Diagnostic methods and drug therapies in patients with ischemic colitis

CT of acute abdomen in the elderly

Abdominal disorders represent 10 to 15% of all Emergency Department visits in elderly patients. This educational review focuses on acute abdomen pathologies specific to the elderly and on their imaging patterns and proposes a strategy for performing CT scans in this population. Bowel obstruction is the most common cause of emergency surgery in the elderly with a higher proportion of colonic obstructions, in particular obstructive colorectal cancer and sigmoid volvulus. Concerning abdominal inflammatory processes, such as cholecystitis, appendicitis, and diverticulitis, gangrenous cholecystitis and complicated appendicitis are relatively frequently encountered due to delayed diagnoses. Bowel ischemia, which includes acute mesenteric ischemia (AMI) and ischemic colitis (IC), is also much more common after the age of 80. Although ischemic colitis is mainly related to cardiovascular risk factors, it can also result from a persistent distension above a colonic cancer or from fecal impaction. Finally, extra-abdominal pathologies responsible for acute abdominal pain, such as inferior myocardial infarction, should not be overlooked. In clinical practice, when possible thanks to sufficient and appropriate radiological resources, we recommend a scan without injection of contrast and an injection depending on the results of the unenhanced scan, decided by the radiologist present at the CT scan room during the examination. CRITICAL RELEVANCE STATEMENT: CT is critical in the diagnosis and management of patients over 75 years old with an acute abdomen, given the difficulty of clinico-biological diagnosis, the frequency of complicated forms, and the morbidity induced by delayed diagnosis. KEY POINTS: The most common site and cause of bowel obstruction in the elderly is large bowel obstruction due to colon cancer. Discrepancy between a poor clinical examination and complicated forms on imaging, particularly for inflammation and infections, is responsible for late diagnosis and increased morbidity. Ischemia, including of the small bowel, colon, and gallbladder are common cause of acute abdomen in elderly. In patients with upper quadrant pain, consider extra-abdominal causes such as pneumonia or myocardial infarction.

Ischemic colitis presenting as a colonic mass: a case report and diagnostic challenges

Ischemic colitis (IC) is a multifaceted condition that often manifests with nonspecific symptoms such as abdominal pain and bloody diarrhea, particularly in older adults with vascular risk factors. Diagnosis is supported by elevated levels of white blood cells, lactate, and C-reactive protein (CRP). Computed tomography (CT) imaging typically reveals wall thickening and fat stranding in watershed areas. Colonoscopy may demonstrate mucosal erythema, ulceration, or necrosis. IC can be differentiated from inflammatory bowel disease (IBD), diverticulitis, and colorectal cancer based on symptom patterns and imaging findings. The absence of specific biomarkers can complicate diagnosis, potentially causing delays. Illustrating these challenges is the case of a 53-year-old male patient who arrived at the hospital exhibiting abdominal pain and diarrhea. Enhanced CT scans and colonoscopy identified a mass in the ileocecal region of the colon, and subsequent tissue biopsy revealed ischemic lesions in the submucosa. Initially diagnosed with IC, the patient's symptoms gradually improved with conservative treatment, which included antibiotics, fluid resuscitation, and bowel rest. Follow-up endoscopy showed significant lesion improvement, and no recurrence was detected during subsequent follow-ups. This case illustrates the healing process of IC as manifested by colon mass under endoscopy. Also, it highlights the critical importance of timely diagnosis and personalized treatment strategies in atypical presentations to improve patient outcomes.

Risk Factors Associated with Progression to Surgery in Patients with Ischemic Colitis

Background/Aims

Ischemic colitis (IC), the most common ischemic syndrome affecting the gastrointestinal tract, results from a decreased blood supply to the colon. Persistent symptoms can lead to complications, necessitating surgery. This study assessed the clinical characteristics and risk factors for poor outcomes in IC.

Methods

This retrospective observational study examined the medical records of 141 patients diagnosed pathologically with IC via surgery or colonoscopy at Chonnam National University Hwasun Hospital between April 2004 and August 2023.

Results

Eighteen (12.8%) and 123 (87.2%) patients were diagnosed by surgical biopsy and biopsy with colonoscopy, respectively. Multivariate analysis identified right-sided colon involvement, fever, and the absence of hematochezia as risk factors for the progression to surgery (odds ratio [OR]=5.924, 95% confidence interval [CI] 1.009-34.767, p=0.049; OR=24.139, 95% CI 5.209-111.851, p<0.001; and OR=0.076, 95% CI 0.013-0.446, p=0.004, respectively). The in-hospital mortality was 5.7% (8/141), and the patients who died exhibited higher rates of shock. The median (interquartile range) hospital stay was 11 (1-219) days. Patients who had longer hospital stays (≥14 days) had a significantly higher rate of fever but a lower rate of hematochezia.

