Systematic review on the treatment of ischaemic colitis

Precision medicine in intestinal ischemia: the emerging role of biomarkers

Intestinal ischemia (IIs) is a significant gastrointestinal condition characterized by reduced blood flow to the bowel, leading to inflammation and injury. Early diagnosis and management are crucial for preventing severe complications. Under this point of view, circulating biomarkers can enhance patient stratification and guide therapeutic decisions. Fatty acid-binding proteins (FABPs), specifically I-FABP and L-FABP, are small cytosolic proteins released upon enterocyte membrane integrity loss, with elevated plasma levels indicating early intestinal ischemia. Stromal Cell-Derived Factor-1 (SDF-1) regulates stem cell function and shows significantly higher levels in patients with IIs and cardiovascular disease compared to controls. D-Lactate, a bacterial fermentation byproduct, is another significant marker, with higher serum levels observed in intestinal ischemia cases. Alpha-glutathione S-transferase combats intracellular oxidative stress, with significantly elevated levels in acute mesenteric ischemia patients. Additionally, SM22, a small smooth muscle protein, shows higher plasma levels in patients with transmural ischemia compared to those with mucosal ischemic lesions and healthy controls. These biomarkers are promising for their roles in early detection and differentiation of IIs from other gastrointestinal conditions. Therapeutic strategies, including anti-inflammatory therapies, have shown efficacy in managing IIs symptoms and preventing recurrence. This review aims to inform clinicians and researchers about the current advancements in biomarker research and therapeutic approaches for IIs, emphasizing the importance of integrating these biomarkers and treatments into clinical practice to improve the management and prognosis of the disease.

Ischemic Colitis Is a Risk Factor for Clostridium difficile Infection

Introduction: Clostridium difficile infection (CDI) is an anaerobic infection that can carry detrimental outcomes for patients and is a growing burden to the US healthcare system. Various theories have been proposed for the etiopathogenesis of CDI, including antibiotic use, dysbiosis, and acid suppression. The role of ischemia in CDI has not been explored. We hypothesize that tissue ischemia is a risk factor for the development of CDI. The study aimed to assess whether ischemia was a risk factor for CDI using ischemic colitis as a target population.

Methods: We performed a case-control study using the National Inpatient Sample (NIS) database in 2013. The study group included all patients with ischemic colitis (ICD 9 Code: 557.0, 557.1, 557.9) and the control group included all patients with diverticulitis (ICD 9 Code: 562.11, 562.13). Univariable and multivariable analyses were performed to assess the risk factors associated with CDI (ICD 9 Code: 008.45). The case and control groups were compared using the chi-square test for analysis. Continuous variables were compared using t-tests and categorical variables were compared using Rao-Scott chi-square tests. In addition, multivariable logistic regression analysis was performed to assess the association between disease group and CDI while adjusting for confounders. Univariable analysis was performed to assess differences between subjects with ischemic colitis and those with diverticulitis; continuous variables were compared using t-tests and categorical variables were compared using Rao-Scott chi-square tests. All analyses were done using SAS (version 9.4, The SAS Institute, Cary, NC).

Results: We analyzed more than 30 million hospitalizations in 2013, with 120,490 being Ischemic colitis-related admissions and 309,940 being diverticulitis-related admissions. The rate of CDI was more in the ischemic colitis group than in the diverticulitis group (odds ratio [OR] = 1.39; 95% confidence interval [CI] [1.03-1.88], p=0.03). After adjusting for all variables, multivariate analysis showed CDI was associated with ischemic colitis (OR = 2.06; 95% CI 1.59-2.65, p<0.001).

Conclusion: CDI was shown to be more prevalent in ischemic colitis than in diverticulitis control in this population-based study. As C. difficile is an anaerobe, we hypothesize that tissue hypoxia is a risk factor for its development. Further studies are needed to validate our findings.

Bad blood: ischemic conditions of the large bowel

PURPOSE OF REVIEW

Colon ischemia is the most common form of intestinal ischemic injury and is seen frequently in an elderly population. This disease is usually self-limited, and many causes have been identified. The recent literature has focused on estimates of prognosis, triaging appropriate level of care, and identification of optimal treatments. In this review, we will address our current understanding of colon ischemia including epidemiology, pathophysiology, segmental distribution, presentation, diagnosis, and management.

