Extensive ischaemic colitis-like colonic lesions in eosinophilic granulomatosis with polyangiitis

Eosinophilic granulomatosis with polyangiitis is a rare, immune-mediated, multisystemic disorder belonging to the group of antineutrophil cytoplasmic antibody-associated vasculitides. Gastrointestinal symptoms are relatively common in patients with eosinophilic granulomatosis with polyangiitis, reportedly occurring in ∼22.3% of cases. Vasculitic necrotising lesions normally occur in the intestinal tract, and in the present case, the colonic lesions were remarkably severe and extensive. Pulse steroid therapy combined with cyclophosphamide improved the patient's condition without any serious complications, such as intestinal perforation.

Unique Case of Severe Sepsis and Acute Respiratory Failure in the Setting of Aseptic Epiploic Appendagitis of the Descending Colon

Epiploic appendagitis (EA) is an uncommon intraabdominal pathology resulting in transient, localized pain. The condition is caused by ischemia of one of the epiploic appendages, which are distributed axially along the length of the colon. EA is often mistaken for other more common etiologies of an acute abdomen. Generally, the patients experience focal abdominal pain with no further symptoms or laboratory abnormalities. The authors encountered a 79-year-old male with severe sepsis and acute respiratory failure requiring intubation. He recovered rapidly after the identification and removal of a single EA. This paper reports the first case of EA leading to the systemic dysregulation of sepsis.

[Epiploic appendagitis: an uncommon and nonsurgical cause of abdominal pain]

BACKGROUND

Epiploic appendagitis (AE) is a rare cause of acute abdomen and is often misdiagnosed as other common causes of acute abdomen, such as acute appendicitis, cholecystitis or diverticulitis due to its low incidence and its nonspecific clinical picture. This study presents the clinical course of AE and typical radiological features for an early and correct diagnosis in order to emphasize the importance of an early and correct diagnosis of AE.

METHODS

This is a retrospective review of 43 patients diagnosed with AE between June 2010 and September 2022 at the Charité - University Hospital Berlin, Campus Benjamin Franklin. The medical records were reviewed regarding clinical und radiological features, anatomical location of the AE und treatment methods.

RESULTS

A total of 43 patients (29 male, 11 female) were diagnosed with AE and almost all patients presented with abdominal pain, except in 8 cases (18.6%). Specific findings in computer tomography (CT) with a typical picture of AE were found in 33 patients (76.7%). AE was mostly localized in the left colon: 12 were found in the sigmoid colon (27.9%), 16 in the descending colon (37.2%) and 5 at the junction of the descending colon and the sigmoid colon (11.6%). Of the patients 28 (65.1%) were admitted for conservative treatment and the rest of the patients were treated as outpatients. No patient underwent surgery, all were treated with analgesics (NSAID) and 17 patients received antibiotics in addition.

CONCLUSION

AE is a self-limiting disease and a common mimic of other serious causes of abdominal pain. Due to the emergence of the widespread use of imaging modalities, an early diagnosis of AE and a conservative approach as first choice of treatment in patients with AE could be established.

Insights into acute mesenteric ischaemia: an up-to-date, evidence-based review from a mesenteric stroke centre unit

Radiologists play a central role in the diagnostic and prognostic evaluation of patients with acute mesenteric ischaemia (AMI). Unfortunately, more than half of AMI patients undergo imaging with no prior suspicion of AMI, making identifying this disease even more difficult. A confirmed diagnosis of AMI is ideally made with dynamic contrast-enhanced CT but the diagnosis may be made on portal-venous phase images in appropriate clinical settings. AMI is diagnosed on CT based on the identification of vascular impairment and bowel ischaemic injury with no other cause. Moreover, radiologists must evaluate the probability of bowel necrosis, which will influence the treatment options.AMI is usually separated into different entities: arterial, venous, non-occlusive and ischaemic colitis. Arterial AMI can be occlusive or stenotic, the dominant causes being atherothrombosis, embolism and isolated superior mesenteric artery (SMA) dissection. The main finding in the bowel is decreased wall enhancement, and necrosis can be suspected when dilatation >25 mm is identified. Venous AMI is related to superior mesenteric vein (SMV) thrombosis as a result of a thrombophilic state (acquired or inherited), local injury (cancer, inflammation or trauma) or underlying SMV insufficiency. The dominant features in the bowel are hypoattenuating wall thickening with submucosal oedema. Decreased enhancement of the involved bowel suggests necrosis. Non-occlusive mesenteric ischaemia (NOMI) is related to impaired SMA flow following global hypoperfusion associated with low-flow states. There are numerous findings in the bowel characterised by diffuse extension. An absence of bowel enhancement and a thin bowel wall suggest necrosis in NOMI. Finally, ischaemic colitis is a sub-entity of arterial AMI and reflects localised colon ischaemia-reperfusion injury. The main CT finding is a thickened colon wall with fat stranding, which seems to be unrelated to SMA or inferior mesenteric artery lesions. A precise identification and description of vascular lesions, bowel involvement and features associated with transmural necrosis is needed to determine patient treatment and outcome.

