Ischemic colitis: analysis of risk factors for postoperative mortality

Acute Mesenteric Infarction: The Chameleon of Acute Abdomen Evaluating the Quality of the Diagnostic Parameters in Acute Mesenteric Ischemia

INTRODUCTION/OBJECTIVE

Acute mesenteric ischemia (AMI) is difficult to diagnose. Since the established parameters have low sensitivity and specificity, the aim of this study is to analyze the diagnostic quality of the established parameters of AMI.

METHODS

All patients that underwent emergency surgery due to suspected diagnosis of mesenteric ischemia at the University Medical Center Hamburg-Eppendorf between 2008 and 2014 were evaluated. Overall, 275 patients were enrolled and pre-, intra- and postoperative data were evaluated.

RESULTS

In 200 patients, a mesenteric ischemia was confirmed intraoperatively, and 75 patients had no ischemia. Comparing these groups, the rate of patients with pH < 7.2 (25 vs. 12%; p = 0.021) and elevated mean CRP level (175 ± 117 mg/L vs. 139 ± 104 mg/L; p = 0.019) was significantly higher in ischemic patients. There was no significant difference in the level of preoperative lactate. Concerning abdominal CT scan, a sensitivity and specificity of 61 and 68%, respectively, was found.

CONCLUSION

New diagnostic parameters are needed. So far, explorative laparotomy is the only reliable diagnostic method to detect mesenteric infarction.

Cirrhosis Is Associated With Worse Outcomes in Ischemic Colitis: A Nationwide Retrospective Study

Background

Ischemic colitis (IC) occurs when the blood supply of the large intestine becomes compromised. Cirrhosis is a disease entity in which there is a delicate balance between pro-coagulant and anti-coagulant states. Our aim was to examine the impact cirrhosis has on outcomes in patients with ischemic colitis.

Methods

A retrospective analysis of patients hospitalized with IC in 2017 was evaluated using the National Inpatient Sample database. Baseline demographic data, length of hospital stay (LOS), total hospital charge, rates of colectomy and in-hospital mortality were extracted from the database. Categorical variables were compared using the Chi-square test and continuous variables were compared using t-test.

Results

A total of 29,035 patients with IC were identified, while 420 of these patients also had cirrhosis. Patients with IC and cirrhosis were noted to be younger age at presentation when compared to patients with IC and no cirrhosis (mean 63.9 years vs. 70.4 years; P < 0.001). When comparing both groups, IC patients with cirrhosis were more likely to be male (50% vs. 26.1%; P < 0.001), Black (10.9% vs. 7.6%; P = 0.013) and Hispanic (18% vs. 6.1%; P < 0.001). We found that IC patients with cirrhosis had a longer LOS (7.3 days vs. 4.8 days; P < 0.001), higher total hospital charge ($84,769 vs. $48,347; P < 0.001) and higher mortality rate (10.7% vs. 3.6%; P < 0.001); however, the presence of cirrhosis was not associated with increased odds of undergoing colectomy (odds ratio: 0.31; 95% confidence interval: 0.07 - 1.27; P = 0.104).

Conclusions

The presence of cirrhosis is associated with increased odds of in-hospital mortality in those presenting with IC. This compounds the already high rates of mortality in patients that undergo surgery for IC and could reflect lack of reserve to withstand the ischemic episode in the setting of cirrhosis. Though odds of undergoing colectomy is not increased, patients with cirrhosis warrant closer observation.

Ischemic colitis after enema administration: Incidence, timing, and clinical features

BACKGROUND

Enema administration is a common procedure in the emergency department (ED). However, several published case reports on enema-related ischemic colitis (IC) have raised the concerns regarding the safety of enema agents. Nevertheless, information on its true incidence and characteristics are still lacking.

AIM

To investigate the incidence, timing, and risk factors of IC in patients receiving enema.

METHODS

We consecutively collected the data of all adult patients receiving various enema administrations in the ED from January 2010 to December 2018 and identified patients confirmed with IC following enema. Of 8320 patients receiving glycerin enema, 19 diagnosed of IC were compared with an age-matched control group without IC.

RESULTS

The incidence of IC was 0.23% among 8320 patients receiving glycerin enema; however, there was no occurrence of IC among those who used other enema agents. The mean age ± standard deviation (SD) of patients with glycerin enema-related IC was 70.2 ± 11.7. The mean time interval ± SD from glycerin enema administration to IC occurrence was 5.5 h ± 3.9 h (range 1-15 h). Of the 19 glycerin enema-related IC cases, 15 (79.0%) were diagnosed within 8 h. The independent risk factors for glycerin-related IC were the constipation score [Odds ratio (OR), 2.0; 95% confidence interval (CI): 1.1-3.5, P = 0.017] and leukocytosis (OR, 4.5; 95%CI: 1.4-14.7, P = 0.012).

