Presentation is loading. Please wait.

Presentation is loading. Please wait.

Colonic Ischemia - A Diagnostic Challenge Joint Hospital Surgical Grand Round Dr. Nerissa Mak Department of Surgery North District Hospital.

Similar presentations


Presentation on theme: "Colonic Ischemia - A Diagnostic Challenge Joint Hospital Surgical Grand Round Dr. Nerissa Mak Department of Surgery North District Hospital."— Presentation transcript:

1 Colonic Ischemia - A Diagnostic Challenge Joint Hospital Surgical Grand Round Dr. Nerissa Mak Department of Surgery North District Hospital

2 Why is it difficult to diagnose? Uncommon Uncommon – –incidence rate of 7.2 per 100,000 person- years in the general population 1 Non-specific Insidious Up to 85% of patients completely resolving their illness within 1-2 days 2 1. Cole JA, et al. Am J Gastroenterol 2004;99: Williams, Lester F. et al. Ann of Sur. 182(4): , October 1975

3 Why is it difficult to diagnose? Uncommon Uncommon incidence rate of 7.2 per 100,000 person- years in the general population 1 Non-specific Insidious Up to 85% of patients completely resolving their illness within 1-2 days 2 1. Cole JA, et al. Am J Gastroenterol 2004;99: Williams, Lester F. et al. Ann of Sur. 182(4): , October 1975

4 Why is it difficult to diagnose? Uncommon incidence rate of 7.2 per 100,000 person- years in the general population 1 Non-specific Insidious – –80 -85% of patients completely resolving their illness within 1-2 days 2 1. Cole JA, et al. Am J Gastroenterol 2004;99: Williams, Lester F. et al. Ann of Sur. 182(4): , October 1975

5 Why is it important? % Gangrenous ischemia % Gangrenous ischemia –50 -75% mortality even after surgical resection 1 20% chronic colitis 20% chronic colitis Recurrent bacteremia or persistent fever even without GI symptoms 2 Recurrent bacteremia or persistent fever even without GI symptoms 2 Misdiagnosed as inflammatory bowel disease Misdiagnosed as inflammatory bowel disease Responds poorly to immunosuppressive therapy Responds poorly to immunosuppressive therapy Increased risk of perforation on steroids Increased risk of perforation on steroids 1.Parish KL, et al. Am Surg 1991 Feb;57(2): Cappell MS, Gastroenterol Clin North Am 1998 Dec;27(4):827-60, vi

6 Why is it important? % Gangrenous ischemia % Gangrenous ischemia % mortality even with surgical resection % mortality even with surgical resection 1 20% chronic colitis 20% chronic colitis –Symptomatic stricture, bloody diarrhoea –Recurrent bacteremia or persistent fever even without GI symptoms 2 Misdiagnosed as inflammatory bowel disease Misdiagnosed as inflammatory bowel disease Responds poorly to immunosuppressive therapy Responds poorly to immunosuppressive therapy Increased risk of perforation on steroids Increased risk of perforation on steroids 1.Parish KL, et al. Am Surg 1991 Feb;57(2): Cappell MS, Gastroenterol Clin North Am 1998 Dec;27(4):827-60, vi

7 Why is it important? % Gangrenous ischemia % Gangrenous ischemia % mortality even with surgical resection % mortality even with surgical resection 1 20% chronic colitis 20% chronic colitis Recurrent bacteremia or persistent fever even without GI symptoms 2 Recurrent bacteremia or persistent fever even without GI symptoms 2 Misdiagnosed as inflammatory bowel disease Misdiagnosed as inflammatory bowel disease –Responds poorly to immunosuppressive therapy –Increased risk of perforation on steroids

8 How to diagnose?

9 No widely accepted diagnostic criteria Colonic Ischemia - A Diagnostic Challenge Xiaoping Zou, et al. Dig Dis Sci (2009) 54:2009 – 2015 Clinical Symptoms Radiological Findings Endoscopic Findings

10 Classical triad: Classical triad: –Crampy abdominal pain –Diarrhoea –Hematochezia Clinical Symptoms Reinus JF, et al. Gastroenterol Clin North Am l990;19: Any precipitating factors or risk factors?