Stercoral colitis: CT imaging findings and clinical risk factors

PURPOSE

To describe and update stercoral colitis clinical risk factors, relative frequency, location, and CT imaging features correlated with surgical and pathological results.

METHODS

CT reports over a 5-year period (05/2017-05/2022) at a single medical center were searched. Main inclusion criteria were luminal distention with formed stool, wall thickening, and surrounding inflammation. Positive cases were graded as mild (early or developing stercoral colitis) versus moderate-to-severe based on CT findings. Medical records were reviewed for risk factors and outcome data in moderate-to-severe cases. P-values were tabulated for comparison.

RESULTS

545 total cases (71 (60, 82) years, 278 males) were identified on CT, including 452 mild (82.9%) and 93 moderate-to-severe cases (17%, 67 (55, 79) years, 48 females). Twenty cases showed evidence of perforation (3.7% total cohort, 22% moderate-to-severe cohort). Diagnosis as an incidental finding was frequent (46.0% of mild cases). Most cases involved the rectum (97.6% of mild cohort and 69% of moderate-to-severe cohort). The sigmoid was involved in 31% of moderate-to-severe cases, but 95% of the perforated subcohort (19/20, 13/20 without rectal involvement). Among the moderate-to-severe cohort, perforation was associated with slightly increased wall thickness (6.4 vs. 5.7 mm, p = 0.03), opioid use (50 vs. 23%, p = 0.04), and disease-specific mortality (11 vs. 0%, p =0.04). Perforation was less associated with major neurocognitive disorders (20 vs. 60%, p = 0.003), institutionalized status (5 vs. 38%, p = 0.005), and a prescribed bowel regimen (30 vs. 63%, p = 0.01).

CONCLUSION

Stercoral colitis may be under-reported. Perforation tends to favor sigmoid involvement and a less traditional patient cohort.

Gastrointestinal involvement of passenger lymphocyte syndrome followed by minor ABO-incompatible renal transplantation: A case report

BACKGROUND

People with group O blood are considered universal organ donors compatible with any other blood group. However, in the case of minor ABO-incompatible transplantation, immune-mediated hemolysis may occur due to concomitant transfer of donor B lymphocytes together with the allograft. These passenger lymphocytes can produce antibodies in the recipients erythrocytes, causing hemolytic anemia known as passenger lymphocyte syndrome (PLS).

METHODS

A retrospective chart review was performed.

RESULTS

A 6-year-old boy (A+) underwent transplantation of a kidney from his father (O+). On postoperative day (POD) 6, the patient developed fever with no explainable causes. On POD 11, he presented with abdominal pain, hematochezia, and severe diarrhea, with sudden hemolytic anemia. Since then, GI symptoms have continued. On POD 20, direct antiglobulin test (DAT) was positive, and the anti-A IgM/G titer was 2/32. The results of the anti-A antibody elution test were strongly positive (3+). These findings highly suggested PLS. On the same day, the GI symptoms suddenly worsened, and laboratory findings showed hemolysis and thrombocytopenia with disseminated intravascular coagulation (DIC). Abdominal computed tomography (CT) scans suggested ischemic colitis of venous origin, and the patient underwent segmental colectomy with ileostomy formation on POD 23. To remove the anti-A antibodies, the patient underwent therapeutic plasma exchange (TPE) five times until the DAT and anti-A elution test were negative.

CONCLUSIONS

We report a case of gastrointestinal involvement of PLS that occurred after minor ABO-incompatible kidney transplantation. This is the first report of ischemic colitis as an atypical manifestation of PLS.