CONCLUSION

The incidence of glycerin enema-related IC was 0.23% and occurred mostly in the elderly in the early period following enema administration. Glycerin enema-related IC was associated with the constipation score and leukocytosis.

Predictors of mortality following emergency open colectomy for ischemic colitis: a single-center experience

Background

Ischemic colitis (IC) is a severe emergency in gastrointestinal surgery. The aim of the present study was to identify the predictors of postoperative mortality after emergent open colectomy for IC treatment. Additionally, we compared postoperative outcomes of patients undergoing emergent colectomy due to aortic surgery-related IC (AS-IC group) vs. other IC etiologies (Other-IC group).

Methods

We analyzed records of consecutive patients who underwent emergency open colectomy for IC between 2008 and 2019. Logistic regression analysis was performed to identify clinical and operative parameters associated with postoperative mortality. The AS-IC and Other-IC groups were compared for mortality, morbidity, ICU stay, hospital stay, and survival.

Results

During the study period, 94 patients (mean age, 67.4 ± 13.7 years) underwent emergent open colectomy for IC. In the majority of cases, IC involved the entire colon (53.2%) and vasopressor agents were required preoperatively (63.8%) and/or intraoperatively (78.8%). Thirty-four patients underwent surgery due to AS-IC, whereas 60 due to Other-IC causes. In the AS-IC group, 9 patients had undergone endovascular aortic repair and 25 open aortic surgery; 61.8% of patients needed aortic surgery for ruptured abdominal aortic aneurism (AAA). Overall, 66 patients (70.2%) died within 90 days from surgery. The AS-IC and Other-IC groups showed similar operative outcomes and postoperative complication rates. However, the duration of the ICU stay (19 days vs. 11 days; p = 0.003) and of the total hospital stay (22 days vs. 16 days; p = 0.016) was significantly longer for the AS-IC group than for the Other-IC group. The rate of intestinal continuity restoration at 1 year after surgery was higher for the Other-IC group than for the AS-IC group (58.8% vs. 22.2%; p = 0.05). In the multivariate model, preoperative increased lactate levels, a delay between signs/symptoms’ onset and surgery > 12 h, and the occurrence of postoperative acute kidney injury were statistically associated with postoperative mortality. Neither IC etiology (aortic surgery vs. other etiology) nor ruptured AAA was associated with postoperative mortality.

Conclusion

Emergency open colectomy for IC is associated with high postoperative mortality, which appears to be unrelated to the IC etiology. Preoperative lactate levels, > 12-h delay to surgery, and postoperative acute kidney injury are independent predictors of postoperative mortality.

Stromal cell-derived factor-1 as a serologic biomarker for the diagnosis of colon ischemia with chronic cardiovascular disease

Colon ischemia (CI) is the most common ischemic disorder of the gastrointestinal tract. Although some markers of CI, such as procalcitonin and alkaline phosphatase, have been reported, few specific serum markers have been identified. We investigated whether serum stromal cell-derived factor-1 (SDF-1) is a specific marker of CI and clarified the relationship between serum SDF-1 level and CI according to a history of combined chronic cardiovascular disease (CVD).We measured SDF-1 level and other serological markers in 84 patients (control, n = 20; CI without chronic CVD, n = 21; chronic CVD without CI, n = 20; CI with chronic CVD, n = 23).Patients with CI were older than those without CI. There were more women in the CI groups than those without CI. At admission, SDF-1 level was significantly higher in patients having CI with chronic CVD (P < .001) than in other groups. SDF-1 level was significantly higher at admission than at discharge in patients having CI with chronic CVD (P < .001) but not in patients having CI without chronic CVD. SDF-1 level did not differ according to symptoms, involved sites, or duration of hospitalization. At a cutoff value of 0.5 pg/mL for the SDF-1 level in patients having CI with chronic CVD, the sensitivity and specificity for SDF-1 were 91.3% and 95%, respectively. The area-under-the-curve (AUC) value was 0.95. In the logistic regression analysis, an elevation of the SDF-1 level to >0.5 pg/mL was a significant indicator of CI with chronic CVD [odds ratio (OR), 114.914; 95% confidence interval, 10.51 to >999.999; P < .001].SDF-1 could be a useful early biomarker for the diagnosis of CI in patients with chronic CVD.

What predicts the outcome in patients with intestinal ischemia? A single center experience

BACKGROUND

Acute mesenteric ischemia (AMI) is associated with a mortality of 60-80%. Early diagnosis and rapid treatment have a decisive influence on therapy. The aim of this study was to evaluate the prognostic value of AMI markers on mortality, in order to better anticipate the clinical course and to initiate therapeutic steps at an early stage.