Conclusions

A multidisciplinary approach is crucial for determining the need for surgery in patients with right-sided colon involvement, fever, or the absence of hematochezia.

Antioxidant activities of metal single-atom nanozymes in biomedicine

Nanozymes are a class of nanomaterials with enzyme-like activity that can mimic the catalytic properties of natural enzymes. The small size, high catalytic activity, and strong stability of nanozymes compared to those of natural enzymes allow them to not only exist in a wide temperature and pH range but also maintain stability in complex environments. Recently developed single-atom nanozymes have metal active sites composed of a single metal atom fixed to a carrier. These metal atoms can act as independent catalytically active centers. Metal single-atom nanozymes have a homogeneous single-atom structure and a suitable coordination environment for stronger catalytic activity and specificity than traditional nanozymes. The antioxidant metal single-atom nanozymes with the ability of removing reactive oxygen species (ROS) can simulate superoxidase dismutase, catalase, and glutathione peroxidase to show different effects in vivo. Furthermore, due to the similar structure of antioxidant enzymes, a metal single-atom nanozyme often has multiple antioxidant activities, and this synergistic effect can more efficiently remove ROS related to oxidative stress. The versatility of single-atom nanozymes encompasses a broad spectrum of biomedical applications such as anti-oxidation, anti-infection, immunomodulatory, biosensing, bioimaging, and tumor therapy applications. Herein, the nervous, circulatory, digestive, motor, immune, and sensory systems are considered in order to demonstrate the role of metal single-atom nanozymes in biomedical antioxidants.

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.

Therapeutic effect and study of human umbilical cord blood mononuclear cells in patients with ischaemic bowel disease

Ischaemic bowel disease (ICBD) is a group of intestinal ischaemia syndromes caused by various aetiologies of reduced intestinal blood flow or vascular occlusion. ICBD can present as abdominal pain, bloody stool, and diarrhoea. This disease often occurs in middle-aged and elderly individuals with cardiovascular and cerebrovascular diseases. The incidence of ischaemic bowel disease has been increasing for decades, and it is difficult to diagnose, resulting in rapid disease progression and a high mortality rate. Therefore, fully understanding this disease, improving the diagnosis rate of this disease, and finding appropriate treatment methods are urgently needed to improve the condition and prognosis of patients. Umbilical cord blood stem cells are accessible, have weak immunogenicity, and have various biological functions, such as angiogenesis, inflammation and immune regulation. Many studies have confirmed that cord blood stem cells can relieve ischaemia, and these cells have attracted tremendous amounts of attention in regenerative medicine in recent years. In this paper, we discuss the clinical characteristics of ICBD, analyse the characteristics of human umbilical cord blood mononuclear cells (HUCB-MNCs), and use its to treat ischaemic bowel disease. Additionally, we compare the clinical manifestations and related indicators before and after treatment to evaluate the efficacy and safety of these methods.

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.

Acute abdomen following COVID-19 vaccination: a systematic review

Purpose

Conduct a systematic review of case reports and case series regarding the development of acute abdomen following coronavirus disease 2019 (COVID-19) vaccination, to describe the possible association and the clinical and demographic characteristics in detail.

Materials and Methods

This study included case report studies and case series that focused on the development of acute abdomen following COVID-19 vaccination. Systematic review studies, literature, letters to the editor, brief comments, and so forth were excluded. PubMed, Scopus, EMBASE, and Web of Science databases were searched until June 15, 2023. The Joanna Briggs Institute tool was used to assess the risk of bias and the quality of the study. Descriptive data were presented as frequency, median, mean, and standard deviation.

Results

Seventeen clinical case studies were identified, evaluating 17 patients with acute abdomen associated with COVID-19 vaccination, which included acute appendicitis (n=3), acute pancreatitis (n=9), diverticulitis (n=1), cholecystitis (n=2), and colitis (n=2). The COVID-19 vaccine most commonly linked to acute abdomen was Pfizer-BioNTech (messenger RNA), accounting for 64.71% of cases. Acute abdomen predominantly occurred after the first vaccine dose (52.94%). All patients responded objectively to medical (88.34%) and surgical (11.76%) treatment and were discharged within a few weeks. No cases of death were reported.