Primary Epiploic Appendagitis: A Mimicker of Abdominal Pain

Epiploic appendagitis is a rare cause of acute lower abdominal pain. Epiploic appendices are fat-filled serosal outpouchings of the cecum and sigmoid colon. Primary epiploic appendagitis (PEA) is characterized by epiploic inflammation caused by torsion of the appendage leading to ischemia or thrombosis of the appendage draining vein. Secondary epiploic appendagitis occurs in association with other inflammatory conditions of the abdomen or pelvis, most commonly diverticulitis. PEA is an important clinical mimicker of more severe causes of acute abdominal pain, such as diverticulitis, appendicitis, or gynaecological causes. The ease of access to computed tomography (CT), the diagnostic test of choice, has resulted in increased recognition of PEA. The classic CT findings of PEA are an ovoid mass measuring between 1.5 and 3.5 cm surrounded by a hyperattenuating/hyperdense ring with a centrally located hyperdense area. It is important to diagnose PEA as it is self-limiting and the correct diagnosis can prevent unnecessary hospital admission, antibiotic use, or even surgical intervention. We present a case of a 65-year-old male with a history of diverticulitis, presenting with left lower quadrant abdominal pain who was diagnosed with PEA based on CT and successfully managed with conservative treatment.

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.

Ischemic Colitis Presented as Pseudomembranous Colitis: An Untypical Case from Vietnam

Ischemic colitis (IC) is an underreported chronic disease characterized by the hypoperfusion of the bowel mucosa. The diagnosis and treatment may be challenging because its clinical course resembles other colitis or even colorectal malignancies. This paper reports an untypical case to underline the diversity of IC manifestation. A 68-year-old man with several comorbidities was admitted because of abdominal pain with a 6-month duration and a mass in the left lower quadrant. Colonoscopy revealed erosive pseudomembranous colitis narrowed colon segments with ulcerated mucosa mimicking colorectal cancer and inflammatory bowel disease. The stool cultures and Clostridium difficile toxin tests were negative. After the failure of conservative therapy, the Hartmann procedure with temporary ileostomy was performed uneventfully. The histological results of the surgical specimens revealed IC with focal pseudomembranous areas.

Rare Clinical Association between Clostridioides difficile Infection and Ischemic Colitis: Case Report and Literature Review

Background and Objectives: Gut microbiota plays an important role in the wellbeing of the host through different interactions between microflora constituents. In certain instances, Clostridioides difficile may pullulate, causing infection with associated colitis that may vary in terms of severity from mild disease to severe colitis, with increased associated mortality due to its complications. However, there are few literature data regarding the association between Clostridioides difficile and ischemic colitis. Case report: We report the case of a 30-year-old male patient, overweight, with impending dehydration, who presented with hematochezia and colicky abdominal pain, with positive fecal tests for the detection of Clostridioides difficile infection and endoscopic appearance suggesting ischemic colitis in the sigmoid and left colon, confirmed by computed tomography and histology. The patient was treated with oral Vancomycin, with resolution of symptoms, and was reevaluated through colonoscopy eight weeks after discharge, with endoscopic mucosal normalization and histological scarring process on biopsy samples. Conclusion: We report one of the few cases in the literature of ischemic colitis associated with Clostridioides difficile infection, with resolution of clinical, endoscopic, and histologic changes after specific treatment with oral Vancomycin suggesting a possible association between the two diseases. We also review the existing literature data regarding this comorbid association.

Vasovagal Reaction and Ischemic Colitis Following Blood Donation

Vasovagal reactions are the most common type of adverse reaction after blood donation; however, there are no reports of ischemic colitis as an adverse reaction after blood donation. A previously healthy 55-year-old woman suffered loss of consciousness at the end of her first plasma donation. She was diagnosed with a vasovagal reaction and received hydration. However, she developed persistent left flank pain and watery diarrhea, followed by bloody diarrhea. Abdominal computed tomography confirmed ischemic colitis. She was asked to fast and was eventually discharged 7 days later. We should consider the possibility of ischemic colitis if patients develop persistent abdominal pain after transient hypotension, such as that observed during a vasovagal reaction.