STUDY DESIGN

An analysis from our prospective database of 302 consecutive patients with AMI who were treated surgically in the Department of General Surgery between February 2003 and October 2014 was performed. Uni- and multivariate analysis of risk factors for mortality have been performed in the total cohort and in two subgroups according to their stay in intensive care unit (ICU) at the time of AMI diagnosis.

RESULTS

Of the 302 patients with AMI, 115 were in ICU at the time of diagnosis. Totally, 203 patients underwent computed tomography scan (CT-scan) of the abdomen for diagnosis and 68% of them showed specific signs of AMI. A total of 63 (21%) embolectomies were performed during the surgical procedure. The post-operative mortality rate was 68% (204 patients). Among survivors, 85 (87%) patients developed a short bowel syndrome in the post-operative course. Multivariate analysis showed a significant association between mortality and preoperative lactate>3mmol/L, C-reactive protein>100mg/L and ICU stay at the time of AMI diagnosis.

CONCLUSION

Mortality of patients with AMI remains high. Elevated lactate, elevated C-reactive protein and ICU stay are factors associated with increased mortality. Their presence in a patient with suspicion of AMI should trigger a multidisciplinary management in emergency.

Thigh emphysema as the initial presentation of colon ischemia

The incidence of colon ischemia has increased in recent years, and is associated with high morbidity and mortality. The typical presentations of colon ischemia include abdominal pain, bloody diarrhea, and in severe case, ileus, fever and peritonitis. Here, we document a rare case of colon ischemia presenting with subcutaneous and intramuscular emphysema of the thigh. A 76-year-old woman presented to the emergency department for left thigh pain for three days. Physical examination revealed tenderness without obvious crepitus, erythema or swelling over the left groin area and a soft abdomen without tenderness. Plain abdominal film showed abnormal gas formation at the left thigh and chest film demonstrated subphrenic free air. Abdominal computer tomography found sigmoid perforation causing left retroperitoneal abscess, and subcutaneous and intramuscular emphysema over the left pelvic and thigh region. During operation, irreversible ischemia from the terminal ileum through the cecum to the sigmoid colon with gangrene and retroperitoneal abscess were found. Total colectomy with end ileostomy and peritoneal toilet were performed. However, massive bloody ascites from abdominal drainage developed on the 13th day of admission. She later passed away due to hemorrhagic shock. In conclusion, emphysema of the thigh may rarely be caused by an intestinal lesion, such as colon ischemia. Clinicians should be alert of these unusual presentations to find the hidden underlying etiologies.

Predictive factors of mortality after colectomy in ischemic colitis: an ACS-NSQIP database study

Background

Surgical intervention for ischemic colitis is associated with significant postoperative morbidity and mortality. Predictive factors of adverse outcomes have been reported in the literature, but are based on small sample populations. We sought to identify risk factors for mortality after emergent colectomy for ischemic colitis using a clinical outcomes database.

Methods

The American College of Surgeons National Surgical Quality Improvement Project database was queried from 2010 to 2015 to identify emergent colectomies performed for ischemic colitis using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. Univariate and multivariate logistic regression analysis was used to identify independent risk factors associated with increased risk of mortality.

Results

A total of 4548 patients undergoing emergent colectomies for ischemic colitis were identified. Overall, 30-day postoperative mortality was 25.3%. On univariate analysis, preoperative risk factors associated with a higher rate of mortality include dyspnea, functional status, ventilator dependency, history of chronic obstructive pulmonary disease, ascites, congestive heart failure exacerbation, hypertension, dialysis dependency, cancer, open wounds, chronic steroids, weight loss >10%, transfusions within 72 hours before surgery, septic shock and duration from hospital admission to surgery. Factors that were significant for mortality on logistic regression analysis include elderly age, poor functional status, multiple comorbidities, septic shock, blood transfusion, acute renal failure and the duration of time from hospital admission to surgery.

Conclusions

Postoperative morbidity and mortality rates for ischemic colitis remain significantly high. Identification of risk factors may help patient selection for surgical interventions, and make informed decisions with patients and family members. Although it is certainly challenging, early diagnosis and prompt surgical intervention for patients with ischemic colitis may improve outcomes.

Study type and level of evidence

Therapeutic/care management, level II

Diagnosis and treatment of ischemic colitis

Ischemic colitis (IC) is a common reason of acute lower gastrointestinal bleeding, and it is frequently seen in elderly people. In recent years, both the incidence and prevalence of IC have been rising. Most episodes of IC are transient and self-limited and only a minority of cases are severe. IC often has missed and delayed diagnosis. This review mainly focuses on the progress in the understanding of the diagnosis and therapy of IC.

