Risk factors for intestinal ischaemia among patients registered in a UK primary care database: a nested case-control study

Mesenteric Vein Thrombosis following Sleeve Gastrectomy: A Case Report and Review of the Literature

INTRODUCTION

Acute mesenteric ischemia (AMI) is a rare but lethal disease. Mesenteric vein thrombosis (VAMI) is a subtype of AMI. Morbid obesity is usually accompanied by hypertension, hyperlipidemia, or diabetes mellitus, which are risk factors associated with AMI.

CASE PRESENTATION

We present a 28-year-old man with VAMI post-laparoscopic sleeve gastrectomy. He was first misdiagnosed with intestinal obstruction. Superior VAMI was confirmed after computed tomography angiography. Laparotomy, resection of the necrotic small bowel, and ostomy were performed immediately.

CONCLUSION

Patients with morbid obesity accompanied by hypertension, hyperlipidemia, or diabetes mellitus have a high risk of AMI. Abdominal pain with sudden onset should be considered AMI. Anticoagulation therapy post-sleeve gastrectomy might help reduce the incidence of AMI.

Factors that may affect the outcome of acute occlusive mesenteric ischemia. A single-center study

BACKGROUND

Acute mesenteric ischemia is a rare but lethal disease. Acute occlusive mesenteric ischemia consists of mesenteric artery embolism, mesenteric artery thrombosis, and mesenteric vein thrombosis. This study aimed to investigate the factors that may affect the outcome of acute occlusive mesenteric ischemia.

METHODS

Data from acute occlusive mesenteric ischemia patients admitted between May 2016 and May 2022 were reviewed retrospectively. Patients were divided into 2 groups according to whether complications(Clavien‒Dindo ≥ 2) occurred within 6 months of the first admission. Demographics, symptoms, signs, laboratory results, computed tomography angiography features, management and outcomes were analyzed.

RESULTS

59 patients were enrolled in this study. Complications(Clavien‒Dindo ≥ 2) occurred within 6 months of the first admission in 17 patients. Transmural intestinal necrosis, peritonitis, white blood cell count, percentage of neutrophils, percentage of lymphocytes, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, creatine kinase isoenzyme, cardiac troponin I, laparoscopic exploration rate, open embolectomy rate, enterostomy rate, length of necrotic small bowel, length of healthy small bowel, surgical time and intraoperative blood loss differed significantly between groups. Creatine kinase isoenzyme (OR = 1.415, 95% CI: 1.060-1.888) and surgical time (OR = 1.014, 95% CI: 1.001-1.026) were independent risk factors associated with complications(Clavien‒Dindo ≥ 2).

CONCLUSIONS

Our analysis suggests that acute occlusive mesenteric ischemia patients with a creatine kinase isoenzyme level greater than 2.22 ng/mL or a surgical time longer than 156 min are more likely to experience complications'(Clavien‒Dindo ≥ 2) occurrence within 6 months of the first admission.

Prior appendectomy and cerebral infarction as potential risk factors for recurrent ischemic colitis: A retrospective observational study

Background and Aim

Ischemic colitis (IC) is a benign disease associated with acute lower gastrointestinal bleeding and frequent recurrence. While several studies have investigated risk factors for IC onset, few have assessed the risk factors for recurrent IC. This study aimed to identify risk factors for recurrent IC.

Methods

Potential risk factors for recurrence were assessed by examining medical records and laboratory findings in this single-center retrospective study. We extracted the following data from the patients' medical records: patient characteristics, clinical signs and symptoms, laboratory findings, method of treatment, length of hospital stay, disease course, and the frequency of IC morbidities. Patients with IC were selected from a total of 439 312 patients over an 11-year period. Patients were divided into recurrent and nonrecurrent IC groups.

Results

In total, 225 patients met the diagnostic criteria for IC during the specified study period; of these, 204 patients (90.7%) and 21 patients (9.3%) were included in the nonrecurrent and recurrent IC groups, respectively. Univariate and multivariate analyses showed a significant association between IC recurrence and both cerebral infarction (P = 0.008, odds ratio [OR] = 6.3) and history of appendectomy (P = 0.0005, OR = 6.2). The median (interquartile range [IQR]) follow-up time for all patients was 1556 (353-2768) days; this was much longer than the median (IQR) time to recurrence of 291 (64-907) days in the recurrent IC group.

Conclusion

The results of this study suggest that prior cerebral infarction and appendicectomy may be risk factors for IC recurrence.

Acute management of mesenteric emergencies: Tailoring the solution to the problem

Acute mesenteric ischemia (AMI) constitutes a life-threatening problem that can result in death, multiorgan failure, and severe nutritional disability. Although AMI is a rare cause of acute abdominal emergencies, ranging between 1 and 2 individuals per 10,000, the morbidity and mortality rates are high. Arterial embolic etiology composes nearly one-half of AMIs, with a sudden onset of severe abdominal pain considered the most common symptom. Arterial thrombosis is the second most common cause of AMI, which presents similarly to arterial embolic AMI, although often more severe due to anatomic differences. Veno-occlusive causes of AMI are the third most common and are associated with an insidious onset of vague abdominal pain. Each patient is unique, and the treatment plan should be tailored to their individual needs. This may include considering the patient's age, comorbidities, and overall health, as well as their preferences and personal circumstances. A multidisciplinary approach involving specialists from different fields, such as surgeons, interventional radiologists, and intensivists, is recommended for the best possible outcome. Potential challenges in tailoring an optimal treatment plan for AMI may include delayed diagnosis, limited availability of specialized care, or patient factors that make some interventions less feasible. Addressing these challenges requires a proactive and collaborative approach, with regular review and adjustment of the treatment plan as needed to ensure the best possible outcome for each patient.