Stercoral colitis complicated with ischemic colitis: a double-edge sword

BACKGROUND

Stercoral colitis is a rare inflammatory process involving the colonic wall secondary to fecal impaction with high morbidity and mortality; especially if complicated with ischemic colitis, stercoral ulcer formation and subsequent perforation. There are several case reports published on abdominal perforation resulting from stercoral colitis. However, stercoral colitis complicated by ischemic colitis is rare. The purpose of this case report is to describe the potential challenges in the diagnosis and management of stercoral colitis with ischemic colitis.

CASE PRESENTATION

An 87 years old male with history of chronic constipation presents with severe abdominal pain to the emergency department. The patient was hemodynamically stable. On physical examination, the abdomen was mildly distended with moderate tenderness. Lab work was significant for leukocytosis and lactic acidosis. Abdominal CT scan revealed large amount of retained stool in the colon, bowel wall thickening and infiltration of peri-colonic fat, which were suggestive for stercoral colitis. Patient was started on IV fluids and antibiotics. He was given an enema, followed by laxative and manual disimpaction of stool. Colonoscopy was performed and biopsies were obtained. Tissue biopsy was significant for focal active colitis with regenerative glandular changes and neural hyperplasia.

CONCLUSION

Elevated lactic acid level secondary to ischemia of the bowel wall with CT scan findings aid in establishing the diagnosis of stercoral colitis complicated with ischemic colitis. Urgent treatment with laxatives and fecal disimpaction is indicated to prevent perforation and peritonitis.

Serum procalcitonin correlates with colonoscopy findings and can guide therapeutic decisions in postoperative ischemic colitis

BACKGROUND

Postoperative ischaemic colitis (POIC) is a life-threatening vascular gastrointestinal condition. Serum procalcitonin (PCT) levels be of value in the detection of necrosis.

AIMS

To evaluate the correlation between serum PCT levels and the colonoscopic assessment of the severity of POIC.

METHODS

Between January 2007 and November 2014, 150 patients with POIC and PCT data were included in the study. The main outcome measure was the correlation between serum PCT and the colonoscopy-based assessment of the severity of POIC (according to Favier's classification: stage 1/2 without multi-organ failure vs. stage 2/3 with multi-organ failure).

RESULTS

Eighty-five percent of the stage 1 cases (n=22) had a serum PCT level ≤2μg/L; 63% (n=19) of the stage 2 cases with multi-organ failure had a PCT level between 4 and 8μg/L, and 70% (n=52) of the stage 3 cases had a PCT level ≥8μg/L. The PCT level was strongly correlated with the Favier stage (Spearman's rho: 0.701; p<0.0001). PCT levels were similar in stage 2 cases with multi-organ failure and in stage 3 cases (16.06μg/L vs. 7.79μg/L, respectively; p=0.35).

CONCLUSION AND RELEVANCE

Serum PCT is correlated with stage 2/3 POIC requiring surgery. If PCT ≥5μg/L, surgery should be considered.

Fulminant gangrenous ischemic colitis: is it the solely severe type of ischemic colitis?

PURPOSE

The purposes of the study are to evaluate the characteristics of gangrenous colitis and to identify clinicobiological factors.

METHODS

We performed a retrospective study of 75 patients in whom the diagnosis was made endoscopically and confirmed pathologically, between March 2004 and March 2010 at a tertiary teaching hospital. We classified ischemic colitis into the reversible and irreversible types (gangrenous colitis). The influence of factors, such as medical history, symptoms, physical examination, laboratory abnormalities, endoscopic findings, abnormalities on computed tomography, perioperative issues, complications, and several scoring systems, on gangrenous ischemic changes and mortality was evaluated by univariate and multivariate analyses.

RESULTS

Ischemic colitis was classified as gangrenous ischemic type in 19 patients. The sigmoid colon was the most common site of involvement. However, the disease distribution was significantly different between the two groups. Pancolitis was most commonly observed for fulminant gangrenous colitis. A difference between the two groups was detected for several factors: age, mortality, physiologic score, APACHE II, mean arterial pressure at the time of admission, heart rate, albumin level, and sodium bicarbonate concentration. Multivariate analysis indicated four factors predictive of gangrenous colitis: absence of hematochezia, abdominal tenderness, absence of diarrhea, and albumin level. Another multivariate analysis excluding gangrenous change factors for mortality indicated four factors: arterial pH, serum sodium bicarbonate (metabolic acidosis), albumin (<3.0), and arterial oxygenation.