11 Profound Shock 1 Profound Shock 1 Vascular Vascular –Iatrogenic 2 –Major artery occlusion –Venous thrombosis Inflammatory Inflammatory Hypercoagulable states Hypercoagulable states –Small artery occlusion Atherosclerotic, diabetes Atherosclerotic, diabetes Vasculitis Vasculitis Colonic obstruction/ dilatation Colonic obstruction/ dilatation –Mechanical –Pseudo-obstruction Medications Medications Others (airplane flights, marathon running) Others (airplane flights, marathon running) Etiology for Ischemic Colitis 1.Gandhi SK, et al. Dis Colon Rectum 1996;39: Zelenock GB, et al. Surgery 1989;106:771-9

12 Profound Shock 1 Profound Shock 1 Vascular Vascular –Iatrogenic 2 –Major artery occlusion –Venous thrombosis Inflammatory Inflammatory Hypercoagulable states Hypercoagulable states –Small artery occlusion Atherosclerotic, diabetes Atherosclerotic, diabetes Vasculitis Vasculitis Colonic obstruction/ dilatation Colonic obstruction/ dilatation –Mechanical –Pseudo-obstruction Medications Medications Others (airplane flights, marathon running) Others (airplane flights, marathon running) Etiology for Ischemic Colitis 1.Gandhi SK, et al. Dis Colon Rectum 1996;39: Zelenock GB, et al. Surgery 1989;106:771-9

13 Profound Shock 1 Profound Shock 1 Vascular Vascular –Iatrogenic 2 –Major artery occlusion –Venous thrombosis Inflammatory Inflammatory Hypercoagulable states Hypercoagulable states –Small artery occlusion Atherosclerotic, diabetes Atherosclerotic, diabetes Vasculitis Vasculitis Colonic obstruction/ dilatation Colonic obstruction/ dilatation –Mechanical –Pseudo-obstruction Medications Medications Others (airplane flights, marathon running) Others (airplane flights, marathon running) Etiology for Ischemic Colitis 1.Gandhi SK, et al. Dis Colon Rectum 1996;39: Zelenock GB, et al. Surgery 1989;106:771-9

14 Profound Shock 1 Profound Shock 1 Vascular Vascular –Iatrogenic 2 –Major artery occlusion –Venous thrombosis Inflammatory Inflammatory Hypercoagulable states Hypercoagulable states –Small artery occlusion Atherosclerotic, diabetes Atherosclerotic, diabetes Vasculitis Vasculitis Colonic obstruction/ dilatation Colonic obstruction/ dilatation –Mechanical –Pseudo-obstruction Medications Medications Others (airplane flights, marathon running) Others (airplane flights, marathon running) Etiology for Ischemic Colitis 1.Gandhi SK, et al. Dis Colon Rectum 1996;39: Zelenock GB, et al. Surgery 1989;106:771-9

15 Suspected for ischemic colitis if Suspected for ischemic colitis if –older than 60 –Hemodialysis –Hypertension –Hypoalbuminemia –diabetes mellitus –constipation-inducing medications The presence of four or more risk factors was 100 percent predictive of ischemic colitis. The presence of four or more risk factors was 100 percent predictive of ischemic colitis. Risk factors for ischemic colitis Park CJ, et al. Dis Colon Rectum Feb;50(2):232-8.

16 High index of suspicious High index of suspicious – Typical presentations – Vulnerable history e.g. shock or post AAA repair; ESRF on hemodialysis e.g. shock or post AAA repair; ESRF on hemodialysis – Elderly with cardiovascular disease Clinical Symptoms

17 AXR AXR Barium enema Barium enema CT CT Angiography Angiography Radiological Findings

18 Jordan H. Wolff, et al. J Clin Gastroenterol 2008;42:472 – 475 AXR

19 Insensitive and nonspecific In one series, abnormal findings were present in 21% of patients Rapid identification of perforation or intestinal obstruction Wolf EL, et al. Surg Clin North Am 1992;72: AXR

20 Greenwald, David A, et al. Jn of Clin Gastroent 1998: 27(2), pp Barium enema

21 The most useful diagnostic test before the era of colonoscopy – –suggestive findings in up to 75% of patients Colonoscopy is now the gold standard Higher sensitivity to detect mucosal injury Able to take biopsy Residual contrast of barium enema makes visualization obscure when arteriography or endoscopy is later used Scholz FJ. Radiol Clin North Am 1993;31: Sreenarasimhaiah J. BMJ. 2003;326:1372 – 1376 Barium enema