Colon Ischemia: An Update for Clinicians

Colon ischemia (CI) is an underrecognized entity associated with high morbidity and mortality. Establishing the diagnosis and initiating appropriate and timely treatment is critical for improving outcomes. Colon ischemia is a disease spectrum that requires a full understanding for recognition and treatment. This review outlines the full spectrum of CI management from initial presentation to medical and surgical treatment.

Histological Spectrum of Large Intestinal Lesions with Clinicopathological Correlation

INTRODUCTION

Large intestine is affected by various types of lesions, both non-neoplastic and neoplastic. Due to vague symptoms, the clinical diagnosis is usually delayed. A battery of laboratory tests including biopsy is essential to arrive at a specific diagnosis for appropriate management.

MATERIALS AND METHODS

This five years study was done during the period of 2005 to 2010 in a tertiary care centre which included 124 biopsies and resected specimens of large intestine and 64 from Anal canal. All tissues were fixed in formalin, stained with H&E and special stains like Periodic Acid Schiff (PAS), Reticulin, Zeihl Neelsen (ZN) along with Immunohistochemistry (IHC) were done as and when required.

RESULTS

Out of the 124 cases of large intestine 38 were non-neoplastic, 77 were neoplastic and 9 were inadequate biopsies. Sixty four cases from Anal canal included 55 non-neoplastic and 9 neoplastic lesions. The non-neoplastic conditions included congenital anomalies, infective and ischaemic lesions while neoplastic included benign and malignant lesions. Most of the cases presented with symptoms like abdominal pain, vomiting and constipation.

CONCLUSION

We observed that neoplastic lesions were more common in large intestine while non-neoplastic lesions were frequently seen in Anal canal. Present study emphasizes the need for early histopathological diagnosis for appropriate treatment.

A meta-analysis of the predictive accuracy of postoperative mortality using the American Society of Anesthesiologists' physical status classification system

BACKGROUND

The American Society of Anesthesiologists' physical status (ASA) tool has been applied to determine compensation, risk adjustment and risk prediction, but little is known about the accuracy and generalizability of this tool for prediction of postoperative mortality.

METHODS

We systematically investigated prior published reports of associations between ASA physical status and mortality to test the hypothesis that ASA physical status will have varying accuracy in prediction of postoperative mortality across surgical populations with varying surgical risk of mortality. We used random effects models and metaregression to account for heterogeneity.

RESULTS

Combining 77 studies with 165,705 patients, the ASA physical status tool demonstrated the following pooled performance (95 % confidence intervals)--sensitivity 0.74 (0.73, 0.74), specificity 0.67 (0.67, 0.67), and area under summary receiver operating curve 0.736 (0.725, 0.747). Metaregression revealed that study death rates and surgical specialty were significant factors.

CONCLUSION

ASA physical status is a better predictor of postoperative mortality in settings with lower rather than higher death rates.

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.

Poor prognostic factors in patients who underwent surgery for acute non-occlusive ischemic colitis

INTRODUCTION

Ischemic colitis (IC) is a disease with high postoperative morbidity and mortality. Knowledge of the risk factors for postoperative mortality could be helpful in clinical decision making and in optimizing postoperative treatment.

METHODS

From a prospective database, we conducted a retrospective medical record review of 50 patients who underwent surgery for IC between 2003 and 2011 at our institution. We analyzed the causes and potential risk factors for early mortality after surgery for IC.

RESULTS

The early postoperative mortality and morbidity rates were 30.0% (15/50) and 54% (27/50), respectively. The two most common causes of death were multi-organ failure (66.7%, 10/15) and fulminant septic shock (20.0%, 3/15). Univariate analysis showed that postoperative mortality was significantly associated with preoperative nephropathy, coronary artery disease, a previous history of cardiovascular surgery, an ASA score ≥ 4, surgical delay ≥ 3 days, preoperative hemodynamic instability, and use of pre- and intraoperative adrenergic vasopressors. In the multivariate analysis, a previous history of cardiovascular surgery (odds ratio [OR], 8.2; 95% confidence interval [CI], 1.2-56.5) and surgical delay ≥ 3 days (OR, 5.7; 95% CI, 1.2-27.9) were identified as independent risk factors for postoperative mortality.

CONCLUSIONS

Because surgical delay is an avoidable determinant of early mortality, a high index of suspicion and early surgical intervention can increase survival. A routine postoperative evaluation for IC may be helpful in patients with a previous history of cardiovascular surgery.

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.

Surgery for ischemic colitis: outcome and risk factors for in-hospital mortality

PURPOSE

Surgery for ischemic colitis is associated with high perioperative morbidity and mortality, but the risk factors for mortality and major surgical complications are unclear.