RECENT FINDINGS

Research has recently been focused on factors associated with poor outcome. The medical comorbidities identified include chronic obstructive pulmonary disease (COPD), hepatic cirrhosis, and chronic aspirin use. Serological markers are noninvasive tools that can triage severity. Recent studies have shown procalcitonin, C-reactive protein, D-dimer, and neutrophil counts can help predict those at greatest risk for poor outcome. The timing of colonoscopy relative to symptomatic onset also can help predict severity. Early colonoscopy allows for quicker identification of ischemic stigmata, reducing the chance of misdiagnosis and potentially unnecessary and harmful treatment. The treatment of colon ischemia has classically been conservative with antimicrobials reserved for those with moderate or severe disease. Recent retrospective analysis calls into question the utility of antibiotics in the treatment of colon ischemia, although the data is not convincing enough to advise against antimicrobial treatment in patients with severe and fulminant disease.

SUMMARY

It is an exciting time for research focused on colon ischemia. With an improved knowledge, awareness of associated risk factors and predictors of severity, clinicians now have enhanced clinical tools to diagnose and triage patients earlier in the disease. This should help institute prompt and appropriate therapies ultimately improving outcomes.

The Uncertain Effect of Antimicrobial Therapy in the Treatment of Patients with Ischemic Colitis

Although antimicrobial therapy is recommended for patients with moderate or severe ischemic colitis, its beneficial effects are unclear. In the present study, the role of antimicrobial therapy in the treatment of ischemic colitis was investigated. Patients with ischemic colitis were retrospectively identified between January 2004 and June 2019. The characteristics and outcomes of patients who received antibiotics (antibiotics group) and those who did not (no-antibiotics group) were compared. Clinical outcomes included death, surgery, and readmission within 30 days, fasting duration, and hospital stay. Data from 186 patients were analyzed; 122 patients were in the antibiotics group and 64 in the no-antibiotics group. Composite outcome of death, surgery, and readmission within 30 days occurred in 3.3% of patients in the antibiotics group and 3.1% of patients in the no-antibiotics group (p > 0.999). Fasting duration was not significantly different between the two groups (median days, 4.0 vs. 4.0, p = 0.253). However, hospital stays were longer in the antibiotics group than in the no-antibiotics group (median days, 9.0 vs. 7.0, p = 0.043). In patients with ischemic colitis, there was no statistically significant difference in the incidence of death, surgery, and readmission within 30 days between patients who received antibiotics and those who did not receive antibiotics.

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.

Insights into the pathogenesis of catastrophic antiphospholipid syndrome. A case report of relapsing catastrophic antiphospholipid syndrome and review of the literature on ischemic colitis

We present the case of a woman with a severe clinical history of antiphospholipid syndrome and persistent positivity for lupus anticoagulant, IgG anticardiolipin and IgG anti-β2Glycoprotein I antibodies. An acute clinical onset characterized by severe abdominal pain immediately followed by circulatory shock and histological colonic small vessel thrombosis pattern pointed to a diagnosis of ischemic colitis. The subsequent rapid onset of pulmonary alveolitis and heart failure associated to subendocardial hypoperfusion led to a diagnosis of definite catastrophic antiphospholipid syndrome (CAPS). Conventional triple therapy together with a broad-spectrum preventive antibiotic therapy were quickly initiated, and the outcome was favorable. We evaluated the patients with ischemic colitis in CAPS described in the literature between 1992 and May 2019 and our CAPS case. In accordance with the "two-hit" hypothesis and on the basis of the patients' data, we would like to speculate that the colonic wall necrosis related to ischemic colitis damaged the intestinal barrier causing loss of resistance to bacteria and leading to endotoxemia and bacteremia with bacteria translocation through the circulatory stream to the lungs and heart. The bacteria acted as the priming factor which favored the binding of β2Glycoprotein I to the endothelium vessels in the colon, lungs, and heart following activation of anti-β2Glycoprotein I antibodies which attached to the domain I of β2Glycoprotein I. This was followed by complement activation which triggered the thrombotic and cytokine storm. If further clinical studies confirm this hypothesis, the treatment of CAPS could be more targeted and effective.