22 The most useful diagnostic test before the era of colonoscopy suggestive findings in up to 75% of patients Colonoscopy is now the gold standard – –Higher sensitivity to detect mucosal injury – –Able to take biopsy – –Residual contrast of barium enema makes visualization obscure when arteriography or endoscopy is later used Scholz FJ. Radiol Clin North Am 1993;31: Sreenarasimhaiah J. BMJ. 2003;326:1372 – 1376 Barium enema

23 Karen M. Horton, et al. Radiographics 2000:3; 20: CT

24 Y Sumitomo, et al. J of Gastroentro and Hepato 22 (2007) 134 Jordan H. Wolff, et al. J Clin Gastroenterol 2008;42:472 – 475 CT

25 Not specific for ischemic colitis Initial investigation of choice – –Non- invasive – –Rule out other DDx – –More extra-luminal information Esp vascular occlusion on CTA Philpotts LE, et al. Radiology. 1994;190:445 – 449. CT

26 Angiography Usually NOT indicate in ischemic colitis – –Majority of ischemic colitis are non- occlusive disease Guttormson NL, et al. Dis Col Rect 1989;32:

27 Angiography Exception – –? Acute mesenteric ischemia – –in Isolated Right Colon Ischemia Associated with occlusion of the SMA mortality rates >50% mortality rates >50% Tendler DA. Semin Gastrointest Dis 2003;4:66-16

28 The gold standard of diagnosis Features suggestive of ischemic colitis Features suggestive of ischemic colitis – –segmental involvement – –abrupt transition between normal and affected mucosa – –rectal sparing –within 5-7 days –rapid resolution within 5-7 days Sreenarasimhaiah J. Curr Gastroenterol Rep. 2005;7:421 – 426 Su C, et al. Am J Gastroenterol 1998;93: Colonoscopy

29 Transient ischemic colitis Xiaoping Zou, et al. Dig Dis Sci 2009:54; 2009 – 2015 Patchy edematous & Erythematous mucosa longitudinal ulcerations petechial hemorrhages interspersed with pale areas

30 Severe ischemic colitis Xiaoping Zou, et al. Dig Dis Sci 2009:54; 2009 – 2015 Cyanotic, scattered ulcerations pseudomembranes pseudopolyps

31 Severe ischemic colitis Xiaoping Zou, et al. Dig Dis Sci 2009:54; 2009 – 2015 Greenwald, David A, et al. Jn of Clin Gastroent 1998: 27(2), pp Pseudotumor Gangrene in dusky background

32 Stricture of ischemic colitis Xiaoping Zou, et al. Dig Dis Sci 2009:54; 2009 – 2015 Greenwald, David A, et al. Jn of Clin Gastroent 1998: 27(2), pp Lumen stricture & mucosa granularity Stricture mimicking a neoplasm

33 The gold standard of diagnosis –Invasive –As initial investigation in selected cases Highly suspicious of acute ischemic colitis with no peritoneal sign Highly suspicious of acute ischemic colitis with no peritoneal sign Suspicious of chronic colitis Suspicious of chronic colitis Endoscopic Findings

34 Take home message … Think of it Think of it –High risks group –Recurrent disease Look for it Look for it – Combination of clinical features, radiological & endoscopic findings –Acute and chronic colitis

35 Q&A

36 3

37 Gastroenterology May; 118(5):

38 2

39 © 1999 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.11 FIG. 8 FIG. 8. Ischemic colitis in sigmoid colon, characterized by superficial mucosal necrosis with sloughing, crypt atrophy, and mild fibrosis. The morphologic features are similar to those seen in pseudomembranous colitis. The clinical history of this case (cerebrovascular accident in an elderly woman) and the presence of crypt atrophy and mild fibrosis support a diagnosis of ischemic colitis.

