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Colonic Ischemia: What really matters?

Colonic Ischemia: What really matters?. Clinical pitfalls in acute management Dr. Stewart Chan Kwong Wah Hospital. Case Scenario. M/31 Good past heath Amateur Marathon runner Sudden onset left-sided abdominal pain and mild per rectal bleeding after a Marathon race

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Colonic Ischemia: What really matters?

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  1. Colonic Ischemia: What really matters? Clinical pitfalls in acute management Dr. Stewart Chan Kwong Wah Hospital

  2. Case Scenario • M/31 • Good past heath • Amateur Marathon runner • Sudden onset left-sided abdominal painand mild per rectal bleeding after a Marathon race • Episodic pain during training in the preceding 2 months

  3. PE: afebrile, stable vitals • Soft abdomen with mild LLQ tenderness • PR: small amount of altered blood • WCC16.3 • Amylase / ABG normal • CXR: no free gas • AXR: no dilated bowels

  4. CT: edematous descending colon with pericolic stranding

  5. Diagnosis: MILD Ischemic Colitis C Grames and CSB-caban. Case report: Ischemic colitis in an endurance runner. Case Reports in Gastrointestinal Medicine, Vol 2012, Article ID 356895

  6. Colonic Ischemia: Why does it matter • 3rd most frequent cause of per-rectal bleeding • 15% develops life-threatening gangrenous changes • 60% perioperative mortality • 30% develops chronic complications • Chronic colitis, ulcers, stricture, recurrence Brandt LJ et al. Surg Clin North Am. 1992

  7. Colonic ischemia: what really matters • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 20% cases progresses to gangrene formation

  8. Colonic ischemia: what really matters • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 20% cases progresses to gangrene formation

  9. Predisposing factors should be actively sought for • Common predisposing factors • Shock from any causes • Colonic obstruction: volvulus, stenotictumour, stricture • Post-operative: e.g. aortic surgery • 2% after endovascular repair; 7% after open repair • Cardiovascular diseases: AF, DM, HT, hyperlipidemia, heart failure, chronic renal failure, peripheral vascular diseases Brewster et al. Surgery 1991 Hurwitz et al. Surg Gynae Obstet 1960

  10. 100% predictive of ischemic colitis when symptoms of per rectal bleeding and lower abdominal pain are associated with 4 or more of the risk factors • Age >60 • Hemodialysis • Hypertension • DM • Hypoalbuminemia • Constipation Park CJ et al. Dis Colon Rectum 2007

  11. In 10% cases, a predisposing factor is readily identifiable on admission • Go search for predisposing factors when they are apparently absent • Cardiac workup (ECG, Holter, ECHO) • An embolic source is present in 1/3 cases of ischemic colitis • Young patients: OCPs, cocaine, strenuous exercises, underlying coagulopathies and vasculitides Hourmand-Ollivier I et al. Am J Gastroenterol 2003

  12. Colonic ischemia: what really matters • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 20% cases progresses to gangrene formation

  13. Right colonic involvement carries poor prognosis • Most cases affect the left colon; 25% cases involves right colon as well • Right colonic involvement carries 2x higher mortality (23%) and 5x higher risk requiring laparotomy (60%) • Need to rule out acute mesenteric ischemia • Associates with general hypoperfusion state, NSAID use • Red flags • Right sided abdominal pain • Absence of per rectal bleeding • Severe pain out of proportion to the tenderness Huguier M, et al. Am J Surg 2006 Sotiriadis J et al. Am J Gastroenterol 2007

  14. Colonic ischemia: what really matters • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 20% cases progresses to gangrene formation

  15. Colonoscopy is the gold standard in diagnosis • Mild: erythematous and edematous mucosa; ecchymosis; petechiae and erosions <1cm Endoscopic classification and clinical course of ischemic colitis. Toursarkissian & Thompson

  16. Colonic “single-strip” sign • a longitudinal linear ulcer occurring in mild cases of ischemic colitis, usually over the left colon • 75% pathological correlation with ischemic colitis Zuckerman GR et al. Am J Gastroenterol. 2003