CONCLUSION

Absence of diarrhea and hematochezia, presence of abdominal tenderness, and hypoalbuminemia could be the predictors for development of gangrenous changes of ischemic colitis.

Natural history of outpatient-onset ischemic colitis compared with other lower gastrointestinal bleeding: a long-term cohort study

PURPOSES

The long-term clinical course of outpatient-onset ischemic colitis remains unknown. Our aims are to elucidate the in- and out-of-hospital clinical outcomes of ischemic colitis and compare them with those of lower gastrointestinal bleeding (LGIB).

METHOD

A cohort of 370 outpatients was hospitalized for ischemic colitis (n = 57) or other LGIB (n = 313). All patients had undergone colonoscopy. During hospitalization, the need for transfusion or interventions, further bleeding, mortality, and length of hospital stay were measured. After discharge, long-term recurrence and mortality were analyzed by the Kaplan-Meier method.

RESULTS

Colonoscopy revealed that 88% of ischemic colitis cases were left sided. Compared with other LGIB, ischemic colitis cases had significantly lower transfusion requirements (p < 0.01), further bleeding (p = 0.02), endoscopic intervention (p < 0.01), and shorter hospital stay (p = 0.03). No significant differences between the groups were noted in the need for surgery, angiographic procedures, or mortality during hospitalization. During a mean follow-up of 22 months, rebleeding was significantly lower (log-rank test; p < 0.01) in ischemic colitis cases (5.3%) than in other LGIB cases (19.4%) after discharge. During the mean follow-up period of 29 months, 1 patient (1.8%) with ischemic colitis and 18 patients (5.8%) with other LGIB died (log-rank test; p = 0.41).

CONCLUSIONS

Outpatient-onset ischemic colitis patients usually had left-sided colitis, recovered with conservative short-term treatment and had lower transfusion requirements and further bleeding compared with other LGIB patients. After discharge, patients with outpatient-onset ischemic colitis had lower recurrence over the long term than other LGIB patients.

[An analysis of clinical characteristics and risk factors for ulceration in ischemic colitis]

OBJECTIVE

To investigate the clinical manifestations and risk factors related to ulcer in patients with ischemic colitis (IC).

METHODS

Clinical data of sixty-three IC patients with definite diagnosis from June 2002 to June 2012 in the PLA General Hospital were retrospectively analyzed. All patients were classified into ulcer group (23 cases) and non-ulcer group (40 cases) according to the presence of ulcer or not. Clinical manifestations and risk factors related to ulcer lesions were compared in the two groups. Logistic regression model was used for statistical analysis.

RESULTS

There were 50 men and 13 women enrolled, with an average age of 70 years old. The main clinical manifestations included abdominal pain [85.7% (54/63) ], diarrhea [54.0% (34/63)], hematochezia [41.3% (26/63)]. In comparison with non-ulcer group, the ulcer group showed higher incidences of chronic constipation [34.8% (8/23) vs 12.5% (5/40) , P = 0.03], enteric-coated aspirin intake [52.2% (12/23) vs 25.0% (10/40), P = 0.03] and abdomen tenderness [82.6% (19/23) vs 52.5% (21/40), P = 0.02]. Chronic constipation and enteric-coated aspirin intake were independent risk factors related to ulcer lesions (OR = 3.38, P = 0.04; OR = 5.91, P = 0.03). Patients with abdomen tenderness had higher incidence of ulcer lesion (OR = 3.12, P = 0.04). The most common location of IC was left colon [69.8% (44/63)]. No difference of site distribution was found in ulcer and non-ulcer group (P = 0.066). Splanchnic atherosclerosis in the ulcer group was more common than in non-ulcer group [88.2% (15/17) vs 58.3% (14/24), P = 0.038]. The duration of hospitalization was significantly longer in ulcer group [ (14.3 ± 7.1) d vs (6.2 ± 4.1) d, P < 0.01]. Higher white blood cell (WBC) count and lower hemoglobin (Hb) were seen in ulcer group than those in non-ulcer group [(10.17 ± 3.32) ×10(9)/L vs (7.25 ± 3.15)×10(9)/L, P = 0.018; (98 ± 27) g/L vs (126 ± 35) g/L, P = 0.041].