METHODS

In this retrospective single institution cohort study of all patients undergoing colorectal surgery for histologically proven ischemic colitis between 2004 and 2010, we evaluated surgical outcomes and risk factors for in-hospital mortality and major surgical complications.

RESULTS

For the 100 patients included in the study, in-hospital mortality was 54 %; major surgical complications, defined as anastomotic leakage or rectal stump and stoma complications, occurred in 16 %. In the multivariable analysis, hospital death was more likely in patients with right-sided (odds ratio [OR] 3.8; 95 % confidence interval [CI] 1.2, 12; P = 0.022) or pan-colonic ischemia (OR 11; 95 % CI 2.8, 39; P < 0.001), both relative to left-sided ischemia. Decreased preoperative pH level (OR 2.5 per 0.1 decrease; 95 % CI 1.5, 4.1; P < 0.001) and prior cardiac or aortic surgery (OR 2.4; 95 % CI 0.82, 6.8; P = 0.109) were further important risk factors for in-hospital mortality. Major postoperative surgical complications were more likely in patients with ischemic alterations at the resection margin of the histological specimen (OR 3.7; 95 % CI 1.2, 11; P = 0.022).

CONCLUSIONS

Colonic resection for ischemic colitis is associated with high in-hospital mortality, especially in patients with right-sided or pan-colonic ischemia. In patients developing acidosis, early laparotomy is essential. Since resection margins' affection seems to be underestimated upon surgery, resections should be performed wide enough within healthy tissue.

Prognosis and follow-up of 135 patients with ischemic colitis over a five-year period

AIM

To study the prognosis (recurrence and mortality) of patients with ischemic colitis (IC).

METHODS

This study was conducted in four Spanish hospitals, participants in the Ischemic Colitis in Spain study We analyzed prospectively 135 consecutive patients who met criteria for definitive or probable IC according to Brandt criteria, and follow up these patients during the next five years, retrospectively. Long-term results (recurrence and mortality) were evaluated retrospectively after a median interval of 62 mo (range 54-75 mo).

RESULTS

Estimated IC recurrence rates were 2.9%, 5.1%, 8.1% and 9.7% at years 1, 2, 3 and 5 years, respectively. Five-year survival was 69% (93 of 135) and 24% (10 of 42 patients) died for causes related to the IC. Among these 10 patients, 8 died in their first episode at hospital (4 had gangrenous colitis and 4 fulminant colitis) and 2 due to recurrence.

CONCLUSION

The five-year recurrence rate of IC was low. On the other hand, mortality during follow-up was high and was not associated with ischemic colitis.

Rectal ischemia mimicked tumor mass

Ischemic proctitis is a rare disease which is usually encountered in elderly with comorbidities. We present a case of an 80-year old man with severe coronary disease who presented with severe hematochezia and hypotension. Endoscopy revealed a rectal mass 3-4 cm above the dental line and rectosigmoid mucosal inflammation compatible with ischemic colitis. The rectal insult was so intense that it resembled a neoplasmatic lesion. We discuss the causes, the prognostic factors, and the clinical and therapeutic challenges of this rare, albeit life-threatening entity, and we review the relative literature. A percentage of 10%–20% of patients with ischemic colitis usually have a distal potentially obstructing lesion or disorder such as cancer, diverticulitis or fecal impaction. Ischemic colitis, when mucosal and submucosal edema is severe and hemorrhagic nodules are large enough, can mimic a neoplasmatic lesion. The best treatment approach is a conservative management initially with a close clinical followup and after stabilization a repetition of rectal endoscopy with new biopsies. Early recognition of this clinical entity is of paramount importance to implement appropriate therapy (conservative or surgical) and avoid potentially fatal treatment of presumed inflammatory or infectious bowel diseases.

A review of ischemic colitis: is our clinical recognition and management adequate?

Ischemic colitis is a common cause of hospital admissions; however it is frequently confused intellectually with mesenteric ischemia and often misdiagnosed as infectious diarrhea or Clostridium difficile colitis. Ischemic colitis is caused by non-occlusive insult to the small vessels supplying the colon without a clear precipitating factor. It is more common in females and in patients above 60 years of age. The classic presentation includes sudden onset of lower abdominal pain followed by the urge to defecate and bloody diarrhea. Focal right-sided ischemic colitis has more pain and a worse prognosis. Choosing the correct diagnostic studies is challenging and requires proficient knowledge of the disease. Management is usually conservative, however around 10-20% of the patients will require surgery. Acute ischemic colitis usually resolves; nevertheless some patients may develop chronic segmental colitis or a stricture. One ischemic colitis caveat is that it may be the first sign of undiagnosed cardiac disease. A firm grasp on this common yet little discussed condition is valuable to a gastrointestinal consultant and hospitalist alike.