Ischemic colitis caused increased early and delayed mortality

Background

Ischemic colitis remains a challenge for the surgeon, both in its diagnosis and treatment. Data from a single tertiary center, of patients diagnosed with ischemic colitis, was collected. An attempt was made to delineate the patients requiring surgical intervention.

Methods

A retrospective study was undertaken in patients diagnosed with ischemic colitis admitted to Rambam Health Care Campus between 2011 and 2016. The primary outcome was defined as mortality. Secondary outcomes were defined as complications during conservative treatment and postoperative course.

Results

Sixty-three patients were diagnosed with ischemic colitis during the study period. The mean age at presentation was 72.5 years, with a female predominance (62%). The overall mortality rate was 29% (18/63). Six patients (50%) of those operated died. An older age, comorbidities and higher lactate levels present risk factors for a worse outcome.

Conclusions

Ischemic colitis continues to present a challenge in its management. A better understanding of the disease process is required. And one needs to adhere to sound surgical principles for a timely diagnosis and treatment, especially in older patients with worrisome clinical, laboratory, and imaging features.

Ischaemic colitis: uncertainty in diagnosis, pathophysiology and management

Ischaemic colitis is the most common form of gastrointestinal ischaemia, but may be confused with acute mesenteric ischaemia, inflammatory bowel disease or infectious colitis. This review article outlines the current classification, epidemiology and risk factors, as well as approaches about diagnosis and management to guide clinical practice. It also identifies areas for further research.

Advents in the Diagnosis and Management of Ischemic Colitis

BACKGROUND

Ischemic colitis (IC) is a common type of ischemic insult, resulting from decreased arterial blood flow to the colon. This disease can be caused from either atherosclerotic occlusive vascular disease or non-occlusive disease. The aim of this study is to present the diagnostic methodology and management of this severe disease based on current literature.

METHODS

A literature search has been done including articles referring to modern diagnosis and management of IC.

RESULTS

IC is usually a transient disease, but it can also cause gangrene of the colon, requiring emergency surgical exploration. Diagnosis is troublesome and is based on imaging examinations, mainly computerized tomography, which in association with colonoscopy can delineate the distribution pattern and severity of disease.

CONCLUSION

The majority of patients with mild disease have usually complete clinical recovery within a short period. The severe forms of the disease carry high morbidity and mortality rates and prompt surgical intervention is the only way to improve the associated severe prognosis.

The predictors of the severity of ischaemic colitis: a systematic review of 2823 patients from 22 studies

AIM

The study reviews the literature related to ischaemic colitis (IC) as the evidence base to identify factors predicting severity.

METHOD

A systematic review of the literature was conducted on the predictors of the severity of IC. Severe IC or adverse outcome of IC was defined as a patient requiring surgery or who died. MEDLINE, Embase and Cochrane Library databases were searched from inception to 15 January 2015. Manual searches of reference lists from potentially relevant papers and meetings were also performed.

RESULTS

In all, 22 studies involving 2823 patients were identified; 19 were case series, two were case-control studies and one was a cohort study. The overall adverse outcome rate was 22.0% (620/2823). The prognostic predictors for surgery or mortality which were most frequently reported included right sided IC, peritonitis, shock or arterial hypotension (< 90 mmHg), male gender, tachycardia and lack of rectal bleeding. Thirteen studies relating to the right colon from which data could be extracted were further analysed. The right colon was involved in 277 cases, with an incidence of adverse outcomes of 48.4% (134/277), while in the non-right colonic involvement group the incidence was significantly lower at 12.1% (142/1175) (P = 0.000).

CONCLUSION

The incidence of adverse outcome in patients with IC remains high. Male gender, tachycardia, lack of rectal bleeding, peritonitis, shock or arterial hypotension (< 90 mmHg) and right sided IC are predictors of poor prognosis. Right-sided IC, shock or arterial hypotension (< 90 mmHg) and signs of peritonitis may be the most significant predictors of severity.