GI factors, potential to predict prostate motion during radiotherapy; a scoping review

Purpose

A scoping literature review was conducted to identify gastrointestinal (GI) factors most likely to influence prostate motion during radiotherapy. We proffer that patient specific measurement of these GI factors could predict motion uncertainty during radiotherapy, facilitating personalised care by optimising treatment technique e.g., daily adaption or via bespoke patient pre-habilitation and preparation.

Methods

The scoping review was undertaken as per JBI guidelines. Searches were conducted across four databases: Ovid Medline®, EMBASE, CINAHL and EBSCO discovery. Articles written in English from 2010-present were included. Those pertaining to paediatrics, biological women exclusively, infectious and post-treatment GI morbidity and diet were excluded.Common GI factors impacting men were identified and related symptoms, incidence and measurement tools examined. Prevalence among persons with prostate cancer was explored and suitable assessment tools discussed.

Results

A preliminary search identified four prominent GI-factors: mental health, co-morbidity and medication, physical activity, and pelvic floor disorder. The scoping search found 3644 articles; 1646 were removed as duplicates. A further 1249 were excluded after title and abstract screening, 162 remained subsequent to full text review: 42 mental health, 53 co-morbidity and medication, 39 physical activity and 28 pelvic floor disorder.Six GI factors prevalent in the prostate cancer population and estimated most likely to influence prostate motion were identified: depression, anxiety, diabetes, obesity, low physical activity, and pelvic floor disorder. Reliable, quick, and easy to use tools are available to quantify these factors.

Conclusion

A comprehensive GI factor assessment package suitable to implement into the radiotherapy clinic has been created. Unveiling these GI factors upfront will guide improved personalisation of radiotherapy.

Basic demographic characteristics and prevalence of comorbidities in acute mesenteric ischemia: a systematic review and proportional meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to examine and assess the basic demographic characteristics and prevalence of comorbidities in acute mesenteric ischemia (AMI) and its various subtypes.

PATIENTS AND METHODS

A literature search was conducted by using the databases PubMed, EMBASE, and Google Scholar (to June 1, 2022). Random-effects or fixed-effects models were selected to pool means and proportions and their corresponding 95% confidence intervals (CI), based on heterogeneity between studies. The results of meta-analyses for basic demographic characteristics and prevalence (proportions) of each specific comorbidities of acute mesenteric ischemia (AMI) and its various subtypes were described.

RESULTS

Ninety-nine studies were included in the meta-analysis, including 17,103 patients with AMI. Furthermore, 7941 patients with subclass diagnoses of AMI were identified, including 3,239 patients with arterial occlusive mesenteric ischemia (AOMI), 2,977 patients with nonocclusive mesenteric ischemia (NOMI), and 1,725 patients with mesenteric venous thrombosis (MVT). As a surgical emergency, AMI is associated with older patients and a high likelihood of multisystem comorbidities. Comorbidities of AMI involved multiple systemic diseases, including cardiovascular disease, endocrine and metabolic diseases, kidney diseases, digestive diseases, respiratory diseases, cerebrovascular diseases, vascular diseases, and cancer.

CONCLUSION

The basic demographic characteristics and the prevalence of comorbidities of different subtypes of AMI are different. The management of comorbidities should be an essential part of improving the prognosis of AMI patients and may contribute to precise prevention of AMI.

The association between irritable bowel syndrome and ischemic colitis: a systematic review and meta-analysis

INTRODUCTION

Studies have suggested an association between ischemic colitis and irritable bowel syndrome (IBS) although the results were inconsistent. This systematic review and meta-analysis were performed to comprehensively examine the association between IBS and ischemic colitis by identifying all available cohort and case-control studies and combining their effect estimates together.

EVIDENCE ACQUISITION

EMBASE, MEDLINE and Google Scholar databases were systematically reviewed up to June 2020. Eligible study had to be either cohort or case-control studies that evaluated whether patients with IBS have a higher risk of ischemic colitis than individuals without IBS. Point estimates and standard errors from each eligible study were combined together using the generic inverse variance method of DerSimonian and Laird.

EVIDENCE SYNTHESIS

The systematic review identified three cohort and eight case-control studies. The pooled analysis found a significantly higher risk of ischemic colitis among patient with IBS with the pooled odds ratio of 2.50 (95% CI, 2.00-3.14; I² 57%). Funnel plot was relatively symmetric and was not suggestive of presence of publication bias.

CONCLUSIONS

A significantly increased risk of ischemic colitis among patients with IBS was observed in this systematic review and meta-analysis.

Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis

OBJECTIVE

To estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022.

ELIGIBILITY CRITERIA

Studies reporting data on the incidence and outcomes of AMI in adult populations.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment with modified Newcastle-Ottawa scale were performed using predeveloped standard forms. The outcomes were the incidence of AMI and its different forms in the general population and in patients admitted to hospital, and the mortality of AMI in its different forms.

