Colon ischemia: Right-sided colon involvement has a different presentation, etiology and worse outcome. A large retrospective cohort study in histology proven patients

Contrast-induced ischemic colitis following coronary angiography: A case report

BACKGROUND

Ischemic colitis (IC) is common, rising in incidence and associated with high mortality. Its presentation, disease behavior and severity vary widely, and there is significant heterogeneity in therapeutic strategies and prognosis. The common causes of IC include thromboembolism, hemodynamic insufficiency, iatrogenic factors and drug-induced. However, contrast-induced IC, especially isolated right colon ischemia is rarely reported.

CASE SUMMARY

A 52-year-old man was admitted to the hospital due to intermittent chest distress accompanied by palpitation. Coronary angiography was performed using 60 mL of the iodinated contrast agent iohexol (Omnipaque 300), and revealed moderate stenosis of the left anterior descending artery and right coronary artery. At 3 h post-procedure, he complained of epigastric pain without fever, diarrhea and vomiting. Vital signs remained normal. An iodixanol-enhanced abdominal computed tomography (CT) scan revealed thickening, edema of the ascending and right transverse colonic wall and inflammatory exudate, without thrombus in mesenteric arteries and veins. Following 4 days of treatment with antibiotic and supportive management, the patient had a quick and excellent recovery with disappearance of abdominal pain, normalization of leucocyte count and a significant decrease in C reactive protein. There was no recurrence of abdominal pain during the patient's two-year follow-up.

CONCLUSION

This case emphasizes that contrast-induced IC should be considered in the differential diagnosis of unexplained abdominal pain after a cardiovascular interventional procedure with the administration of contrast media. Timely imaging evaluation by CT and early diagnosis help to improve the prognosis of IC.

Colonic involvement in acute mesenteric ischemia: prevalence, risk factors, and outcomes

OBJECTIVES

This study aimed to investigate the prevalence, risk factors, and outcomes of colonic involvement in patients with acute mesenteric ischemia (AMI).

METHODS

CT scans from a prospective cohort of 114 AMI patients treated in an intestinal stroke center between 2009 and 2018 were blindly reviewed by two radiologists. Colon involvement was defined on CT scan by the presence of at least one of the following CT colonic features: wall thickening, pneumatosis, decreased wall enhancement, dilatation, or perforation. In addition, the clinical, biological, and radiological characteristics of patients with and without colonic involvement were compared to identify risk factors for colonic involvement on CT and its impact on morbidity and mortality.

RESULTS

Colonic involvement was identified in 32/114 (28%) patients with AMI, the right colon being more frequently involved (n = 29/32, 91%). Wall thickening (n = 27/32) was the most common CT finding. Occlusion of the inferior mesenteric artery was the only statistically significant risk factor for colonic involvement (35% vs. 15%, p = 0.02). Patients with colonic involvement on CT vs. those without had more frequently transmural colonic necrosis (13% vs. 0%, p = 0.006), short bowel syndrome (16% vs. 4%, p = 0.04), need for long-term parenteral support (19% vs. 5%, p = 0.03), and death during follow-up (22% vs. 10%, p = 0.03).

DISCUSSION

In patients with AMI, colonic involvement is associated with increased morbidity and mortality and should be carefully searched for during initial CT scan assessment.

KEY POINTS

• In a prospective cohort of acute mesenteric ischemia patients from an intestinal stroke center, 28% had an associated colonic involvement on CT. • Colonic involvement on CT most commonly affected the right colon, and the occlusion of the inferior mesenteric artery was the only risk factor. • Colonic involvement on CT was associated with increased morbidity and mortality and should be carefully searched for during initial CT scan assessment.

Colon ischemia: A comprehensive review

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

A Novel Multiparameter Scoring Model for Noninvasive Early Prediction of Ischemic Colitis: A Multicenter, Retrospective, and Real-World Study

INTRODUCTION

Ischemic colitis (IC) is a common gastrointestinal ischemic disease caused by hypoperfusion or reperfusion injury. However, there are few studies on risk factors associated with poor prognoses of the disease. This study aimed to determine the predictors of poor prognoses in patients with IC and establish a prognostic scoring method with good internal and external validity for identifying severe cases in an early stage.

METHODS

We established a prognosis model by conducting a multicenter, retrospective study of patients hospitalized with IC between November 2008 and May 2020. Predictive power was tested using 5-fold internal cross-validation and external validation.

RESULTS

The following 6 factors were included in the prognostic model: neutrophil count, D-dimer level, ischemia of the distal ileum, ischemia of the hepatic flexure, ulceration, and luminal stenosis. The area under the receiver-operating characteristic curve for internal cross-validation of the prediction model was 86%, and that for external validation was 95%. During internal validation, our model correctly identified 88.08% of the patients. It was further found that patients younger than 65 years with a higher neutrophil-to-lymphocyte ratio and higher heart rate had poor prognoses. Patients aged 65 years and older with ischemia of terminal ileum, hepatic flexure, splenic flexure, and intestinal stenosis had poor prognoses.