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.

Update on ischemic colitis: from etiopathology to treatment including patients of intensive care unit

Ischemic colitis is the result of colonic hypoperfusion and is regarded as a relatively rare condition. It can be roughly classified as occlusive and non-occlusive. Pathogenesis includes a usually transient compromise in the colonic vasculature, with a parallel activation of an inflammatory cascade caused primarily by reperfusion. Diagnosis of ischemic colitis remains often difficult and requires a combination of diagnostic techniques, whereas clinical signs are occasionally only seen late as complications. Gold standard is considered to be colonoscopy. Clinical presentation and treatment of ischemic colitis vary widely depending on the degree of ischemia. Patients of intensive care unit (ICU) with ischemic colitis are often under-diagnosed, since the parallel co-morbidities and the nonspecific nature of symptoms that mimic almost any abdominal pathology, can mislead the doctor. Moreover, sedated or ventilated patients can mask many of the characteristic features of ischemic colitis and make the diagnosis challenging. Bedside colonoscopy and diagnostic laparoscopy in ICUs are two options, which seem lately to be reliable and promising in diagnosing ischemic colitis in critically ill patients.

Diarrhea in Critically Ill Patients: The Role of Enteral Feeding

This tutorial presents a systematic approach to the management of diarrhea in the critical care setting. Diarrhea is a common and prevalent problem in critically ill patients. Despite the high prevalence, its management is far from simple. Professionals are confronted with a myriad of definitions based on frequency, consistency, and volume. The causes are complex and multifactorial, yet enteral tube feeding formula is believed to be the perpetrator. Potential causes for diarrhea are discussed, and 3 case reports provide context to examine the treatment from a nutrition perspective. Each scenario is comprehensively addressed discussing potential causes and providing specific clinical strategies contributing to improved bowel function in this patient group. The approach used for diarrhea management is based on a complete understanding of enteral tube formula, their composition, and their impact in the presence of gut dysfunction. Choosing the right feeding formula may positively influence bowel function and contribute to improved nutrition.

Update on Colon Ischemia: Recent Insights and Advances

Colon ischemia (CI) is the most common manifestation of ischemic injury to the gastrointestinal (GI) tract. This usually self-limited disease is being diagnosed more frequently, and the list of known causes is increasing. Local hypoperfusion and reperfusion injury are both thought to contribute to the disease process, which manifests with a wide spectrum of injury including reversible colopathy (subepithelial hemorrhage and edema), transient colitis, chronic colitis, stricture, gangrene, and fulminant universal colitis. The distribution is usually segmental with left-sided disease (e.g., inferior mesenteric artery distribution) being more frequently observed than right-sided involvement (e.g., superior mesenteric artery distribution). Any portion of the colon can be affected, but the anatomic distribution of CI recently has been shown to be associated with outcome. Patients with isolated-right colon ischemia (IRCI) have a different presentation and worse outcomes than other distributions of disease. Although somewhat variable depending on disease location, CI presents with cramping abdominal pains over the segment of colon involved followed by a short course of bloody diarrhea. Diagnosis is usually made clinically and is supported with serologic, radiologic, and colonoscopic findings. Colonoscopy is the most accurate diagnostic study. Most patients respond to conservative supportive therapy although some with more severe disease require antimicrobials and/or surgical intervention.

[Acute mesenteric ischemia]

BACKGROUND

Acute vascular occlusion within the mesenteric circulation leads to ischemic damage of the corresponding bowel segment, which starts on the mucosal level and progresses transmurally.

OBJECTIVES

Report on pathogenesis, clinical picture and treatment of various forms of intestinal ischemia.

MATERIALS AND METHODS

Analysis of the available literature taking into consideration our own experience.