RESULTS

From 3064 records, 335 full texts were reviewed and 163 included in the quantitative analysis. The mean incidence of AMI was 6.2 (95% CI 1.9 to 12.9) per 100 000 person years. On average 5.0 (95% CI 3.3 to 7.1) of 10 000 hospital admissions were due to AMI. Occlusive arterial AMI was the most common form constituting 68.6% (95% CI 63.7 to 73.2) of all AMI cases, with similar proportions of embolism and thrombosis.Overall short-term mortality (in-hospital or within 30 days) of AMI was 59.6% (95% CI 55.5 to 63.6), being 68.7% (95% CI 60.8 to 74.9) in patients treated before the year 2000 and 55.0% (95% CI 45.5 to 64.1) in patients treated from 2000 onwards (p<0.05). The mid/long-term mortality of AMI was 68.2% (95% CI 60.7 to 74.9). Mortality due to mesenteric venous thrombosis was 24.6% (95% CI 17.0 to 32.9) and of non-occlusive mesenteric ischaemia 58.4% (95% CI 48.6 to 67.7). The short-term mortality of revascularised occlusive arterial AMI was 33.9% (95% CI 30.7 to 37.4).

CONCLUSIONS

In adult patients, AMI is a rarely diagnosed condition with high mortality, although with improvement of treatment results over the last decades. Two thirds of AMI cases are of occlusive arterial origin with potential for better survival if revascularised.

PROSPERO REGISTRATION NUMBER

CRD42021247148.

Thromboembolic Events in Patients with Inflammatory Bowel Disease: A Comprehensive Overview

Inflammatory bowel disease (IBD), Crohn’s disease and ulcerative colitis are chronic inflammatory disorders of the intestines. The underlying inflammation activates the coagulation cascade leading to an increased risk of developing arterial and venous thromboembolic events such as deep vein thrombosis and pulmonary embolism. Patients with IBD are at a 2–3-fold increased risk of developing thromboembolism. This risk increases in patients with active IBD disease, flare-ups, surgery, steroid treatment, and hospitalization. These complications are associated with significant morbidity and mortality making them important in clinical practice. Clinicians should consider the increased risk of thromboembolic events in patients with IBD and manage them with appropriate prophylaxis based on the risk. In this review, we discuss the literature associated with the pathophysiology of thromboembolism in patients with IBD, summarize the studies describing the various thromboembolic events, and the management of thromboembolism in patients with IBD.

Acute Mesenteric Ischemia

The surgical treatment of occlusive acute mesenteric ischemia (AMI) without revascularization is associated with an 80% overall mortality. Early diagnosis is crucial, and revascularization may reduce overall mortality in AMI by up to 50%. A diagnosis of AMI requires a high index of clinical suspicion and the collaborative effort of emergency department physicians, general and vascular surgeons, and radiologists. This article provides an overview of the etiology, physiology, evaluation, and management of acute mesenteric ischemia.

Chronic obstructive pulmonary disease 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. Several cardiovascular conditions, such as coronary artery disease, congestive heart failure, and atrial fibrillation, are well-established risk factors for the development of IC. The effects of pulmonary conditions, namely chronic obstructive pulmonary disease (COPD), on IC have not been well studied.

AIMS

Our aim was to elucidate if the presence of COPD worsened outcomes in patients with IC.

METHODS

Retrospective analysis of patients hospitalized with IC in 2016 was evaluated using the National Inpatient Sample database. Baseline demographic data, length of hospital stay (LOS), total hospital cost/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 the t-test.

RESULTS

A total of 25,035 patients with IC were identified while 4482 of these patients also had COPD. We found that IC patients with COPD had a longer LOS (5.8 days vs 4.4 days; P<0.01), higher total hospital charge ($56,682 vs $42,365; P<0.01), higher total hospital cost ($13,603 vs $10,238; P<0.01), higher mortality rate (6.5% vs 3.1%; P<0.01), and higher colectomy rate (5.1% vs 3.7%; P<0.01).

CONCLUSIONS

The presence of COPD portends poor outcomes in patients with IC. This was evidenced by increased risk of death and increased risk of undergoing colectomy. Given these findings, patients with COPD warrant closer observation. We advocate that COPD be considered as part of the risk assessment of patients with acute IC who need surgical intervention.

The correlation between heart failure and the risk of ischemic colitis: a systematic review and meta-analysis

BACKGROUND

Ischemic colitis is a relatively common gastrointestinal disease caused by hypoperfusion of the colon. Recently, studies have suggested an association between heart failure (HF) and ischemic colitis, even though the magnitude of the reported association varied considerably across the studies. This systematic review and meta-analysis were performed to comprehensively explore whether patients with HF are at a higher risk of ischemic colitis compared with individuals without HF by combining the results of all available observational studies.

METHODS

Systematic literature review was performed using EMBASE, MEDLINE and Google Scholar database up to May 2020. Eligible studies could be any observational ones that evaluated whether patients with HF have a higher risk of ischemic colitis than individuals without HF. Point estimates and standard errors from each eligible study were combined together using the generic inverse variance method of DerSimonian and Laird.

RESULTS

The systematic review identified 7 case-control studies and 1 cross-sectional study. The pooled analysis found that patients with HF had a significantly higher risk of ischemic colitis with the pooled odds ratio of 3.42 (95% confidence interval 1.49-7.82; I2 96%). Funnel plot was relatively symmetric and was not suggestive of presence of publication bias.

CONCLUSION

A significantly increased risk of ischemic colitis among patients with HF was demonstrated in this systematic review and meta-analysis.

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.

International Union of Basic and Clinical Pharmacology. CX. Classification of Receptors for 5-hydroxytryptamine; Pharmacology and Function

5-HT receptors expressed throughout the human body are targets for established therapeutics and various drugs in development. Their diversity of structure and function reflects the important role 5-HT receptors play in physiologic and pathophysiological processes. The present review offers a framework for the official receptor nomenclature and a detailed understanding of each of the 14 5-HT receptor subtypes, their roles in the systems of the body, and, where appropriate, the (potential) utility of therapeutics targeting these receptors. SIGNIFICANCE STATEMENT: This review provides a comprehensive account of the classification and function of 5-hydroxytryptamine receptors, including how they are targeted for therapeutic benefit.