DISCUSSION

Patients with ischemia in the hepatic flexure and the distal ileum, endoscopic evidence of ulcer or stenosis, higher neutrophil counts, and higher D-dimer levels have worse prognoses. This information could aid in the selection of timely and appropriate treatment.

A clinical approach to acute mesenteric ischemia

PURPOSE OF REVIEW

To summarize current evidence on acute mesenteric ischemia (AMI) in critically ill patients, addressing pathophysiology, definition, diagnosis and management.

RECENT FINDINGS

A few recent studies showed that a multidiscipliary approach in specialized centers can improve the outcome of AMI. Such approach incorporates current knowledge in pathophysiology, early diagnosis with triphasic computed tomography (CT)-angiography, immediate endovascular or surgical restoration of mesenteric perfusion, and damage control surgery if transmural bowel infarction is present. No specific biomarkers are available to detect early mucosal injury in clinical setting. Nonocclusive mesenteric ischemia presents particular challenges, as the diagnosis based on CT-findings as well as vascular management is more difficult; some recent evidence suggests a possible role of potentially treatable stenosis of superior mesenteric artery and beneficial effect of vasodilator therapy (intravenous or local intra-arterial). Medical management of AMI is supportive, including aiming of euvolemia and balanced systemic oxygen demand/delivery. Enteral nutrition should be withheld during ongoing ischemia-reperfusion injury and be started at low rate after revascularization of the (remaining) bowel is convincingly achieved.

SUMMARY

Clinical suspicion leading to tri-phasic CT-angiography is a mainstay for diagnosis. Diagnosis of nonocclusive mesenteric ischemia and early intestinal injury remains challenging. Multidisciplinary team effort may improve the outcome of AMI.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Ischaemic colitis: practical challenges and evidence-based recommendations for management

Ischaemic colitis (IC) is a common condition with rising incidence, and in severe cases a high mortality rate. Its presentation, severity and disease behaviour can vary widely, and there exists significant heterogeneity in treatment strategies and resultant outcomes. In this article we explore practical challenges in the management of IC, and where available make evidence-based recommendations for its management based on a comprehensive review of available literature. An optimal approach to initial management requires early recognition of the diagnosis followed by prompt and appropriate investigation. Ideally, this should involve the input of both gastroenterology and surgery. CT with intravenous contrast is the imaging modality of choice. It can support clinical diagnosis, define the severity and distribution of ischaemia, and has prognostic value. In all but fulminant cases, this should be followed (within 48 hours) by lower gastrointestinal endoscopy to reach the distal-most extent of the disease, providing endoscopic (and histological) confirmation. The mainstay of medical management is conservative/supportive treatment, with bowel rest, fluid resuscitation and antibiotics. Specific laboratory, radiological and endoscopic features are recognised to correlate with more severe disease, higher rates of surgical intervention and ultimately worse outcomes. These factors should be carefully considered when deciding on the need for and timing of surgical intervention.

Contrast-Enhanced CT for the Diagnosis of Acute Mesenteric Ischemia

OBJECTIVE. The purpose of this article is to provide an overview of the diagnostic and prognostic roles of CT in the management of acute mesenteric ischemia. CONCLUSION. Acute mesenteric ischemia is defined as inadequate blood supply to the gastrointestinal tract resulting in ischemic and inflammatory injury. The prognosis is poor without treatment. Contrast-enhanced CT has become the cornerstone of diagnosis to identify features of vascular disorders and of intestinal ischemic injury and to visualize bowel necrosis.

[Modern treatment of mesenteric ischemia]

Acute mesenteric ischemia is a highly morbid affliction which requires urgent care. Acute mesenteric ischemia consists in an ischemia injury of the small bowel, secondary to vascular insufficiency, either occlusive (thrombosis, embolism, arterial, venous) or non-occlusive (low flow or vasospasm). Given that the superior mesenteric artery supplies the small bowel as well as the right part of the colon, any ischemic process involving the right colon should be considered an acute mesenteric ischemia until proven otherwise. Acute mesenteric ischemia should always be suspected in the setting of a sudden, unusual and intense abdominal pain requiring opioids. Chronic mesenteric ischemia can also be revealed by postprandial abdominal pain associated with significant weight loss. The clinical presentation of mesenteric ischemia is nonspecific. Thus, a suspected diagnosis must be confirmed by imaging usually consisting in an abdominal computed tomography scan. Imaging will also provide guidance with regards to treatment decision. Organ failure, serum lactate elevation as well as bowel loop dilationper imaging are predictive of irreversible intestinal necrosis. In the presence of any of these predictive factors, surgical management should be considered. The modern treatment of mesenteric ischemia in Intestinal Stroke Centers has allowed rates of resection-free survival in nearly two-thirds of patients. The management of mesenteric ischemia relies in a combination of: (1) a medical protocol including oral/enteral antibiotics; (2) the revascularization of viable bowel and (3) the surgical resection of necrosic, non viable intestinal tissue. The inception and development of Intestinal Stroke Centers has been the cornerstone of significantly improved management and survival rates as well as crucial asset in research, specifically in the field of biomarkers associated with early diagnosis.