  17. Moderate: submucosal hemorrhages, hemorrhagic nodules, ulcerations Endoscopic classification and clinical course of ischemic colitis. Toursarkissian & Thompson

  18. Severe: greyish gangrenous changes Endoscopic classification and clinical course of ischemic colitis. Toursarkissian & Thompson

  19. Chronic: ulcers with granulation tissue and pseudopolyps; strictures

  20. Endoscopic severity positively correlates with need for surgery and mortality • Need for surgery: mild (5%); moderate (7%); severe (57%) • Mortality: mild (2%); moderate (5%); severe (48%) Friedland S et al. Gastrointest Endosc 2007 M. Lozano-Maya et al. Rev Esp Enferm Dig 2010

  21. Early colonoscopy to aid diagnosis • mucosal changes dissipate within 48 hours • Contraindicated when peritoneal signs are present • Serial re-examination required to assess progression • Avoid over-inflation / bowel preparation • Consider use of CO2 insufflation Green BT. South M ed J 2005 Baixauli J. Cleve Clin J Med 2003

  22. CT is usually done at acute presentation • Highly sensitive (>95%) but not specific • Detect complications e.g. pneumatosis coli, perforation • Delineate the extent of colonic involvement • Assess patency of major vessels

  23. What really matters when ordering investigations • Barium enema not favored anymore • Classical “thumbprint” sign with 75% sensitivity only • Contraindicatedin suspected gangrene/ perforation • Mesenteric angiogram rarely indicated • Only used in severe cases where acute mesenteric ischemia has to be ruled out

  24. Colonic ischemia: what really matters • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 20% cases progresses to gangrene formation

  25. 20% cases progresses to gangrene formation • Up to 85% cases are self-limiting • Supportive management with bowel rest, fluid resuscitation and antibiotics • 20% cases progress to gangrenous change which mandates urgent laparotomy • Close monitoring of clinical signs and laboratory results (WCC, HCO3, lactate) • Indications for laparotomy • Signs of sepsis, peritonism • Laboratory / imaging / endoscopic evidence of bowel infarction / perforation Gandhi SK et al. Dis Colon Rectum. 1996

  26. Issues when performing laparotomy • Segmental resection of affected bowel • Judicious consideration of primary anastomosis • Use of intra-operative colonoscopy to assess mucosal condition • Resected segment should be opened up and examined to confirm inclusion of healthy colonic margins

  27. Colonic ischemia: what really matters • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 20% cases progresses to gangrene formation

  28. Thank you • C Grames and CSB-caban. Case report: Ischemic colitis in an endurance runner. Case Reports in Gastrointestinal Medicine, Vol 2012, Article ID 356895 • DC Cohen et al. Marathon-induced ischemic colitis: why running is not always good for you. American Journal of Emergency Medicine (2009) 27, 255.e5-e7 • CJ O’Neill, J Gan. Ischemic colitis in an ironman triathlete: A case report and review of the literature. Surgical Practice (2008), 12, 71-72 • F Paterno, WE Longo. Ischemic colitis: risk factors for eventual surgery. The American Journal of Surgery (2010) 200l 646-650 • C Reissfelder, M Koch et al. Ischemic colitis: Who will survive? Surgery (April 2011) Vol 149 Number 4 • C Ryan, John RT, et al. Is Ischemic Colitis Ischemic? Diseases of the Colon & Rectum (March 2011), Vol 54(3), pp 370-373 • PM Glauser, CA Maurer et al. Ischemic Colitis: clinical presentation, localization in relation to risks factors, and long-term results. World J Surg (2011) 35:2549-2554 • JA Bailey, WE Longo et al. Endovascular Treatment of Segmental Ischemic Colitis.Digestive Diseases and Sciences (April 2005) Vol 50, Number 4, pp 774-779 • T Mohanapriya et al. Ischemic Colitis. Indian J Surg (September-October 2012) 74(5): 396-400

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