Quantifying risk factors for ischemic colitis: A nationwide, retrospective cohort study

BACKGROUND

Despite identifying numerous factors associated with colonic ischemia, the relative risk has been variable and not thoroughly evaluated. Hence, we aimed to quantify the risk of diseases and medications associated with ischemic colitis (IC).

METHODS

A population-based retrospective analysis in International Business Machines (IBM) Explorys (1999-2018), a pooled, de-identified database of 57 million patients in the USA, was performed. Odds ratios (OR) were calculated between IC and other diseases/medications. IC patients were also stratified by age to assess trends of IC in different age groups.

RESULTS

A total of 1560 patients had IC in the database. Hyperlipidemia had the highest association with IC (OR 15.3), consistent with prior reports of atherosclerosis being a major risk factor for IC. Hypertension, congestive heart failure, constipation, prior abdominal surgery, and atrial fibrillation all conferred odds greater than 10, which is consistent with prior reports. Novel findings of our study include that beta blockers (OR 9.6) and pro-inflammatory disease states such as vasculitis, rheumatoid arthritis, and malignancy all increase the risk of IC.

CONCLUSION

Early identification of IC is critical for minimizing morbidity and mortality. Epidemiologic information could be integrated with current clinical algorithms to more rapidly identify patients at risk.

Mesenteric vascular disease: A population-based cohort study

OBJECTIVES

Mesenteric vascular disease carries a high risk of mortality and morbidity; however, due to obscure clinical presentation, it can be under-recognized. Currently, epidemiology of mesenteric vascular disease remains poorly defined. The aim of this study is to analyze changes in Scottish mortality rates from mesenteric vascular disease overtime.

METHODS

This is a retrospective, longitudinal population-based cohort study using data extracted from death certificates and Scottish Index of Multiple Deprivation. All deaths related to a vascular disorder of the intestines recorded as an underlying cause of death between 1979 and 2014 were identified using International Classification of Disease-9 or International Classification of Disease-10 code groups. Data included demographics and location of death. The residence postcodes were used to classify socio-economic status using the Scottish Index of Multiple Deprivation.

RESULTS

From 2,142,921 deaths over 36 years, 14,530 (0.7%) were due to mesenteric vascular disease with a median (interquartile range) age of 77 and a 2:1 female to male gender ratio. The mean ± standard deviation age significantly increased from 72.6 ± 12.1 in 1979 to 76.8 ± 11.1 in 2014 (p < 0.001, R² = 0.772). Males were consistently younger than females at the time of death. The two lowest Scottish Index of Multiple Deprivation categories accounted for half of the cohort, throughout the study period (p = 0.068). The adjusted death rate per 100,000 population increased from 7.6 in 1979 to 12.1 in 2014.

CONCLUSIONS

The reported death rates of mesenteric vascular disease in Scotland between 1979 and 2014 have nearly doubled. Mesenteric vascular disease affects twice as many women as men and is associated with social deprivation. The increased reporting of mesenteric vascular disease is likely due to increased recognition and incidence. These implications should be considered when planning healthcare provision in Scotland.

A case of stricture-type ischemic colitis from excessive alcohol consumption, with follow-up to rule out colon cancer

A 69-year-old man was admitted to Hanawa Kousei Hospital with acute hepatitis attributed to alcohol consumption. His condition improved with conservative treatment. Computed tomography (CT) showed localized thickening of the colonic wall at the splenic flexure;carcinoembryonic antigen level was slightly elevated to 9.7 ng/mL. Colonoscopy (CS) showed an ulcerative lesion in the colonic splenic flexure. Ischemic colitis (IC) and type 4 colon cancer were suspected, but biopsy was not confirmatory. Malignancy could not be ruled out by contrast-enhanced CT;repeat CS showed circumferential stenosis of the colonic splenic flexure. Ischemic colitis was suspected based on changes between the first and second CS. Biopsy histopathology led us to diagnose stricture-type IC. Constipation, but not intestinal obstruction, occurred. Conservative treatment improved the stenosis. Excessive alcohol consumption may lead to IC;imaging studies may be useful to distinguish IC from colon cancer. Since most cases of ischemic colitis can be improved with conservative treatment, patients with stricture-type ischemic colitis may also be treated without surgery early on, with follow-up that includes careful, periodic imaging.

Risk of acute mesenteric ischemia in patients with diabetes: A population-based cohort study in Taiwan

BACKGROUND AND AIMS

Diabetes is a common and complex endocrine disorder that often results in hyperglycemia, which has been strongly implicated in several cardiovascular and cerebrovascular events that cause disability. Acute mesenteric ischemia (AMI) is a vascular emergency with high mortality rates. We conducted a population-based cohort study that utilizes data from medical claims databases to investigate whether diabetes increases the risk of AMI.

METHODS

Using claims data from Taiwan's National Health Insurance program, 66,624 diabetic patients were enrolled from 1998 to 2009, and a comparison group of 266,496 individually matched subjects without diabetes was selected. The two groups were followed up until diagnosis of AMI, death, or the end of 2011. Incidence rates of AMI were assessed in both groups. Cox proportional hazards models were used to estimate the hazard ratios of diabetes for AMI.

