Ischaemic colitis and colorectal cancer: some problems and pitfalls

[Ischemic colitis: two forms of clinical presentation and outcome]

OBJECTIVES

To characterize the clinical presentation and outcomes of ischemic colitis in our environment with a view to identifying risk factors.

METHOD

Fifty-one patients diagnosed in our hospital with ischemic colitis over a 5-year period (1998-2002) were retrospectively analyzed. Demographic data, clinical symptoms, diagnosis and treatment were studied. Two groups (surgical patients [n = 28] and nonsurgical patients [n = 23]) were compared.

RESULTS

No significant differences between the two groups were found in demographic data and associated disease. Diagnosis was performed by colonoscopy in nonsurgical patients and by analysis of the surgical specimen in almost all surgical patients. The presenting symptom was lower gastrointestinal bleeding in nonsurgical patients (p < 0.05) and peritonism in surgical patients (p < 0.05). Mortality was significantly higher in patients older than 80 years than in younger patients.

CONCLUSIONS

Lower gastrointestinal bleeding was more common as the presenting symptom in transitory forms of ischemic colitis. An acute abdomen indicates serious forms requiring surgery. Therefore the initial clinical symptoms determine the treatment provided. Advanced age is a poor prognostic factor for ischemic colitis. Risk factors in our series were presentation as acute abdomen and advanced age.

Delayed ischemic gangrene change of distal limb despite optimal decompressed colostomy constructed in obstructed sigmoid colon cancer: A case report

Creating blow-hole colostomy for decompression could provide a time-saving and efficient surgical procedure for a severely debilitated case with a completely obstructed colorectal cancer. Complications are reported as prolapse, retraction, and paracolostomal abscess. However, complication with an ischemic distal limb has not been reported. We report a case of critical intra-abdominal disease after decompressed colostomy for relieving malignant sigmoid colon obstruction; a potential fatal condition should be alerted. A 76-year-old male visited our emergency department for symptoms related to obstructed sigmoid colon tumor with foul-odor vomitus containing fecal-like materials. An emergent blow-hole colostomy proximal to an obstructed sigmoid lesion was created, and resolution of complete colon obstruction was pursued. Unfortunately, extensive abdominal painful distention with board-like abdomen and sudden onset of high fever with leukocytopenia developed subsequently. Such surgical abdomen rendered a secondary laparotomy with resection of the sigmoid tumor along with an ischemic colon segment located proximally up to the previously created colostomy. Eventually, the patient had an uneventful postoperative hospital stay. In the present article, we have described an emergent condition of sudden onset of distal limb ischemia after blow-hole colostomy and concluded that despite the decompressed colostomy would resolve acute malignant colon obstruction efficiently; impending ischemic bowel may progress with a possible irreversible peritonitis. Any patient, who undergoes a decompressed colostomy without resection of the obstructed lesion, should be monitored with leukocyte count and abdominal condition survey frequently.

A case of colonic ischemia mimicking carcinoma

In this article, we describe a case of colonic ischemia masquerading as colonic carcinoma in a 75-yr-old female. Although this clinical diagnostic problem has been described before, it is rather unusual that the clinical, roentgenographical, endoscopic, and even histopathologic evaluation could not exclude carcinoma with certainty.

A case of colonic ischemia mimicking carcinoma

In this article, we describe a case of colonic ischemia masquerading as colonic carcinoma in a 75-yr-old female. Although this clinical diagnostic problem has been described before, it is rather unusual that the clinical, roentgenographical, endoscopic, and even histopathologic evaluation could not exclude carcinoma with certainty.

Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia

Ischemic colitis accounts for approximately half of all cases of mesenteric vasculopathy. The clinical presentation varies depending on underlying cause, extent of vascular obstruction, rapidity of ischemic insult, degree of collateral circulation, and presence of comorbidity. Ischemic colitis is usually diagnosed by colonoscopy. Only approximately 20% of patients require surgery because of signs or laboratory findings of peritonitis or because of clinical deterioration. Approximately 20% of patients develop chronic colitis from irreversible colonic ischemic injury, which manifests clinically as persistent diarrhea, rectal bleeding, or weight loss and endoscopically as a colonic stricture or mass. Chronic mesenteric ischemia is almost always caused by significant atherosclerotic stenosis involving at least two mesenteric arteries, usually the superior mesenteric artery and celiac axis. The classic symptomatic triad of postprandial pain, fear of eating, and involuntary weight loss occurs with advanced disease.

Ischemic colitis

Ischemic colitis represents the most common form of gastrointestinal ischemia. The presumed etiologies are numerous; however, it typically develops "spontaneously," in the absence of major vasculature occlusion, and in the presence of viable intestine elsewhere. It is most usefully classified into gangrenous and nongangrenous forms, the latter of which may be subdivided into transient and chronic types. Ischemic colitis may develop in people who are otherwise healthy, although a variety of clinical settings, such as shock, predispose to its occurrence. It usually presents as an acute abdominal illness with bloody diarrhea. Diagnosis is confirmed by colonoscopy. Therapy and outcome are dependent on the severity of disease. Nongangrenous colonic ischemia usually requires only medical management and is associated with a good prognosis. The chronic subtype may lead to the sequelae of persistent segmental colitis or colonic strictures, occasionally requiring surgery. Urgent operative intervention and a high morbidity and mortality are the hallmarks of gangrenous colonic ischemia. Special considerations must be given to those patients in whom ischemic colitis develops in the context of colon carcinoma or obstructing colon lesions, after abdominal aortic surgery, and following cardiopulmonary bypass. This review will discuss the clinical spectrum of ischemic colitis.