terms of Wallace score and Chiu classification. Similarly, a significant difference was determined between the control group and pentoxifylline and tadalafil groups (p < .01), but no significant difference was established between the pentoxifylline group and tadalafil group (p = .33). MDA measurement was found on an average to be 63.7 in the control group, 22.7 in group 3 and 22.8 in group 4 (p = 001).

CONCLUSION

Although tadalafil is superior to pentoxifylline, both drugs are considered to have positive effects.

Ischemic colitis: A forgotten entity. Results of a retrospective study in 118 patients

OBJECTIVE

The aim of our study was to document our 6-year experiences in identifying the clinical characteristics, laboratory findings, risk factors and the outcomes of patients with ischemic colitis (IC) in a community hospital setting.

METHODS

The medical records of patients who were diagnosed with IC from 2007 to 2013 in two community hospitals were retrospectively reviewed. Their clinical characteristics, laboratory results, radiological, endoscopic and histological evidence, anatomic location of the lesion, comorbidities, concomitant use of drugs, and so on, were collected.

RESULTS

A total of 118 patients with IC was identified, most were elderly individuals with a female predominance. The most common symptoms were abdominal pain, rectal bleeding and diarrhea. Hypertension, hyperlipidemia, coronary artery disease and diabetes mellitus were the most common comorbidities. Erythema, edema and erosions/ulcerations were the most common endoscopic findings. Left colon was the most affected location of lesion (84.8%), and there was one case of pancolitis. The descending colon was the most common affected segment, while rectum was the least affected segment. Severe IC occurred in 12.7% of the patients. Death within 30 days from the diagnosis of the disease occurred in 4.2%.

CONCLUSIONS

IC is majorly occurred in elderly with a female predominance. Cardiovascular disease and its associated risk factors are the most common comorbidities. Left colon is the most affected location of the disease and the overall mortality rate was 4.2%. Physicians should make every effort to identify these patients, especially those with high risks.

Stenotic ischemic colitis treated with laparoscopy-assisted surgery

Ischemic colitis is the most common type of intestinal ischemia. The etiology of this condition is multifactorial, and the diagnosis is based on a combination of clinical symptoms, as well as endoscopic and histological findings. Although conservative therapy is effective in most cases, surgery still plays a key role in the treatment of ischemic colitis. Here, we describe a case of a 73-year-old man in whom laparoscopy-assisted left colectomy was performed 80 d after the onset of ischemic colitis. He recovered completely after surgery, and the pathological findings were consistent with ischemic colitis. To the best of our knowledge, there are no detailed reports of laparoscopic surgery for chronic segmental stenotic ischemic colitis. We discussed the usefulness of laparoscopic surgery, comparing it with endoscopic treatment, and we propose an optimal treatment strategy from a viewpoint of stenosis length and duration of disease.