RESULTS

Frequently, predisposing diseases and risk factors are present (e.g., cardiac diseases, hypercoagulability, status post cardiac surgery, circulatory failure, or administration of vasoconstrictive drugs). Acute small bowel ischemia-caused by either mesenteric embolism, mesenteric artery thrombosis, nonocclusive mesenteric ischemia (NOMI) or mesenteric venous thrombosis-represents an acute emergency. If this condition is suspected clinically, the diagnosis must be established immediately by computed tomography of the abdomen with intravenous administration of contrast medium in order to prevent irreversible damage to the small bowel. Medical treatment is supportive. If possible, occluded vessels may be re-opened either by radiologic intervention or surgically. Irreversibly damaged bowel segments must be surgically removed. Ischemic colitis has a benign course in most cases if limited to reversible mucosal damage. The diagnosis is based mainly on colonoscopy and computed tomography findings, and treatment is symptom oriented. Rarely, severe manifestations with a worse prognosis due to considerable comorbidities occur. In such cases, surgical removal of the ischemic bowel is frequently required.

CONCLUSION

Even today, acute mesenteric ischemia is associated with a poor prognosis. To improve survival and to reduce long-term morbidity, a rapid and systematic diagnostic workup is mandatory.

The role of hypercoagulability in ischemic colitis

OBJECTIVE

The aim of this study is to evaluate the role of thrombophilia-hypercoagulability in ischemic colitis (IC).

MATERIAL AND METHODS

Thrombophilia and fibrinogen were evaluated in 56 cases of IC and 44 controls with known predisposing factors but no evidence of IC. Thrombophilic factors tested were: protein C (PC), protein S, antithrombin (AT), resistance to activated protein C (APCR), lupus anticoagulant (LA), factor V G1691A mutation (FV Leiden), prothrombin G20210A mutation, methylenetetrahydrofolate reductase (MTHFR) gene C677T and A1298C mutations and plasminogen activator inhibitor-1 (PAI-1) gene 5G/4G and 4G/4G polymorphisms.

RESULTS

In IC group were recorded: i) low levels of PC and AT (p = 0.064 and p = 0.022, respectively); ii) low levels of APCR (normal: >2, p = 0.008); iii) high levels of fibrinogen (p = 0.0005); iv) higher number of homozygotes for MTHFR A1298C and C677T mutations (p = 0.061 and p = 0.525 (Pearson chi-square), respectively); v) greater prevalence of 5G/4G and 4G/4G polymorphisms (p = 0.031 (Pearson chi-square)) and vi) higher incidence of LA-positive individuals (p = 0.037, Fischer's exact test). Multivariate analysis was performed to determine the effects of prothrombotic factors in IC. 5G/4G polymorphism of PAI-1 gene (odds ratio (OR) 12.29; 95% confidence interval (CI) 2.26-67.00), APCR (OR 0.089; 95% CI 0.011-0.699) and fibrinogen (OR 1.013; 95% CI 1.003-1.023) were determined as predictors of IC.

CONCLUSIONS

This study suggests that hypercoagulability, hereditary or acquired, plays an essential role in the manifestation of IC.

The effects of vardenafil and pentoxifylline administration in an animal model of ischemic colitis

OBJECTIVES

Vardenafil enhances dilatation of vascular smooth muscle and inhibits platelet aggregation. The purpose of this study was to evaluate the clinical effects of vardenafil and pentoxifylline administration in an experimental model of ischemic colitis.

METHODS

Forty female Wistar albino rats weighing 250-300 g were randomized into five experimental groups (each with n = 8) as follows:1) a sham group subjected to a sham surgical procedure and administered only tap water; 2) a control group subjected to a standardized surgical procedure to induce ischemic colitis and administered only tap water; 3) and 4) treatment groups subjected to surgical induction of ischemic colitis followed by the postoperative administration of 5 mg/kg or 10 mg/kg vardenafil, respectively; and 5) a treatment group subjected to surgical induction of ischemic colitis followed by postoperative administration of pentoxifylline at 50 mg/kg/day per day as a single dose for a 3-day period. All animals were sacrificed at 72 h post-surgery and subjected to relaparotomy. We scored the macroscopically visible damage, measured the ischemic area and scored histopathology to determine the severity of ischemia. Tissue malondialdehyde levels were also quantified.