RESULTS

The diabetes cohort had a higher incidence rate than the comparison cohort for AMI (0.56 vs. 0.29 per 1,000 person-years). After adjusting for sex, age, comorbidity, and health system utilization, the adjusted hazard ratio of diabetes was 1.32 (95% confidence interval 1.11-1.56) for AMI. The risk of AMI associated with diabetes was greater in men (adjusted hazard ratio = 1.48, 95% confidence interval 1.17-1.87) than in women (adjusted hazard ratio = 1.17, 95% confidence interval 0.92-1.49).

CONCLUSIONS

There was an increased risk of AMI in patients with diabetes. However, further research is required to understand whether this association is causal or due to a common set of risk factors.

Acute vascular insufficiency of intestine: incidence highest in summer, outcomes worst in winter

BACKGROUND

The incidence of acute vascular insufficiency of intestine (AVII) is on the rise in the USA and is associated with significant morbidity and mortality. Seasonal variations have been observed in the onset of several gastrointestinal diseases. It is thus far unknown whether the incidence, in-hospital mortality rates, and length of hospital stay (LOS) of AVII vary in different seasons.

AIMS

The aims of this study were to study the seasonal variations in the (1) incidence, (2) in-hospital mortality, and (3) LOS of AVII in the USA.

METHODS

We used the Nationwide Inpatient Sample to identify patients aged ≥ 18 years hospitalized from the years 2000-2014. We used the Edwards recognition with estimation of cyclic trend method to study the seasonal variation of AVII hospitalizations and z test to compare the seasonal incidences (peak-to-low ratio), mortalities, and LOS.

RESULTS

A total of 1,441,447 patients were hospitalized with AVII (0.3% of all hospitalizations). Patients with AVII were older (69.0 ± 0.1 vs 56.9 ± 0.1) and more commonly females (65.4% vs 35.5%) than patients without AVII (p < 0.001). The incidence of AVII increased through the summer to peak in September (peak/low ratio 1.028, 95% CI 1.024-1.033, p < 0.001). Patients with AVII hospitalized in winter had the highest mortality (17.3%, p < 0.001) and LOS (9.2 ± 0.7 days, p < 0.001).

CONCLUSIONS

The incidence of AVII in the USA peaks in late summer. The in-hospital mortality rates and LOS associated with AVII are the highest in winter. Physicians could be cognizant of the seasonal variations in the incidence, in-hospital mortality, and LOS of AVII.

Cardiocerebral and peripheral vascular risks in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic inflammatory disease that mainly affects the digestive tract. In addition to intestinal manifestations, it also has many extraintestinal manifestations. There have been a number of reports of IBD with secondary opportunistic infections, perforation, cancer, etc. IBD is reported with more and more cardiovascular events, but the conclusions are still controversial. At present, clinicians pay insufficient attention to the assessment of cardiocerebral and peripheral vascular risks in IBD. This article reviews the relevant literature on cardiovascular, cerebrovascular and peripheral vascular risks in IBD published in recent years, with an aim to help clinicians be familiar with these risks and develop individualized management regimens in clinical practice.

Duplex ultrasound in the early diagnosis of acute mesenteric ischemia: a longitudinal cohort multicentric study

OBJECTIVE

Acute mesenteric ischemia (AMI) is a life-threatening condition requiring time-dependent treatment; thus, early recognition may improve outcomes. We hypothesized that clinician-performed mesenteric vessels duplex ultrasound (DUS) could facilitate early identification of patients with AMI in high-risk patients presenting with abdominal pain.

METHODS

This was a single-operator, observational, prospective cohort study. Patients aged at least 65 presenting to Emergency Departments with acute abdominal pain and no clear diagnosis after an initial work-up were enrolled. All patients underwent multidetector computed tomography and these findings provided the reference standard in this study. DUS of the celiac artery and superior mesenteric artery (SMA) were obtained to measure the peak systolic velocity (PSV) and were performed within 24 h of admission. PSVs outside the normal range were considered to indicate AMI.

RESULTS

Of 49 patients identified, 47 were consented to enrollment and diagnostic images were obtained in 45 (96%). Fifteen patients (33%) had AMI (six occlusive, nine nonocclusive disease). Among these, 12 (80%) had abnormal DUS velocities. SMA PSV showed a sensitivity of 78.57% [95% confidence interval (CI): 49.2-95.34], a specificity of 64.52% (95% CI: 45.37-80.77), a positive predictive value of 50% (95% CI: 28.22-71.78), and a negative predictive value of 86.96% (95% CI: 66.41-97.22) for AMI. DUS had a sensitivity of 100%, a specificity of 64%, and a negative predictive value of 100% for occlusive AMI. Assessment of celiac artery PSV did not improve diagnostic performance.

CONCLUSION

In this single-operator pilot study, mesenteric vessel DUS was performed successfully in the Emergency Department, with a high proportion of diagnostic images obtained. A normal SMA PSV was associated with a low risk of occlusive AMI.

Influence of splanchnic artery stenosis on the in-hospital clinical course of elderly patients

BACKGROUND

Chronic mesenteric ischaemia (CMI) has a long asymptomatic period, but little is known about the clinical implications of this phase of the disease, particularly in the elderly, who are most exposed to the condition.

AIMS

The aim of the present observational study was to survey the in-hospital clinical course of elderly patients during the non-specific phase of the disease due to occlusion of at least one splanchnic artery.

METHODS

For a median of 29 months, we followed up 85 patients aged 65 and over who, for various clinical reasons, had undergone computed tomographic and magnetic resonance angiography during 2010 at Padua Teaching Hospital, assessing economic impact and reasons for admission.