A 10-year longitudinal analysis of surgical management for acute ischemic colitis

INTRODUCTION

Our objective was to review our 10-year experience of surgical resection for acute ischemic colitis (IC) and to assess the predictive value of previously reported risk-stratification methods.

METHODS

We retrospectively reviewed all adult patients at our institution undergoing colectomy for acute IC between 2000 and 2009. Descriptive statistics were calculated. Long-term survival was assessed using Kaplan-Meier methods and in-hospital mortality using multivariate logistic regression. Patients were risk-stratified based on previously reported methods, and discriminatory accuracy of predicting in-hospital mortality was evaluated by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.

RESULTS

A total of 115 patients were included for analysis, of which 37 % (n = 43) died in-hospital. The median survival was 4.9 months for all patients and 43.6 months for patients surviving to discharge. Seventeen patients subsequently underwent end-ostomy reversal at our institution, with in-hospital mortality of 18 % (n = 3) and ICU admission for 35 % (n = 6). The discriminatory accuracy of risk stratification in predicting in-hospital mortality based on ROC AUC was 0.75.

CONCLUSION

Acute IC continues to remain a very deadly disease. Patients who survive the initial acute IC insult can achieve long-term survival; however, we experienced high rates of death and complications following elective end-ostomy reversal. Risk stratification provides reasonable accuracy in predicting postoperative mortality.

Ischemic colitis: the ABCs of diagnosis and surgical management

Ischemic colitis (IC) is a rare condition. As ischemia is often transient and clinical symptoms are reversible, its exact incidence is unknown. In current clinical practice, two types of IC are described according to the severity: severe IC, with transmural colonic ischemia and/or multi-organ failure (MOF), and mild IC, without MOF and spontaneous favourable evolution in most cases. Two clinical contexts are encountered: spontaneous IC (SIC) and postoperative IC (POIC), mainly after aortic surgery. As there is no specific clinico-biologic symptom of IC, emergent CT-scan and rectosigmoidoscopy are required for diagnosis confirmation, surgical decision and prognosis analysis. IC surgical treatment is not consensual but can be standardized according to organ function and the degree of ischemia: surgical treatment in case of colonic necrosis with deep ischemia and/or MOF; observation for superficial ischemia without organ dysfunction; systematic medical care. Surgery is required in 20% of cases, and consists in extended colectomy without continuity restoration and prophylactic cholecystectomy. Continuity restoration is feasible in one third of survivors, who are exposed to a high risk of severe cardiovascular events.

Systematic review of the management of ischaemic colitis

AIM

The study reviews the literature related to ischaemic colitis (IC) to establish an evidence base for its management and to identify factors predicting severity and mortality.

METHOD

A systematic review of the English language literature was conducted according to recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE, Embase and Cochrane Library databases were searched using the keyword search 'ischaemic colitis OR colon ischaemia OR colonic ischaemia OR management ischaemic colitis'. IC is often misdiagnosed so only studies where the diagnosis was supported by histopathology in every case were included. Critical appraisal was performed of included studies using predefined quality assessment checklists and narrative data synthesis.

RESULTS

In all, 2610 publications were identified. Of these, eight retrospective case series and three case controlled studies describing 1049 patients were included. Medical management was used in 80.3% patients of whom 6.2% died. Surgery was required in 19.6% of whom 39.3% died. The overall mortality of IC was 12.7%. Lack of rectal bleeding, peritonism and renal dysfunction were commonly quoted predictors of severity; however, right sided IC appeared to be the most significant predictor of outcome.

CONCLUSION

Most patients with IC can be managed conservatively. Right sided IC may be the most significant predictor of severity.

Postoperative complications following colectomy for ulcerative colitis: a validation study

Background

Ulcerative colitis (UC) patients failing medical management require colectomy. This study compares risk estimates for predictors of postoperative complication derived from administrative data against that of chart review and evaluates the accuracy of administrative coding for this population.

Methods

Hospital administrative databases were used to identify adults with UC undergoing colectomy from 1996–2007. Medical charts were reviewed and regression analyses comparing chart versus administrative data were performed to assess the effect of age, emergent operation, and Charlson comorbidities on the occurrence of postoperative complications. Sensitivity, specificity, and positive/negative predictive values of administrative coding for identifying the study population, Charlson comorbidities, and postoperative complications were assessed.