CONCLUSIONS

Chronic constipation, enteric-coated aspirin intake and splanchnic atherosclerosis are risk factors related to ulcer in IC patients. Abdomen tenderness, high WBC and low Hb strongly indicate possible IC with ulcer.

[Colonic necrosis and stricture due to non-occlusive ischemic colitis. Report of two cases and review of the literature]

BACKGROUND

Non-occlusive ischemic colitis appears to be a collection of diseases rather than a single entity. The presumed etiologies are numerous; however, it typically develops spontaneously in the absence of major vasculature occlusion. It includes a wide clinical spectrum ranging from mild to severe forms. Some patients may develop complications and management of this disorder depends on disease severity.

OBJECTIVE

Report of two cases and review of the literature.

CLINICAL CASE

Two cases are described, both requiring surgery with primary anastomosis. One patient had colonic gangrene that required an open right colectomy and the other a totally laparoscopic left colectomy for a stricture.

CONCLUSION

Non-occlusive ischemic colitis is idiopathic. Some patients requiring surgery may be selected to undergo primary anastomosis and laparoscopic surgery.

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.

Ischemic colitis in five points: an update 2013

BACKGROUND

Ischemic colitis is the most common form of intestinal ischemia. The presence of diarrhea and mild lower gastrointestinal bleeding should guide the diagnosis. Although many laboratory tests and radiographic images may suggest the diagnosis, colonic endoscopic with histological analysis of biopsies is the gold standard for identification of colonic ischemia. aim : The aim of this study was to resume in 5 points: the epidemiology, the clinical features, the diagnostic approach and the management of ischemic colitis in five points. methods: Review of literature. results: Incidence of ischemic colitis was between 3 and 10%. The clinical presentation is predominated by the non gangrenous form associating abdominal pain, tenderness, diarrhea and lower gastrointestinal bleeding. The most frequent causes are represented by systemic hypoperfusion. Laboratory tests can orientate the diagnosis but are unspecific. Radiographic images based on computed tomography or more recently magnetic resonance imaging may suggest the diagnosis, but the confirmation will be given by endoscopic visualization of colonic mucosa with histological analysis of biopsies. Conservative treatment is the most often sufficient to improve colonic lesions. Surgical treatment is reserved for perforations and strictures.

CONCLUSION

The incidence of colonic ischemia is difficult to ascertain. The diagnosis is usually made by medical history, examination, and endoscopy which have become the diagnostic procedure of choice. A high index of suspicion and prompt management are essential for optimum outcomes in patients with colonic ischemia.

[Rectal bleeding during pregnancy]

BACKGROUND

Ischaemic colitis is a relatively rare disease that predominantly affects elderly patients. This disorder has varying underlying causes and diverse clinical symptoms.

CASE DESCRIPTION

A 29-year-old primigravida was admitted to our hospital with rectal bleeding and diffuse abdominal pain. The number of leucocytes and the CRP were elevated. Because the patient was pregnant a sigmoidoscopy without sedation was performed. The endoscopic image and histopathology of the biopsies revealed ischaemic colitis. Our patient recovered quickly under conservative treatment.

CONCLUSION

Ischaemic colitis is usually self-limiting and a conservative treatment will suffice. Ischaemic colitis during pregnancy has been reported extremely rarely and the aetiology is unknown.

Lubiprostone induced ischemic colitis

Ischemic colitis accounts for 6%-18% of the causes of acute lower gastrointestinal bleeding. It is often multifactorial and more commonly encountered in the elderly. Several medications have been implicated in the development of colonic ischemia. We report a case of a 54-year old woman who presented with a two-hour history of nausea, vomiting, abdominal pain, and bloody stool. The patient had recently used lubiprostone with close temporal relationship between the increase in the dose and her symptoms of rectal bleeding. The radiologic, colonoscopic and histopathologic findings were all consistent with ischemic colitis. Her condition improved without any serious complications after the cessation of lubiprostone. This is the first reported case of ischemic colitis with a clear relationship with lubiprostone (Naranjo score of 10). Clinical vigilance for ischemic colitis is recommended for patients receiving lubiprostone who are presenting with abdominal pain and rectal bleeding.