RESULTS

Thirty-four of these patients had at least one occluded artery, and 68 % of them had at least one hospital admission. Elderly CMI patients were characterised by a higher number of admissions (median 2 vs 1 p = 0.05) and a higher cost (6044 vs 1733 Euros p = 0.04), but did not present typical gastrointestinal symptoms. The higher number of hospital admissions was not due to specific clinical risks (admitting wards: general medicine: 32 vs 29 %, p = 0.77; general surgery 8 vs 14 %, p = 0.73; vascular surgery: 26.5 vs 20 %, p = 0.46).

CONCLUSIONS

In the asymptomatic phase of CMI, hospitalised elderly patients with at least one occluded splanchnic artery can be subject to a more challenging in-hospital clinical course.

Ischemic Bowel Syndrome in Patients with Spinal Cord Injury: A Nationwide Study

Purpose

The aim of this study was to determine whether spinal cord injuries (SCI) is associated with increased risk of ischemic bowel syndrome (IBS) in an Asian population by analyzing data from the National Health Insurance Research Database (NHIRD) in Taiwan.

Methods

Patients aged ≥20 years in the inpatient database with newly identified SCI from 2000 to 2011 were selected as the SCI cohort. For the non-SCI cohort, patients were selected based on a 1:4 risk-set sampling. Hospitalization with a new diagnosis of IBS during the follow-up was the main outcome measure. We used the standard univariable and multivariable Cox proportional hazard regression models to determine adjusted subhazard ratios (SHR) and 95% confidence interval (CI) in the SCI and non-SCI cohorts.

Results

Patients with SCI were at significant risk for IBS, with an adjusted SHR (aSHR) of 1.25, 95% CI = 1.04–1.51. Multivariable analysis showed individuals with SCI were associated with a greater risk of IBS than individuals without SCI among males (aSHR = 1.47, 95% CI = 1.16–1.86), all age groups (≤49 y: aSHR = 2.15, 95% CI = 1.24–3.74; 50–65 y: aSHR = 1.82, 95% CI = 1.15–2.88; >65 y: aSHR = 1.39, 95% CI = 1.11–1.74) and those without comorbidities (aSHR = 1.41, 95% CI = 1.04–1.93). Comorbidities including diabetes, hypertension, heart failure, coronary artery disease (CAD), Stroke, and end stage renal disease (ESRD) significantly increased the risk of IBS.

Conclusion

Patients hospitalized for SCI have increased risks of developing IBS. Though the mechanism that predisposes SCI patients to IBS is unclear, we suggest that physicians promptly identify and treat correctable risk factors.

ESTES guidelines: acute mesenteric ischaemia

PURPOSE

Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria.

METHODS

A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords "mesenteric ischaemia", "bowel ischaemia" and "bowel infarction". The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group.

RESULTS

The resultant recommendations are presented in this paper.

CONCLUSIONS

The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.

Abdominal Fat Accumulation, as Measured by Computed Tomography, Increases the Risk of Ischemic Colitis: A Retrospective Case-Control Study

BACKGROUND AND AIM

Visceral fat contributes to insulin resistance and atherosclerosis. We retrospectively investigated whether abdominal fat accumulation, as measured by computed tomography, is a risk of ischemic colitis and related clinical outcomes.

MATERIALS AND METHODS

Outpatient-onset ischemic colitis patients (n = 58) and age- and sex-matched controls (n = 58) underwent colonoscopy and computed tomography. Associations between body mass index, visceral adipose tissue area, subcutaneous adipose tissue area, and ischemic colitis were estimated using odds ratios adjusted for hypertension, diabetes mellitus, and dyslipidemia.

RESULTS

In multivariate analysis, ischemic colitis was significantly associated with subcutaneous adipose tissue area (P for trend 0.030) and marginally associated with visceral adipose tissue area (P for trend 0.094), but was not associated with body mass index (P for trend 0.460). The adjusted odds ratios for the highest quartile of subcutaneous and visceral adipose tissue in ischemic colitis were 3.48 (1.06-11.4) and 2.43 (0.74-8.00), respectively, compared with the lowest quartile. When body mass index was considered simultaneously, ischemic colitis remained associated with subcutaneous adipose tissue (P for trend 0.016) and visceral adipose tissue (P for trend 0.077). No significant differences were noted between any of the obesity indices and the distribution type of colitis, blood transfusion requirement, or length of hospital stay.

CONCLUSION

Abdominal fat accumulation measured by computed tomography, but not body mass index, was associated with outpatient-onset ischemic colitis. Ischemic colitis remained associated with abdominal fat, even when body mass index was simultaneously considered. However, clinical outcomes of ischemic colitis were not associated with abdominal fat accumulation.

Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies

AIM

The primary aim of this study was to determine whether the in-hospital mortality for acute mesenteric infarction has reduced in the last decade. The secondary aim was to determine if there was a statistical difference in mortality between patients having acute primary mesenteric infarction due to different causes.

METHOD

A literature search was performed of PubMed, Ovid (Embase) and Google Scholar databases. Studies on acute mesenteric infarction of primary vascular pathology were included for pooled analyses while studies that had reported comparative mortality between arterial, venous and non-occlusive mesenteric infarction (NOMI) were included in meta-analyses. Their quality was assessed using the National Institute for Health and Care Excellence assessment scale. Odds ratios (ORs) of mortality were calculated using a Mantel-Haenszel random effect model.

