Ischemic colitis following colonoscopy in an elderly patient on cardiovascular medication

Colonoscopy-related colonic ischemia

Colonoscopy is a risk factor for colon ischemia. The colon is susceptible to ischemia due to its minor blood flow compared to other abdominal organs; the etiology of colon ischemia after colonoscopy is multifactorial. The causative mechanisms include splanchnic circulation impairment, bowel preparation, drugs used for sedation, bowel wall ischemia due to insufflation/barotrauma, and introduction of the endoscope. Gastroenterologists must be aware of this condition and its risk factors for risk minimization, early diagnosis, and proper treatment.

Effects of Drugs and Excipients on Hydration Status

Despite being the most essential nutrient, water is commonly forgotten in the fields of pharmacy and nutrition. Hydration status is determined by water balance (the difference between water input and output). Hypohydration or negative water balance is affected by numerous factors, either internal (i.e., a lack of thirst sensation) or external (e.g., polypharmacy or chronic consumption of certain drugs). However, to date, research on the interaction between hydration status and drugs/excipients has been scarce. Drugs may trigger the appearance of hypohydration by means of the increase of water elimination through either diarrhea, urine or sweat; a decrease in thirst sensation or appetite; or the alteration of central thermoregulation. On the other hand, pharmaceutical excipients induce alterations in hydration status by decreasing the gastrointestinal transit time or increasing the gastrointestinal tract rate or intestinal permeability. In the present review, we evaluate studies that focus on the effects of drugs/excipients on hydration status. These studies support the aim of monitoring the hydration status in patients, mainly in those population segments with a higher risk, to avoid complications and associated pathologies, which are key axes in both pharmaceutical care and the field of nutrition.

Review article: the pharmacological causes of colon ischaemia

BACKGROUND

Colon ischaemia is the most common ischaemic disorder of the gastrointestinal system, can affect any segment of the colon, and may present with a range of symptoms. Diagnosis can be challenging due to symptom overlap with other conditions, varied aetiology, and often rapid and self-resolving course.

AIM

To review comprehensively the literature regarding the pharmacological aetiologies of colonic ischaemia to enhance the understanding of the various mechanisms of disease, presentations, distribution, and outcomes.

METHODS

A PubMed search for "colon ischaemia" and "ischaemic colitis" alone as well as in combination with various known pharmacologic causes was performed. Only the highest quality and relevant literature was included in this review. The quality of the literature for each association was rated by the authors and a consensus was made when discrepancies were encountered. Only associations that were deemed "moderate" or "strong" were included.

RESULTS

The literature considering pharmacologically associated colonic ischaemia is diverse, lacks codification and is characterised by numerous case reports and case series. Constipation-inducing drugs, digoxin, hormonal therapies, illicit drugs, immunomodulators, laxatives, and NSAIDs were strongly associated with colonic ischaemia. Antimicrobials, appetite suppressants, chemotherapies, decongestants, diuretics, ergot alkaloids, serotonin agents, statins, and vasopressor agents were moderately associated.

CONCLUSIONS

Patients presenting with abdominal pain, diarrhoea, or bloody stool need to be evaluated for the possibility of this condition and treated accordingly. Timely diagnosis is necessary to improve patient outcomes. This review aims to increase awareness among clinicians regarding the presentation of pharmacologically induced colonic ischaemia.

Gastrointestinal Side Effects of Antiarrhythmic Medications: A Review of Current Literature

Antiarrhythmic drugs are commonly prescribed cardiac drugs. Due to their receptor mimicry with several of the gastrointestinal tract receptors, they can frequently lead to gastrointestinal side effects. These side effects are the most common reasons for discontinuation of these drugs by the patients. Knowledge of these side effects is important for clinicians that manage antiarrhythmic drugs. This review focuses on the gastrointestinal side effects of these drugs and provides a detailed up-to-date literature review of the side effects of these drugs. The review provides case reports reported in the literature as well as possible mechanisms that lead to gastrointestinal side effects.

Post Colonoscopy Ischaemic Colitis in a Patient without Risk Factors for Colon Ischemia: A Case Report

Ischaemic colitis is the most common form of intestinal ischaemia and is more common in the elderly and in the people having risk factors for colonic ischaemia. Colonoscopy procedure itself is a rare cause of ischaemic colitis. Fewer than 20 cases of ischaemic colitis caused by colonoscopy procedure have been reported in the english literature till date. This patient presented to us within hours of routine colonoscopy with rectal bleeding and lower abdominal pain. On repeat colonoscopy, the patient had mucosal oedema and ulcerations in the descending colon and sigmoid colon. Computed tomography of abdomen and biopsy of the involved segment confirmed ischaemic colitis. The patient recovered with conservative management.