40

41 Tx – emergent surgery Despite conservative management, still 20% of patients with ischemic colitis will require surgery because of peritonitis or clinical deterioration (1) – –At laparotomy, all affected bowel should be resected, and the mucosa of the specimen should be examined to ensure normal surgical margins – –Questionably viable areas of colon are generally resected unless extensive areas of small and large bowel are affected, in which case these areas are left intact and a second-look operation is planned 12 to 24 hours later (2) – –Primary anastomosis is usually not performed because of the risk of anastomotic leaks – –A colostomy is formed with the proximal colonic loop and the distal loop is either exteriorized as a mucous fistula or closed to form a Hartman pouch Despite resection, the mortality rates exceed 50% in those with infarcted bowel (3)

42 Tx – elective operation Those with a persistent unhealed segment of diseased colon may develop frequent fevers or recurrent sepsis, even in the absence of symptoms referable to the colon; such patients should be treated with resection of the diseased bowel. (1) Those with a persistent unhealed segment of diseased colon may develop frequent fevers or recurrent sepsis, even in the absence of symptoms referable to the colon; such patients should be treated with resection of the diseased bowel. (1) Patients with persistent diarrhea, bleeding, or protein-losing colonopathy of more than 2 weeks' duration are at increased risk of perforation and should also have the diseased bowel resected. Patients with persistent diarrhea, bleeding, or protein-losing colonopathy of more than 2 weeks' duration are at increased risk of perforation and should also have the diseased bowel resected. Patients with episodes of silent ischemia leading to segmental ulcerating colitis often are misdiagnosed as having inflammatory bowel disease. In this setting, response to steroid therapy typically is poor, and use of steroids in such patients may be associated with an increased risk of perforation. Patients with episodes of silent ischemia leading to segmental ulcerating colitis often are misdiagnosed as having inflammatory bowel disease. In this setting, response to steroid therapy typically is poor, and use of steroids in such patients may be associated with an increased risk of perforation. Patients who have unyielding symptoms despite medical therapy require a segmental resection. Patients who have unyielding symptoms despite medical therapy require a segmental resection. In general, recurrence does not follow resection. In general, recurrence does not follow resection.

43 Outcome Prognosis typically is favorable, with a majority of patients completely resolving their illness within 24 to 48 hours Prognosis typically is favorable, with a majority of patients completely resolving their illness within 24 to 48 hours –And complete clinical and roentgenographic resolution occurs within 2 weeks. A minority go on to develop irreversible injury A minority go on to develop irreversible injury –manifests as gangrene and perforation, universal fulminant colitis*, stricture, or chronic segmental colitis –Ischemic strictures that produce no symptoms should be observed, and some will return to normal in 12 to 24 months with no specific therapy –if symptoms of obstruction develop, segmental resection is required.

44 Case 1 76/F 76/F Presented with symptomatic AAA with endovascular repair done Presented with symptomatic AAA with endovascular repair done c/o colicky abdominal pain 1 week after the operation c/o colicky abdominal pain 1 week after the operation –Associated with bloody diarrrhoea PE showed mild tenderness over LLQ, no peritoneal sign PE showed mild tenderness over LLQ, no peritoneal sign –PR: bright red blood Sigmoidoscopy: confirmed ischaemic colitis Sigmoidoscopy: confirmed ischaemic colitis Conservative therapy was initiated Conservative therapy was initiated –Developed peritoneal sign on day 25 Open left hemicolectomy with colostomy was done Open left hemicolectomy with colostomy was done The patient developed multiple organ failure and died after 2 months. The patient developed multiple organ failure and died after 2 months. Nevelsteen I, et al. Acta Chir Belg Sep-Oct;106(5):

45 Case 2 20/M 20/M Presented with colicky abdominal pain and bloody diarrhoea for 1 day Presented with colicky abdominal pain and bloody diarrhoea for 1 day –Cocaine use 8 hours before the onset of symptoms PE showed diffuse tenderness with no peritoneal sign PE showed diffuse tenderness with no peritoneal sign –PR: bright red blood AXR: non specific gas pattern AXR: non specific gas pattern CT abdomen with contrast: mucosal thickening of the descending colon CT abdomen with contrast: mucosal thickening of the descending colon Colonoscopy & biopsy: ischemic colitis of left colon Colonoscopy & biopsy: ischemic colitis of left colon Managed conservatively Managed conservatively –Symptoms subsided gradually Discharged on day 3 Discharged on day 3 Jeffery D. Linder, et al. South Med Jn 2000:9; 93:

46 ?virtual colonoscopy

47


Download ppt "Colonic Ischemia - A Diagnostic Challenge Joint Hospital Surgical Grand Round Dr. Nerissa Mak Department of Surgery North District Hospital."

Similar presentations


Ads by Google