RESULTS

The mean Gomella ischemic areas were 63.3 mm2 in the control group; 3.4 and 9.6 mm2 in the vardenafil 5 and vardenafil 10 groups, respectively; and 3.4 mm2 in the pentoxifylline group (p = 0.0001). The mean malondialdehyde values were 63.7 nmol/g in the control group; 25.3 and 25.6 nmol/g in the vardenafil 5 and vardenafil 10 groups, respectively; and 22.8 nmol/g in the pentoxifylline group (p = 0.0001).

CONCLUSION

Our findings indicate that vardenafil and pentoxifylline are effective treatment options in an animal model of ischemic colitis. The positive clinical effects produced by these drugs are likely due to their influence on the hemodynamics associated with vascular smooth muscle and platelet functions.

Ischaemic colitis: indications, extent, and results of standardized emergency surgery

BACKGROUND

Acute ischaemic colitis can occur postoperatively, mainly after aortic surgery, or spontaneously. Surgical treatment is debated. Study aim was to describe factors related to ischaemic colitis severity, determine if postoperative and spontaneous ischaemic colitis share similar outcomes, and evaluate results of standardized management.

METHODS

191 consecutive cases of ischaemic colitis observed from 1997 to 2012 were retrospectively analyzed: 119 (62%) after surgery and 72 (38%) spontaneous. Colon resection was performed for endoscopic type 2 colitis with multiple organ failure, and for every type 3. Types 1 and 2 without multiple organ failure were managed nonoperatively.

RESULTS

Seventeen patients (9%) were managed nonoperatively, without mortality. Mortality rate after resection was 48% (84/174), within 9 days (range, 0-152). Multivariate analysis found 2 independent factors associated with postoperative death: age≥75 years and multiple organ failure. The context in which ischaemic colitis occurred was not a risk factor for mortality. Mortality rates were 51% for final type 3 (66% with multiple organ failure, 17% without), 53% for final type 2 with multiple organ failure, and 0% for type 1 or type 2 without multiple organ failure.

CONCLUSION

An aggressive surgical approach in patients with ischaemic colitis seems justified in patients with multiple organ failure and findings of severe form of ischaemia at endoscopy.

Surgical Management of Severe Colitis in the Intensive Care Unit

Severe colitis, an umbrella encompassing several entities, is one of the most common acute gastrointestinal disorders resulting in critical illness. Clostridium difficile infection is responsible for the majority of nosocomial diarrhea with fulminant C difficile colitis (CDC) carrying a high mortality. Optimal outcomes can be achieved by early identification and treatment of fulminant CDC, with appropriate surgical intervention when indicated. Ischemic colitis, on the other hand, is uncommon with a range of etiological factors including abdominal aortic surgery, inotropic drugs, rheumatoid diseases, or often no obvious triggering factor. Most cases resolve with nonsurgical management; however, prompt recognition of full-thickness necrosis and gangrene is crucial for good patient outcomes. Fulminant colitis is a severe disease secondary to progressive ulcerative colitis with systemic deterioration. Surgical intervention is indicated for hemorrhage, perforation, or peritonitis and failure of medical therapy to control the disease. Although, failure of medical management is the most common indication, it can be difficult to define objectively and requires a collaborative multidisciplinary approach. This article proposes some simple management algorithms for these clinical entities, with a focus on critically ill patients.

Management of ischemic colitis

Ischemic colitis is a commonly misunderstood clinical condition. Although the colon is the most common region of ischemia in the gastrointestinal tract, many surgeons have difficulty with diagnosis and treatment of ischemic colitis. The process can occur from either occlusive vascular disease or nonocclusive disease, and can be gangrenous or nongangrenous. Differentiating gangrenous from nongangrenous disease can be a difficult clinical challenge as both sets of patients generally present with abdominal pain and bloody diarrhea. Although the majority of patients have transient ischemia with nongangrenous colitis that can be successfully managed nonoperatively, prompt recognition and surgical intervention is critical in patients with gangrenous colitis. In this article, the diagnosis and treatment of ischemic colitis is reviewed with emphasis on a systematic, evidence-based approach to management.