Results

Compared to chart review, administrative data estimated a higher magnitude of effect for emergent admission (OR 2.52 [95% CI: 1.80–3.52] versus 1.49 [1.06–2.09]) and Charlson comorbidities (OR 2.91 [1.86–4.56] versus 1.50 [1.05–2.15]) as predictors of postoperative complications. Administrative data correctly identified UC and colectomy in 85.9% of cases. The administrative database was 37% sensitive in identifying patients with ≥ 1Charlson comorbidity. Restricting analysis to active comorbidities increased the sensitivity to 63%. The sensitivity of identifying patients with at least one postoperative complication was 68%; restricting analysis to more severe complications improved the sensitivity to 84%.

Conclusions

Administrative data identified the same risk factors for postoperative complications as chart review, but overestimated the magnitude of risk. This discrepancy may be explained by coding inaccuracies that selectively identifying the most serious complications and comorbidities.

Transmural colonic ischemia: clinical features and computed tomography findings

Our purpose was to describe the computed tomography features of transmural colonic ischemia in correlation with clinical, laboratory and histopathological findings of 14 patients who underwent colectomy (9 female and 5 male; mean age, 68 years). Seven patients died (50%). Transmural necrosis involved the right colon in 10 patients (10/14, or 72%). Eleven patients showed thickened colonic wall (11/14, or 79%), 10 pneumatosis (10/14, or 71%), 5 gas in the portal venous system (5/14, or 36%), and 14 fat stranding (14/14, or 100%).

Using National Surgical Quality Improvement Program (NSQIP) data for risk adjustment to compare Clavien 4 and 5 complications in open and laparoscopic colectomy

BACKGROUND

Laparoscopic colectomy has been associated with fewer postoperative complications than open colectomy. However, it is unclear whether this is true for the most severe complications typically requiring treatment in an intensive care unit (ICU). The authors hypothesized that laparoscopic colectomy patients have fewer of the most severe complications even after adjustment for comorbidity risk.

METHODS

Using the National Surgical Quality Improvement Program (NSQIP) public use files for 2005-2008, the authors identified all laparoscopic (n = 12,455) and open (n = 33,190) colectomies by current procedural terminology (CPT) code. Using the Clavien classification for postoperative complications, they identified NSQIP data points most consistent with Clavien grade 4 complications requiring ICU care (postoperative septic shock, postoperative dialysis, pulmonary embolism, myocardial infarction, cardiac arrest, prolonged ventilatory requirements, need for reintubation) or grade 5 complication (mortality). Statistical analysis was performed using SPSS software. Odds ratios were calculated to compare laparoscopic and open colectomy regarding the probability of having any Clavien class 4 or 5 complication. Logistic regression was performed to account for the effect of preoperative conditions (American Society of Anesthesiology class, wound class, gender, preoperative functional status, preoperative albumin level, azotemia, thrombocytopenia, emergency case, and age >70 years) on complications.

RESULTS

The univariate odds ratio showed a 2.27- to 5.52-fold greater likelihood that a patient would have a complication requiring ICU admission if open rather than laparoscopic surgery was performed (p < 0.001). Multivariate logistic regression accounting for preoperative comorbidities that might affect outcome showed persistence of an increase in complications, with an odds ratio range of 1.63 to 2.21.

CONCLUSION

Evaluation of the NSQIP database demonstrated that laparoscopic colectomy confers an independent protective effect on the frequency of ICU-level (Clavien grade 4) complications and mortality. The protective effect remained evident after correction for preoperative conditions that might have affected outcome.

Clinical effectiveness of fresh frozen plasma compared with fibrinogen concentrate: a systematic review

Introduction

Haemostatic therapy in surgical and/or massive trauma patients typically involves transfusion of fresh frozen plasma (FFP). Purified human fibrinogen concentrate may offer an alternative to FFP in some instances. In this systematic review, we investigated the current evidence for the use of FFP and fibrinogen concentrate in the perioperative or massive trauma setting.

Methods

Studies reporting the outcome (blood loss, transfusion requirement, length of stay, survival and plasma fibrinogen level) of FFP or fibrinogen concentrate administration to patients in a perioperative or massive trauma setting were identified in electronic databases (1995 to 2010). Studies were included regardless of type, patient age, sample size or duration of patient follow-up. Studies of patients with congenital clotting factor deficiencies or other haematological disorders were excluded. Studies were assessed for eligibility, and data were extracted and tabulated.

Results

Ninety-one eligible studies (70 FFP and 21 fibrinogen concentrate) reported outcomes of interest. Few were high-quality prospective studies. Evidence for the efficacy of FFP was inconsistent across all assessed outcomes. Overall, FFP showed a positive effect for 28% of outcomes and a negative effect for 22% of outcomes. There was limited evidence that FFP reduced mortality: 50% of outcomes associated FFP with reduced mortality (typically trauma and/or massive bleeding), and 20% were associated with increased mortality (typically surgical and/or nonmassive bleeding). Five studies reported the outcome of fibrinogen concentrate versus a comparator. The evidence was consistently positive (70% of all outcomes), with no negative effects reported (0% of all outcomes). Fibrinogen concentrate was compared directly with FFP in three high-quality studies and was found to be superior for > 50% of outcomes in terms of reducing blood loss, allogeneic transfusion requirements, length of intensive care unit and hospital stay and increasing plasma fibrinogen levels. We found no fibrinogen concentrate comparator studies in patients with haemorrhage due to massive trauma, although efficacy across all assessed outcomes was reported in a number of noncomparator trauma studies.