Conclusion

Acute abdomen is a rare complication of great interest in the medical and surgical practice of COVID-19 vaccination. Our study is based on a small sample of patients; therefore, it is recommended to conduct future observational studies to fully elucidate the underlying mechanisms of this association.

Ischemic Colitis in a Young Female Following Herbal Supplement Ingestion

Ischemic colitis is typically considered a disease of the elderly, given their atherosclerotic risk factors and other comorbidities. Ischemic colitis in the younger population is considered very uncommon. We present an interesting case of a young female presenting with abdominal pain and hematochezia found to have ischemic colitis on pathological biopsy results after a colonoscopy. She was an otherwise healthy female with no medical problems prior to her hospitalization but endorsed recent use of a bitter herbal tea to relieve her symptoms. Here, we review potential causes of ischemic colitis, including herbal remedies, which have been linked to causing hypercoagulable and hypotensive states.

Unexpected form of ischemic colitis: A case report

Ischemic colitis (IC) is an ischemic injury to the colon caused by an occlusive arterial blood supply or blocked venous return. Colonoscopic manifestations most frequently include colonic mucosal edema and erosion, while tubular channels are rare. It is also known as colon cast, and doctors often misdiagnose it when they encounter it. The present study presents a rare form of IC. An 80-year-old man visited The Affiliated People's Hospital of Ningbo University (Ningbo, China) due to abdominal pain and bloody stools. He had no significant comorbidities and had not taken medication. Physical examination suggested tenderness in the left lower abdomen. Abdominal computed tomography (CT) showed thickening of the sigmoid colon wall. Laboratory tests showed positive fecal occult blood, whereas routine blood tests, including blood coagulation, were normal. Diagnostic colonoscopy revealed sigmoid colon narrowing. There was a long strip of tissue in the sigmoid with a cystic and smooth head, the base of the pedicle was edematous and anabrotic. Abdominal CT angiography revealed no abnormality of the mesenteric artery. The day after colonoscopy, the patient expelled a 17-cm strip of tissue from his anus. Pathological examination revealed inflammatory necrotic colonic mucosa. After 1 week, repeat colonoscopy revealed the strip had been shed, the sigmoid mucosa was edematous and anabrotic, but other intestinal segments were normal.

Acute ischemic colitis associated with oral decongestant use: a systematic review

Background and Aim

Acute ischemic colitis (IC) has been linked with the use of oral decongestants. However, clinical evidence on this association remains limited. We aim to evaluate the occurrence and clinical outcomes of acute IC following over-the-counter (OTC) use of pseudoephedrine and phenylephrine.

Methods

We conducted a systematic review of the MEDLINE, Google Scholar, Scopus, and Embase databases between inception and July 20, 2022. Specific search terms were used. The inclusion criteria consisted of English-language articles describing acute IC secondary to pseudoephedrine or phenylephrine.

Results

A total of 18 case reports (level of clinical evidence: IV) fulfilled our inclusion criteria. The mean age of patients was 51.6 ± 15.3 years, with 14 (77.8%) cases reported in women. The clinical presentation was mainly related to abdominal pain 16 (88.9%), hematochezia 15 (83.3%), and/or abdominal tenderness 10 (55.6%). The medical background showed that 5 (27.8%) patients were previously healthy. In the 13 (72.2%) patients with comorbidities, hypertension 6 (46.2%), a history of tobacco use 5 (38.5%), and psychiatric illnesses 4 (30.8%) were commonly reported. Leukocytosis was encountered in 13 (72.2%) patients. Diagnostic investigations included a combination of computed tomography scan and colonoscopy in 10 (55.6%), colonoscopy alone in 6 (33.3%), and flexible sigmoidoscopy in 1 (5.6%) patient. Colonoscopic biopsy was the mainstay of diagnosis in 15 (83.3%) patients. Treatment was based on supportive care in 18 (100%), concurrent antibiotic use in 2 (11.1%), and surgical intervention in 1 (5.6%) patient. Recurrent episodes of IC occurred in 4 (22.2%) patients.

Conclusions

Acute IC secondary to oral decongestants remains a rare but important clinical phenomenon. Clinical suspicion and imaging findings are important for the early diagnosis.

Relevance to Patients

In unexplained cases of IC, clinicians should specifically inquire about oral decongestants since they are OTC and patients commonly fail to reveal their usage. These drugs should be avoided for transient cold symptoms, especially in women.