Transmural Colonic Infarction after Routine Colonoscopy in a Young Patient without Risk Factors

Colonoscopy is one of the most widely used procedures in medical practice for the diagnosis and treatment of many benign and malignant diseases of the colorectal tract. Colonscopy has become the reference procedure for screening and surveillance of colorectal cancer. The overall rate of adverse events is estimated to be about 2.8 per 1,000 procedures, while complications requiring hospitalization are about 1.9 per 1,000 colonoscopies. Mortality from all causes and colonoscopy-specific mortality are estimated to be 0.07 and 0.007%, respectively. An exceptional fearsome postcolonoscopy complication is colon ischemia (CI); only few cases have been reported worldwide. We present the case of a 43-year-old woman who presented to the emergency department complaining of abdominal pain; fever and rectal bleeding appeared 12 h after a voluntary 'screening' colonoscopy. She had no risk factors for CI. Her laboratory tests showed alterations in inflammatory markers and a computed tomography scan showed a circumferential thickening in the left colon and free fluid in the abdomen. After 12 h of observation and conservative therapy, the clinical state of the patient worsened with the rising of signs of peritonitis. Laparoscopy showed that colon infarction extended from the distal third of the transverse colon to the proximal rectum. Laparotomy, resection of the pathological colon and terminal colostomy were performed. The specimen examined confirmed an extended ischemic colitis and transmural infarction on the antimesocolic side, in the absence of a vasculitis. The patient underwent recanalization after 8 months. CI after colonoscopy is a rare and alarming complication that must be known and taken into account in the differential diagnosis of symptomatic cases after colonoscopy, particularly in patients with known risk factors. The diagnosis is mainly based on clinical data, imaging and especially endoscopy. Treatment is almost always conservative but, in some cases in which the pathological process appears irreversible, surgery becomes mandatory.

Incidence of ischemic colitis in treated, commercially insured hypertensive adults: a cohort study of US health claims data

BACKGROUND

Ischemic colitis (IC) incidence rates (IRs) among treated hypertensive patients are poorly understood, and existing literature on the subject is sparse. Antihypertensive drugs may raise the risk of developing IC. Novel antihypertensive agents—such as the direct renin inhibitor aliskiren—have not been assessed for IC risk.

OBJECTIVES

The aims of this study were to evaluate (1) the IRs of probable IC (pIC) in treated hypertensive adults, with a focus on aliskiren-treated patients; (2) the antihypertensive therapies used; and (3) the IRs of pIC in non-hypertensive adults.

METHODS

This study selected hypertensive and non-hypertensive patients (N = 2,356,226 each) from a US health plan claims database. pIC was defined as diagnosis of IC within 3 months after colonoscopy, recto-sigmoidoscopy, or colectomy. IRs were calculated per 100,000 person-years (PYs) with 95% confidence intervals (CIs) and stratified by antihypertensive regimen.

RESULTS

IRs of pIC in hypertensive and non-hypertensive subjects were 18.6 (95% CI 17.6-19.8) and 4.0 (95% CI 3.4-4.7), respectively. The non-hypertensive cohort consisted of younger patients who may have been less prone to developing IC. The overall (i.e., all antihypertensive regimens combined) monotherapy IR per 100,000 PYs was 17.5 (95% CI 16.2-18.8), the overall dual-combination regimen IR per 100,000 PYs was 19.5 (95% CI 17.37-21.83), and the overall triple-plus combination regimen IR per 100,000 PYs was 27.7 (95% CI 22.72-33.38).

CONCLUSION

Study results indicate that the treated hypertensive patients may have a higher risk of pIC compared with non-hypertensive populations. The quantity of antihypertensive agents prescribed may contribute to IC more than treatment duration.

Acute rectocolitis following endoscopy in health check-up patients--glutaraldehyde colitis or ischemic colitis?

PURPOSE

Acute rectocolitis is a rare complication that follows endoscopy. It could be caused by glutaraldehyde or ischemic injury. The clinical, endoscopic, radiological, and pathological features of glutaraldehyde-induced colitis may mimic those of ischemic colitis. We reported our experiences regarding this problem.

METHODS

The medical records of patients with acute rectocolitis following endoscopy treated at Kaohsiung Veterans General Hospital since 2001 were reviewed. The indication of endoscopy was health check-up for all patients. Published English-language studies regarding acute rectocolitis following endoscopy were also reviewed.

RESULTS

An outbreak of six patients occurred in April 2002 and one cirrhotic patient was admitted in July 2008. All patients developed a self-limited syndrome of abdominal pain and bloody diarrhea within 48 h of uncomplicated endoscopy. One severely ill patient required hospitalization to receive intravenous fluid and antibiotics. After the investigation in April 2002, glutaraldehyde-induced colitis was diagnosed due to a defect in the endoscope-cleansing procedure. There were no any deficiencies in the cleansing procedure in July 2008. Considering the patient's concomitant disease, we postulated that ischemic colitis with cirrhosis-related intestinal inflammation and endotoxemia was the possible diagnosis in this sporadic case.

CONCLUSIONS

Endoscopists should be aware of this iatrogenic complication in patients presenting with acute rectocolitis, especially in those who have undergone recent endoscopic examination. An outbreak of acute rectocolitis following endoscopy should be considered glutaraldehyde-induced and should lead to an investigation of cleansing and equipment-disinfection procedures. In the absence of strong evidence of an outbreak, an infectious disease, or contamination of glutaraldehyde, a sporadic case should be considered ischemic colitis especially in patients with relevant concomitant diseases or predisposing factors.