Conclusions

The weight of evidence does not appear to support the clinical effectiveness of FFP for surgical and/or massive trauma patients and suggests it can be detrimental. Perioperatively, fibrinogen concentrate was generally associated with improved outcome measures, although more high-quality, prospective studies are required before any definitive conclusions can be drawn.

Systematic review on the treatment of ischaemic colitis

AIM

Ischaemic colitis is uncommon. Aetiological factors include abdominal aortic surgery, drugs (especially inotropics) or rheumatoid diseases, such as Takayasu's or Buerger's diseases. However, there is often no triggering factor, and it may be part of multifactorial cardiac, respiratory, renal or metabolic failure.

METHOD

A systematic review of the current literature on the management of ischaemic colitis was carried out.

RESULTS

Ten retrospective trials (841 patients) were included. No randomized controlled or prospective trial of the management of ischaemic colitis was found.

CONCLUSION

There is very little evidence base for the management of this condition.

Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study)

BACKGROUND

There is a lack of prospective studies evaluating the natural history of colonic ischaemia (CI). We performed such a study to evaluate the clinical presentation, outcome, and mortality as well as clinical variables associated with poor prognosis.

METHODS

An open, prospective, and multicentre study was conducted in 24 Spanish hospitals serving a population of 3.5 million people. The study included only patients who met criteria for definitive or probable CI. A website (www.colitisisquemica.org) provided logistical support.

RESULTS

A total of 364 patients met criteria for inclusion. CI was suspected clinically in only 24.2% of cases. The distribution of clinical patterns was as follows: reversible colopathy (26.1%), transient colitis (43.7%), gangrenous colitis (9.9%), fulminant pancolitis (2.5%), and chronic segmental colitis (17.9%). A total of 47 patients (12.9%) had an unfavorable outcome as defined by mortality and/or the need for surgery. Multivariate analysis identified the following signs as independent risk factors for an unfavorable outcome: abdominal pain without rectal bleeding [odds ratio (OR) 3.9; 95% confidence interval (CI) = 1.6-9.3], non-bloody diarrhoea (OR 10; 95% CI = 3.7-27.4), and peritoneal signs (OR 7.3; 95% CI = 2.7-19.6). Unfavorable outcomes also were more frequent in isolated right colon ischaemia (IRCI) compared with non-IRCI (40.9 vs. 10.3%, respectively; p < 0.0001). The overall mortality rate was 7.7%.

CONCLUSIONS

The clinical presentation of CI is very heterogeneous, perhaps explaining why clinical suspicion of this disease is so low. The presence of IRCI, and occurrence of peritoneal signs or onset of CI as severe abdominal pain without bleeding, should alert the physician to a potentially unfavorable course.

Risk factors for mortality-morbidity after emergency-urgent colorectal surgery

BACKGROUND

The aim of this study was to assess the risk factors associated with mortality and morbidity following emergency or urgent colorectal surgery.

MATERIALS AND METHODS

All data regarding the 462 patients who underwent emergency colonic resection in our institution between November 2002 and December 2007 were prospectively entered into a computerized database.

RESULTS

The median age of patients was 73 (range 17-98) years. The most common indications for surgery were: 171 adenocarcinomas (37%), 129 complicated diverticulitis (28%), and 35 colonic ischemia (7.5%). Overall mortality and morbidity rates were 14% and 36%, respectively. In multivariate analysis, the only parameter significantly associated with postoperative mortality was blood loss >500 cm(3) (odds ratio (OR) = 3.33, 95% confidence interval (CI) 1.63-6.82, p = 0.001). There were three parameters which correlated with postoperative morbidity: ASA score > or =3 (OR = 2.9, 95% CI 1.9-4.5, p < 0.001), colonic ischemia (OR = 3.4, 95% CI 1.4-7.7, p = 0.006), and stoma creation (OR = 2.2, 95% CI 1.4-3.4, p = 0.0003).

CONCLUSIONS

The main risk factors for postoperative morbidity and mortality following emergency colorectal surgery are related to: (1) patients' ASA score, (2) colonic ischemia, and (3) perioperative bleeding. These variables should be considered in the elaboration of future scoring systems to predict outcome of emergency colorectal surgery.