Recurrent Thromboembolic Events While on Anticoagulation Lead to the Diagnosis of Metastatic Lung Adenocarcinoma: A Case Report

Lung cancer can lead to hypercoagulability that causes thromboembolic events such as pulmonary emboli, deep vein thrombosis, ischemic strokes, and non-bacterial thrombotic endocarditis. While it is not uncommon for cancer to cause thromboembolic events, it is unusual for thrombotic events to be the first manifestation of cancer. In the following report, we review the case of a 59-year-old woman who presented with melena and abdominal pain. She had a pertinent history of multiple thromboembolisms while on anticoagulation four months before this presentation. Upon admission, it was discovered that the patient had new pulmonary emboli, and further workup revealed that her gastrointestinal symptoms were due to ischemic colitis. While initial imaging showed no evident masses that would heighten suspicion of cancer, she had persistent abdominal lymphadenopathy. Therefore, she also underwent an abdominal lymph node biopsy which revealed metastatic lung adenocarcinoma, a possible cause of her hypercoagulable state. This case report highlights the importance of considering malignancy in the differential of a patient with recurrent thromboembolism and raises the question of whether standardized screening for malignancy in patients with multiple thromboembolic events would be beneficial.

[Features of the upper gastrointestinal tract mucous membrane state in patients with atherosclerosis of the mesenteric arteries]

AIM

To evaluate the clinical and endoscopic features of diseases of the upper gastrointestinal tract (GIT) in patients with atherosclerosis of the mesenteric arteries (MA).

MATERIALS AND METHODS

The study included 48 patients with atherosclerosis of MA and 43 patients without atherosclerosis of MA, who were hospitalized in the department of vascular surgery of the Chelyabinsk Regional Clinical Hospital in the period from 2019 to 2021. All patients underwent multispiral computed tomoangiography of the visceral and lower limb arteries, esophagogastroduodenoscopy.

RESULTS

Assessment of lesions of the upper gastrointestinal tract revealed a higher incidence of erosive and ulcerative gastroduodenopathies among patients with atherosclerosis of MA (60.4%), compared with patients without atherosclerosis MA (39.5%); p=0.047. Signs of severe atrophy according to the data of histological examination were statistically significantly more frequent among patients with atherosclerosis of MA (29.2 and 11.6%; p=0.031). According to the results of logistic regression, the following predictors of erosions and ulcers of the upper gastrointestinal tract were revealed: the severity of stenosis of the superior mesenteric artery (SMA) is more than 35%, the body mass index (BMI) is less than 25.9 and the total score on the HADS scale is more than 6.5 points for depression (p=0.008).

CONCLUSION

Erosive-ulcerative gastroduodenopathies and atrophy of the gastric mucosa are significantly more common in the group of patients with MA atherosclerosis. The main risk factors for erosions and ulcers of the upper gastrointestinal tract in patients with MA atherosclerosis are: the severity of SMA stenosis is more than 35%, a decrease in BMI is less than 25.9 and an increase in the HADS score is more than 6.5 points.

Colitis as the Main Presentation of COVID-19: A Case Report

The main symptoms of coronavirus disease (COVID-19) are fever, cough, tiredness, and loss of smell and taste. Gastrointestinal symptoms are less common. A 38-year-old female patient, previously healthy, presented with a history of hematochezia up to 8 times per day, followed by abdominal cramps, urgency, and chills for two days. She did not have any respiratory symptoms and was previously vaccinated for COVID-19. She was afebrile, with normal vital signs. Blood samples showed normal complete blood count and increased C-reactive protein (CRP), fibrinogen, and D-dimer levels (66 mg/L, 4.1 g/L, and 2302 μ/L FEU, respectively). Stool samples for stool culture, C. difficile, and viral examination came back negative. On day 3, she reported a mild cough, fever and loss of smell and taste. Nasopharyngeal swab for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) PCR test came back positive. On day 6, the patient still had hematochezia accompanied by abdominal cramps, but fever and respiratory symptoms withdrew. CRP, fibrinogen, and D-dimers were still elevated, as well as liver enzyme levels. Sigmoidoscopy was performed with biopsies taken from sigmoid and rectum for histology and PCR SARS-CoV-2 testing. CT angiography showed no signs of thrombosis in mesenteric veins or arteries. PCR test for SARS-CoV-2 virus from rectal biopsy sample was positive. Patient was treated with methylprednisolone iv for two days and peroral prednisone afterwards, with mesalamine, metronidazole and enoxaparin. Sigmoidoscopy was repeated after two weeks showing only mild hyperemia. At that time, the patient had normal stool, normal CRP, liver enzyme, fibrinogen, and D-dimer levels, and normocytic anemia (hemoglobin level of 103 g/L). We wanted to show that severe gastrointestinal symptoms, such as hemorrhagic colitis, can be the main presentation of COVID-19, even in young patients with no prior comorbidities. In such a case, PCR test in biopsy samples can be performed to prove SARS-CoV-2 infection of bowel mucosa.