RESULTS

The total number of patients was 4527 and the male/female ratio was 1912/2247. The pooled in-hospital mortality was 63%. There was no significant reduction of in-hospital mortality rate in the last decade (P = 0.78). There was a significant difference in in-hospital mortality between acute arterial mesenteric infarction (73.9%) compared with acute venous mesenteric infarction (41.7%) [OR 3.47, confidence interval (CI) 2.43-4.96, P < 0.001] and NOMI (68.5%) compared with acute venous mesenteric infarction (44.2%) (OR 3.2, CI 1.83-5.6, P < 0.001). There was no difference in mortality between acute arterial mesenteric infarction and NOMI (OR 1.08, CI 0.57-2.03, P = 0.82).

CONCLUSION

In-hospital mortality rate has not changed in the last decade. Patients with arterial mesenteric infarction or with NOMI are over three times more likely to die during the first hospital admission compared with those with venous mesenteric infarction.

A population-based study of incidence, risk factors, clinical spectrum, and outcomes of ischemic colitis

BACKGROUND & AIMS

Little is known about progression of ischemic colitis (IC) among unselected patients. We aimed to estimate the incidence, risk factors, and natural history of IC in a population-based cohort in Olmsted County, Minnesota.

METHODS

We performed a retrospective population-based cohort and nested case-control study of IC. Each IC case was matched to 2 controls from the same population on the basis of sex, age, and closest registration number. Conditional logistic regression, the Kaplan-Meier method, and proportional hazards regression were used to assess comorbidities, estimate survival, and identify characteristics associated with survival, respectively.

RESULTS

Four hundred forty-five county residents (median age, 71.6 years; 67% female) were diagnosed with IC from 1976 through 2009 and were matched with 890 controls. The age-adjusted and sex-adjusted incidence rates of IC nearly quadrupled from 6.1 cases/100,000 person-years in 1976-1980 to 22.9/100,000 in 2005-2009. The odds for IC were significantly higher among subjects with atherosclerotic diseases; odds ratios ranged from 2.6 for individuals with coronary disease to 7.9 for individuals with peripheral vascular disease. Of IC cases, 59% survived for 5 years (95% confidence interval, 54%-64%), compared with 90% of controls (95% confidence interval, 88%-92%). Age >40 years, male sex, right-sided colon involvement, concomitant small bowel involvement, and chronic obstructive pulmonary disease were all independently associated with mortality (P < .05).

CONCLUSIONS

The incidence of IC increased during the past 3 decades in a population-based cohort in Minnesota. IC typically presents in older patients with multiple comorbidities and is associated with high in-hospital mortality (11.5%) and rates of surgery (17%).

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.

Long-term risk of mesenteric ischemia in patients with inflammatory bowel disease: a 13-year nationwide cohort study in an Asian population

BACKGROUND

It is unclear whether patients with inflammatory bowel disease (IBD) have higher risks of developing mesenteric ischemia.

METHODS

We enrolled 9,363 patients who had been hospitalized because of IBD between January 1998 and December 2010, along with 37,452 control patients who were matched at a 1:4 proportion for age, sex, and index year. We accounted the cumulative incidences and hazard ratios (HRs) of developing mesenteric ischemia during the 13-year study period.

RESULTS

Patients with IBD had a considerably higher incidence rate of subsequent mesenteric ischemia compared with the controls (22.7 vs 3.09 per 10,000 person-years), with adjusted HR of 6.33 (95% confidence interval: 4.75 to 8.43). A multivariate stratified analysis showed that the mesenteric ischemia risk after adjustment for comorbidities is significantly higher in patients of all age groups, particularly in patients younger than 44 years (adjusted HR: 48.0; 95% confidence interval: 11.3 to 203.9). Moreover, patients with IBD were at highest risk of developing mesenteric ischemia within the first year of follow-up.

CONCLUSIONS

Careful follow-up and effective therapy are necessary to reduce the excessive risk in these patients.

Risk of cardiovascular disease in inflammatory bowel disease

Abundant scientific evidence supporting an association between inflammatory bowel disease (IBD) and venous thromboembolic events, caused by an IBD related hypercoagulability, is acknowledged and thromboprophylactic treatment strategies are now implemented in the management of IBD patients. In contrary, the risk of arterial thromboembolic disease, as ischemic heart disease, cerebrovascular events, and mesenteric ischemia in patients with IBD remains uncertain and the magnitude of a potentially increased risk is continuously debated, with ambiguous risk estimates among studies. The evident role of inflammation in the pathogenesis of atherosclerosis forms the basis of a biological plausible link; the chronic systemic inflammation in IBD patients increases the risk of atherosclerosis and thereby the risk of thrombotic events. Further, studies have shown that the burden of traditional risk factors for atherosclerosis, such as obesity, diabetes mellitus, and dyslipidemia is lower in IBD populations, thus further strengthen the role of non-traditional risk factors, as chronic inflammation in the linking of the two disease entities. Likewise, mortality from cardiovascular disease in IBD remains questioned. The aim of the current review is to give an up-date on the existing evidence of the possible association between IBD and cardiovascular disease and to discuss traditional and non-traditional risk factors.

Thromboembolic events and cardiovascular mortality in inflammatory bowel diseases: a meta-analysis of observational studies

OBJECTIVE

Patients with inflammatory bowel disease (IBD) are at increased risk of having venous thromboembolism. The magnitude of this risk has yet to be determined. The question of whether IBD patients have an increased risk of arterial thromboembolism and cardiovascular (CV) mortality remains controversial.

DESIGN

We searched MEDLINE, Cochrane Library, EMBASE and international conference abstracts and included all controlled observational studies that evaluated the incidence of venous and/or arterial thromboembolic events (TE) and CV mortality in adult IBD.