Acute extensive ischemic enteritis in a young man diagnosed with wireless capsule endoscopy: a case report

Ischemic enteritis is caused by either the interruption or significant reduction of arterial inflow to the small intestine. Risk factors are old age, diabetes mellitus and cardiovascular disease. It is very rare in young patients. We experienced a 21-year-old man with recurrent acute ischemic enteritis who was diagnosed with capsule endoscopy. He had previously taken medications for pulmonary hypertension and obstruction of both carotid arteries, and about 20 months earlier, he had been admitted due to hematochezia. Two sessions of angiography did not reveal the cause of hematochezia. At that time, capsule endoscopy showed mucosal edema and erythema in the terminal ileum, suggesting healed ischemic enteritis. The patient was admitted again due to hematochezia. Abdominal computed tomography showed focal celiac trunk stenosis and diffuse wall thickening of the small intestine, suggesting ischemic enteritis. Capsule endoscopy showed multiple active ulcers and severe hemorrhage with exudate, extending from the proximal jejunum to the terminal ileum. Using capsule endoscopy, the patient was diagnosed with acute extensive ischemic enteritis. Because endoscopic images of ischemic enteritis have rarely been reported, we report a case of a 21-year-old man who was diagnosed acute extensive ischemic enteritis with capsule endoscopy.

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.

Predictors of severity in ischaemic colitis

PURPOSE

Ischaemic colitis (IC) is an inadequate perfusion leading to potentially life-threatening colonic inflammation. The aim was to identify patient characteristics that predict severity in biopsy-confirmed IC.

METHODS

A retrospective study of consecutive patients admitted with a robust diagnosis of IC over a 5-year period was performed. As IC is often misdiagnosed, strict inclusion criteria including supporting histopathology, exclusion of inflammatory bowel disease, absence of recent antibiotics or negative stool sampling with testing for Clostridium difficile were adhered to. Due to differing pathophysiology involved, patients suffering IC due to injury to colonic perfusion from vascular procedures or tumours were also excluded. Patients were divided by outcomes into a severe IC group including those that needed surgery or suffered mortality and a non-severe IC group that included patients managed medically with good evolution during their index admission. Patient characteristics were analysed to identify statistically significant predictors of severity (p < 0.05).

RESULTS

Thirty-two patients (11 males, 21 females; mean age 72.5) met the inclusion criteria. Medical management was adopted in 23 patients with a single mortality (4.3%). Nine patients were managed surgically with two mortalities (22.2%), giving an overall mortality of 9.4% and a severe IC group consisting of ten patients. Significant prognostic predictors of severity included: right-sided IC (p = 0.0002), guarding (p = 0.001), lack of bleeding per rectum (p = 0.005) and chronic constipation (p = 0.02).

CONCLUSIONS

The majority of patients with IC can be managed conservatively. Right-sided IC, guarding, lack of bleeding per rectum and chronic constipation are associated with severe IC.

Miscellaneous colitides

PURPOSE OF REVIEW

A variety of diseases cause symptomatic inflammation of the colon. The epidemiology, clinical features, and/or endoscopic appearance of these conditions are distinct and histologic findings are often definitive.

RECENT FINDINGS

Recent literature adds to our understanding of the epidemiology and treatment of these disorders.

SUMMARY

Microscopic colitis, ischemic colitis, eosinophilic colitis, and drug-induced colitis, all cause diarrhea, often with abdominal pain, due to inflammation of the colon. Careful consideration of the clinical features and colonic mucosal biopsies usually lead to the correct diagnosis and appropriate therapy.

Colon ischemia: recent insights and advances

Ischemic colitis is the most common manifestation of ischemic injury to the gastrointestinal tract, and the variety of defined causes is increasing. Local hypoperfusion and reperfusion injury are both thought to contribute to the disease process, which manifests with a wide spectrum of injury including reversible colopathy (subepithelial hemorrhage and edema), transient colitis, chronic colitis, stricture, gangrene, and fulminant universal colitis. The distribution is typically segmental. Older studies showed that any portion of the colon can be involved; recently, it was established that the site of involvement and prognosis can be correlated. In particular, isolated involvement of the right side of the colon was shown to have a different presentation and worse outcome than ischemic colitis involving other segments. Diagnosis is usually made clinically and supported by radiologic imaging and colonoscopic evaluation. Most patients respond to conservative supportive therapy, although some with severe disease require surgical intervention.