Acute Ischaemic Colitis- A Case Report

Acute ischaemic colitis (AIC) is being increasingly recognised as an uncommon cause of abdominal pain associated with fresh bleeding per rectum. It is paramount to maintain a high index of suspicion and adopt appropriate management strategies to avoid complications and inappropriate interventions. In this paper, we describe a case of AIC and review literature pertinent to the management of this condition. Keywords: Ischaemic colitis, acute abdomen, management.

Systemic lupus erythematosus complicated with acute myocardial infarction and ischemic colitis

Acute myocardial infarction (AMI) is one of the most severe manifestations in patients with systemic lupus erythematosus (SLE). Ischemic colitis, mainly caused by intestinal vasculitis, is also one of the most serious, but uncommon, complications in SLE patients. "SLE vasculitis" simultaneously involving cardiac and gastrointestinal vessels has yet to be reported. This is the first report of SLE accompanying AMI, ischemic colitis and perforation of the digestive tract possibly due to SLE vasculitis, which was dramatically improved by treatment with high-dose glucocorticoid.

[A woman with acute upper abdominal pain]

A 42-year-old woman came to the emergency department with acute abdominal pain. CT-scan showed an isolated dissection of the A. mesenterica superior and signs of ischaemic colitis. The patient was treated with endovascular stent placement in the artery and partial small bowel resection.

Development and validation of a novel prognostic scoring model for ischemic colitis

PURPOSE

This study was conducted to identify prognostic factors affecting the course of ischemic colitis and to develop a prognostic scoring model.

METHODS

We analyzed medical records of consecutive patients with ischemic colitis treated between October 2002 and September 2008 at Severance Hospital, Seoul, Republic of Korea. Patients were excluded if results of endoscopy were unavailable. Patients were classified as having severe ischemic colitis on the basis of outcome (improvement delayed for more than 2 weeks, complications requiring surgery, or death). Univariate analyses and multivariate logistic regression analyses with backward stepwise selection were used to identify clinical, endoscopic, and laboratory variables associated with severe ischemic colitis. A novel prognostic scoring model was derived from the data, with probability of severe ischemic colitis and risk index determined for 8 risk groups based on independent risk factors identified by multivariate analyses. Predictive power was tested by means of 10-fold cross-validation, with area under the receiver operating characteristic curve representing discrimination accuracy.

RESULTS

Analyzable data were available for 153 of 173 consecutive patients. Ischemic colitis was classified as severe in 20 patients. Multivariate analyses showed the following significant independent predictors of severe ischemic colitis: tachycardia (adjusted odds ratio = 4.6; 95% CI, 1.4-14.7), shock within 24 hours after admission (adjusted odds ratio = 6.5; 95% CI, 2.0-21.2), and endoscopic evidence of ulceration (adjusted odds ratio = 9.9; 95% CI, 2.0-48.8). Probability of severe ischemic colitis and risk index were 74 times higher for patients with all 3 risk factors (group 8) than for patients with none (group 1). Internal validation showed the area under the receiver operating characteristic curve to be 0.91 (95% confidence interval, 0.86-0.96).

CONCLUSIONS

Endoscopic findings and instability of vital signs were associated with the disease course of ischemic colitis. A novel scoring model based on presence of tachycardia, shock within 24 hours after admission, and endoscopic evidence of ulceration provides a method of assessing patient prognosis and should be further validated.

A successfully treated case of hyperosmolar hyperglycemic state complicated with rhabdomyolysis, acute kidney injury, and ischemic colitis

A 48-year-old Japanese male was admitted to our hospital due to hyperosmolar hyperglycemic state (HHS), combined with rhabdomyolysis and acute kidney injury. His blood sugar levels were gradually decreased by fluid resuscitation and insulin infusion; however, his renal function worsened, and he developed bloody stools. He required continuous hemodiafiltration to improve his hemodynamics. As colonoscopy revealed longitudinal ulcers, ischemic colitis was diagnosed. We treated him conservatively at first, but when we found the ulceration of the sigmoid colon had penetrated the mesenterium, colectomy was indicated. After surgery, his general condition improved. Careful monitoring of complications related to HHS is important.