RESULTS

33 studies enrolling 207,814 IBD patients and 5,774,898 controls and capturing 3,253,639 hospitalizations of IBD patients and 936,411,223 hospitalizations of controls reported a risk of arterial and/or venous TE or CV mortality were included. The risk of venous TE was increased in IBD patients compared to the general population (RR, 1.96; 95% CI, 1.67-2.30) contrary to the risk of arterial TE (RR, 1.15; 95% CI, 0.91-1.45). There was an increased risk of deep venous thrombosis (RR, 2.42; 95% CI, 1.78-3.30), pulmonary embolism (RR, 2.53; 95% CI, 1.95-3.28), ischemic heart disease (RR, 1.35; 95% CI, 1.19-1.52) and mesenteric ischemia (RR, 3.46; 95% CI, 1.78-6.71). Differences in methodology were great between studies resulting in a significant heterogeneity in all previous analysis. CV mortality in IBD patients was not increased compared to the general population (SMR, 1.03; 95% CI, 0.93-1.14).

CONCLUSION

The risk of TE is increased in patients with IBD. This difference is mainly due to an increased risk of venous TE. There is no increased risk of arterial TE or CV mortality in IBD patients, but an increased risk of both ischemic heart disease and mesenteric ischemia.

Risk factors of recurrent ischemic colitis: a multicenter retrospective study

BACKGROUND/AIMS

Recurrence of ischemic colitis (IC) has not been studied extensively. The aim of this study was to investigate the characteristics of recurrent IC in the community setting and to identify any risk factors.

METHODS

We conducted a retrospective study in two community hospitals. Medical records of patients with IC from January 2007 to January 2013 were reviewed. Demographic details, clinical features, co- morbidities, concomitant use of medications,laboratory studies, imaging findings, endoscopic and histological features, surgery, hospital stay, and death within 30 days were collected. Patients were divided into two groups (recurrent IC group, non-recurrent IC group).

RESULTS

A total of 118 patients with IC were identified. IC recurred in 10 patients (8.5%) during the study period. Half of the patients in the recurrent IC group were current smokers as compared to only 18.7% of patients in the non-recurrent group. In the recurrent IC group, 20.0% of patients never smoked as compared to 61.7% in the non-recurrent group (p=0.027).Abdominal aortic aneurysm (AAA) was more frequent in the recurrent IC group (40.0% vs. 4.7%; p=0.003). No differences in other clinical symptoms, CT scan findings, comorbidities, endoscopic features, or use of concomitant medications were observed between the two groups. The need for surgical intervention, blood transfusion, intensive care unit stay, mechanical ventilation,length of hospital stay, and anatomic location of affected segments did not differ between the two groups.

CONCLUSIONS

IC recurred in 8.5% of patients during the six-year study period. Current smoking status and presence of AAA were identifying risk factors for recurrence of IC.

Clinical characteristics of ischemic colitis after surgery for colorectal cancer

PURPOSE

This study was performed to clarify the clinical features of ischemic colitis (IC) after colorectal cancer surgery.

METHODS

This study retrospectively reviewed the medical records of 35 patients with IC. Patients were divided into two groups: those who had undergone colorectal cancer surgery (POIC group, n = 13) and those who had not undergone colorectal cancer surgery (NOIC group, n = 22). Gangrenous colitis was seen in one patient in the POIC group, and transient colitis was seen in the remaining 34 patients.

RESULTS

Among the patients with transient colitis, there were significantly more patients without underlying diseases or promoting factors in the POIC group than in the NOIC group (P = 0.01). Abdominal pain was more frequently reported in the NOIC group than in the POIC group as both the initial symptom (P = 0.02) and throughout the disease course (P = 0.02). Ischemic changes occupying more than half the circumference of the intestinal wall were more frequently found in the NOIC group than in the POIC group (P = 0.03).

CONCLUSIONS

Although transient POIC may occur without any underlying disease, severe symptoms rarely occur. However, if POIC occurs in a patient with severe underlying disease, then the occurrence of severe colitis should be considered.

Venous and arterial disease in inflammatory bowel disease

Awareness is increasing that risk of venous thromboembolism and development of atherosclerosis is elevated in patients with some chronic inflammatory diseases. This review aimed to examine the risk of vascular disease in patients with inflammatory bowel disease (IBD) and to identify potential pathogenic mechanisms and therapeutic approaches. An extensive literature search was conducted using MEDLINE database, Cochrane Library and international conference abstracts for studies pertaining to venous and arterial thromboembolism in adult IBD patients. There is a 1.1-3.6 fold risk of venothromboembolism in IBD, affecting 0.55-6.15% of patients. Risks are increased during a flare or with chronically active inflammation. Evidence is building that there may be a modestly increased risk of arterial disease overall, despite evidence that traditional risk factors may be reduced. Multiple pathogenic factors have been identified including endothelial dysfunction, inflammation-mediated calcium deposition in the media of arteries, hyperhomocysteinemia, platelet activation, and altered coagulation and fibrinolysis. The key to active and preventive therapy is to effectively treat inflammation. Recommendations for prophylaxis of venothromboembolism have followed guidelines where they exist and have been extrapolated from studies of other at-risk conditions, as have those for arterial disease, where screening for risk factors and actively treating abnormalities is encouraged. In conclusion, patients with IBD are at considerably increased risk of venothromboembolism and probably of arterial disease, in particular mesenteric ischemia and ischemic heart disease. Increased penetration of gaps between this knowledge and clinical therapeutic action to prevent thromboembolic events into IBD clinical practice is needed.

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.