Sheng-Xue-Xiao-Ban Capsule-induced ischemic colitis and pulmonary embolism in an idiopathic thrombocytopenic purpura patient: a rare case report

BACKGROUND

Sheng-Xue-Xiao-Ban Capsule (SXXBC), as a classic Chinese traditional medicine comprised of natural indigo, cortex moutan, forsythia, herba agrimoniae, and licorice, exhibits a heat-clearing and detoxicating function, hemostasis, and stasis dissipation, which is widely applied to treat idiopathic thrombocytopenic purpura (ITP). However, report on ischemic colitis and pulmonary embolism induced by SXXBC therapy is never disclosed. We report the case of an ITP patient who received SXXBC for ascending platelets that then induced ischemic colitis and pulmonary embolism.

CASE DESCRIPTION

A 74-year-old female patient was admitted in June 2021 due to "bleeding in stool for 1 day," she was then re-admitted in July 2021 due to "repeated bleeding in stool for 2 days". Abdominal computed tomography (CT), colonoscopy, and a pathological examination suggested ischemic colitis according to the American College of Gastroenterology (ACG) clinical guidelines. Pulmonary artery CT angiography suggested pulmonary embolism reflected by multiple filling defects, and the patient presented with shortness of breath. It was noted that the patient had started taken SXXBC for ascending platelets 2 months before the onset of hematochezia. After the diagnosis of hematochezia was made, the patient received phenethylamine and carbazochrome for hemostasis, mesalazine enteric-coated tablets for anti-inflammation, and SXXBC was stopped. The hematochezia then ceased, and the ischemic colitis was attenuated. Afterwards, low-molecular-weight heparin was administered, followed by a 3-week treatment of rivaroxaban anticoagulant, which was taken orally after discharge. The pulmonary embolism was then obviously ameliorated. After excluding other causes, the patient was diagnosed with SXXBC-induced ischemic colitis complicated by pulmonary embolism. After conducting research, we came to the view that natural indigo, which is the main component of SXXBC, contributed to the patient's illness.

CONCLUSIONS

Ischemic colitis complicated with pulmonary embolism are rare; however, close attention such as regular abdominal CT test needs to be paid and preventive steps such as anti-coagulant treatment could to be taken (if symptoms occur) when treating patients with SXXBC.

Ischemic Colitis Presented as Pseudomembranous Colitis: An Untypical Case from Vietnam

Ischemic colitis (IC) is an underreported chronic disease characterized by the hypoperfusion of the bowel mucosa. The diagnosis and treatment may be challenging because its clinical course resembles other colitis or even colorectal malignancies. This paper reports an untypical case to underline the diversity of IC manifestation. A 68-year-old man with several comorbidities was admitted because of abdominal pain with a 6-month duration and a mass in the left lower quadrant. Colonoscopy revealed erosive pseudomembranous colitis narrowed colon segments with ulcerated mucosa mimicking colorectal cancer and inflammatory bowel disease. The stool cultures and Clostridium difficile toxin tests were negative. After the failure of conservative therapy, the Hartmann procedure with temporary ileostomy was performed uneventfully. The histological results of the surgical specimens revealed IC with focal pseudomembranous areas.

Ultrasound Detection of Portomesenteric Venous Gas Is an Early Sign of Bowel Ischaemia in Non-Traumatic Abdominal Pain: Old Dogs, New Tricks—Four Cases Report

Acute bowel ischemia is a severe disease often with a poor outcome. Early diagnosis can improve outcome, but atypical clinical manifestations and nonspecific laboratory and instrumental diagnostic findings may delay computed tomographic angiography (CTA). Portomesenteric venous gas (PVG), indirect sign of pneumatosis intestinalis, is considered a late finding with poor prognosis. We report four cases where PVG, easily identified through point-of-care ultrasonography (POCUS), was an early sign of bowel ischemia leading to a precocious diagnosis confirmed at CTA. In acute non-traumatic abdominal pain, an evidence of PVG could be an early ultrasonographic finding of bowel ischemia in the emergency department.

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.

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.