[Clinical and morphological criteria for microscopic ischemic colitis in patients with chronic coronary heart disease of the digestive system]

We studied the clinical symptoms and functional-morphological changes of the colon in 42 patients with cardiovascular disease, impaired blood flow in the unpaired visceral branches of the abdominal aorta, clinical and instrumental signs of ischemic colon lesions (ICL). Clinical symptoms characteristic of intestinal pathology were observed in all patients, but traditionally described laboratory-instrumental signs of ischemic colitis are installed in only two of them. At the same time, the histological study of the mucosa of the sigmoid colon in 21 of 23 patients revealed necrosis of surface epithelium, reducing the number of goblet cells, focal lymphoid-cell infiltrates and microcirculatory disturbances with the development of stasis, thrombosis and microcirculatory plazmorrags of the colon mucosa. Thus, we have established a new form of ICL--microscopic ischemic colitis. It is the morphological evidence of abdominal pain syndrome, observed in most patients with chronic abdominal ischemia.

Cystic mature teratoma and epidermoid cyst associated with granulosa cell tumour: a rare ovarian scenario. Two case reports and review of the literature

We describe two cases of association between an ovarian granulosa cell tumour and a cystic mature teratoma and an epidermoid cyst. These are very rare combinations that might lead to incorrect diagnostic interpretation, since the simultaneous presence, on routine gross and microscopic examination, of a cystic squamous lesion, intimately connected with (case 1), or contralateral to (case 2) a solid, histologically trabecular or microfollicular tumour, might suggest a diagnosis of a carcinoid tumour in a mature cystic teratoma. The differential diagnostic problems and a review of the literature are presented.

Rectal stenosis caused by foreign body reaction to sodium polystyrene sulfonate crystals (Kayexalate)

Sodium polystyrene sulfonate (SPS) (Kayexalate) is a cation-exchange resin used to treat hyperkaliema. Administered with sorbitol, it usually has minor adverse effects, but it may cause colonic or intestinal necrosis in uremic patients. We report an unusual case of rectal stenosis due to SPS crystals in a 46-year-old man. The patient had been involved in a car accident with severe thoracic and abdominal trauma. During his hospitalization, he presented traumatic acute pancreatitis with ischemic colitis because of hypotension, and acute renal insufficiency treated by hemofiltration and Kayexalate administered by nasogastric tube without sorbitol. Left colon was resected and Hartmann's procedure was performed. Restoration of the colon continuity was performed 13 months later. The rectal lumen was narrowed with a thickened rectal wall. Microscopic examination revealed fibrosis of the submucosa containing numerous basophilic polygonal crystals surrounded by macrophages. This is the first case report of rectal stenosis caused by foreign body reaction to SPS crystals after ischemic colitis.

Can we predict the development of ischemic colitis among patients with lower abdominal pain?

PURPOSE

This study was performed to find clinical risk factors for developing ischemic colitis in patients experiencing lower abdominal discomfort with or without bloody diarrhea.

METHODS

A total of 467 patients who underwent sigmoidoscopy or colonoscopy because of lower abdominal discomforts with or without blood in stool were consecutively enrolled; 147 patients were diagnosed endoscopically and histologically as having ischemic colitis. The control group was composed of the remaining 320 patients with nonspecific endoscopic/histologic findings. Clinical variables were compared between the ischemic colitis group and the control group.

RESULTS

After excluding 67 patients in the ischemic colitis group, we compared the remaining 80 patients to the control group, using various clinical parameters. According to the logistic regression analysis, six factors were significantly related to ischemic colitis: older than aged 60 years (adjusted odds ratio, 5.7; 95 percent confidence interval: 2.6-11.7), hemodialysis (5; 1.2-21.6), hypertension (4.9; 2.3-10.5), hypoalbuminemia (3.5; 1.8-6.7), diabetes mellitus (3.4; 1.3-8.8), and constipation-inducing medications (2.8; 1.1-7.1). Through our analysis, we were able to predict the development of ischemic colitis for the patients with 0, 1, 2, 3, or 4+ risk factors: 8, 21, 55, 79, and 100 percent, respectively.

CONCLUSIONS

Old age, hemodialysis, hypertension, diabetes mellitus, hypoalbuminemia, and constipation-inducing medications are clinically important risk factors for ischemic colitis in patients experiencing lower abdominal discomfort with or without bloody stool. By considering these factors, we were able to predict with high accuracy the development of ischemic colitis.