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Colonic Ischemia: What really matters? Clinical pitfalls in acute management Dr. Stewart Chan Kwong Wah Hospital.

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Presentation on theme: "Colonic Ischemia: What really matters? Clinical pitfalls in acute management Dr. Stewart Chan Kwong Wah Hospital."— Presentation transcript:

1 Colonic Ischemia: What really matters? Clinical pitfalls in acute management Dr. Stewart Chan Kwong Wah Hospital

2 Case Scenario M/31M/31 Good past heathGood past heath Amateur Marathon runnerAmateur Marathon runner Sudden onset left-sided abdominal pain and mild per rectal bleeding after a Marathon raceSudden onset left-sided abdominal pain and mild per rectal bleeding after a Marathon race Episodic pain during training in the preceding 2 monthsEpisodic pain during training in the preceding 2 months

3 PE: afebrile, stable vitalsPE: afebrile, stable vitals Soft abdomen with mild LLQ tendernessSoft abdomen with mild LLQ tenderness PR: small amount of altered bloodPR: small amount of altered blood WCC 16.3WCC 16.3 Amylase / ABG normalAmylase / ABG normal CXR: no free gasCXR: no free gas AXR: no dilated bowelsAXR: no dilated bowels

4 CT: edematous descending colon with pericolic stranding

5 Diagnosis: MILD Ischemic Colitis C Grames and CSB-caban. Case report: Ischemic colitis in an endurance runner. Case Reports in Gastrointestinal Medicine, Vol 2012, Article ID 356895

6 Colonic Ischemia: Why does it matter 3 rd most frequent cause of per-rectal bleeding3 rd most frequent cause of per-rectal bleeding 15% develops life-threatening gangrenous changes15% develops life-threatening gangrenous changes 60% perioperative mortality60% perioperative mortality 30% develops chronic complications30% develops chronic complications Chronic colitis, ulcers, stricture, recurrenceChronic colitis, ulcers, stricture, recurrence Brandt LJ et al. Surg Clin North Am. 1992

7 Colonic ischemia: what really matters 1.20% cases occur in young patients <50 years old 2.Predisposing factors should be actively sought for 3.Right colon involvement carries poor prognosis 4.Colonoscopy is the gold standard for diagnosis 5.20% cases progresses to gangrene formation

8 Colonic ischemia: what really matters 1.20% cases occur in young patients <50 years old 2.Predisposing factors should be actively sought for 3.Right colon involvement carries poor prognosis 4.Colonoscopy is the gold standard for diagnosis 5.20% cases progresses to gangrene formation

9 Predisposing factors should be actively sought for Common predisposing factorsCommon predisposing factors Shock from any causesShock from any causes Colonic obstruction: volvulus, stenotic tumour, strictureColonic obstruction: volvulus, stenotic tumour, stricture Post-operative: e.g. aortic surgeryPost-operative: e.g. aortic surgery 2% after endovascular repair; 7% after open repair2% after endovascular repair; 7% after open repair Cardiovascular diseases: AF, DM, HT, hyperlipidemia, heart failure, chronic renal failure, peripheral vascular diseasesCardiovascular diseases: AF, DM, HT, hyperlipidemia, heart failure, chronic renal failure, peripheral vascular diseases Hurwitz et al. Surg Gynae Obstet 1960 Brewster et al. Surgery 1991

10 100% predictive of ischemic colitis when symptoms of per rectal bleeding and lower abdominal pain are associated with 4 or more of the risk factors100% predictive of ischemic colitis when symptoms of per rectal bleeding and lower abdominal pain are associated with 4 or more of the risk factors Age >60Age >60 HemodialysisHemodialysis HypertensionHypertension DMDM HypoalbuminemiaHypoalbuminemia ConstipationConstipation Park CJ et al. Dis Colon Rectum 2007

11 In 10% cases, a predisposing factor is readily identifiable on admissionIn 10% cases, a predisposing factor is readily identifiable on admission Go search for predisposing factors when they are apparently absentGo search for predisposing factors when they are apparently absent Cardiac workup (ECG, Holter, ECHO)Cardiac workup (ECG, Holter, ECHO) An embolic source is present in 1/3 cases of ischemic colitisAn embolic source is present in 1/3 cases of ischemic colitis Young patients: OCPs, cocaine, strenuous exercises, underlying coagulopathies and vasculitidesYoung patients: OCPs, cocaine, strenuous exercises, underlying coagulopathies and vasculitides Hourmand-Ollivier I et al. Am J Gastroenterol 2003

12 Colonic ischemia: what really matters 1.20% cases occur in young patients <50 years old 2.Predisposing factors should be actively sought for 3.Right colon involvement carries poor prognosis 4.Colonoscopy is the gold standard for diagnosis 5.20% cases progresses to gangrene formation

13 Right colonic involvement carries poor prognosis Most cases affect the left colon; 25% cases involves right colon as wellMost cases affect the left colon; 25% cases involves right colon as well Right colonic involvement carries 2x higher mortality (23%) and 5x higher risk requiring laparotomy (60%)Right colonic involvement carries 2x higher mortality (23%) and 5x higher risk requiring laparotomy (60%) Need to rule out acute mesenteric ischemiaNeed to rule out acute mesenteric ischemia Associates with general hypoperfusion state, NSAID useAssociates with general hypoperfusion state, NSAID use Red flags Red flags Right sided abdominal pain Right sided abdominal pain Absence of per rectal bleeding Absence of per rectal bleeding Severe pain out of proportion to the tenderness Severe pain out of proportion to the tenderness Huguier M, et al. Am J Surg 2006 Sotiriadis J et al. Am J Gastroenterol 2007

14 Colonic ischemia: what really matters 1.20% cases occur in young patients <50 years old 2.Predisposing factors should be actively sought for 3.Right colon involvement carries poor prognosis 4.Colonoscopy is the gold standard for diagnosis 5.20% cases progresses to gangrene formation

15 Colonoscopy is the gold standard in diagnosis Mild: erythematous and edematous mucosa; ecchymosis; petechiae and erosions <1cmMild: erythematous and edematous mucosa; ecchymosis; petechiae and erosions <1cm Endoscopic classification and clinical course of ischemic colitis. Toursarkissian & Thompson

16 Colonic “single-strip” signColonic “single-strip” sign a longitudinal linear ulcer occurring in mild cases of ischemic colitis, usually over the left colona longitudinal linear ulcer occurring in mild cases of ischemic colitis, usually over the left colon 75% pathological correlation with ischemic colitis75% pathological correlation with ischemic colitis Zuckerman GR et al. Am J Gastroenterol. 2003

17 Moderate: submucosal hemorrhages, hemorrhagic nodules, ulcerationsModerate: submucosal hemorrhages, hemorrhagic nodules, ulcerations Endoscopic classification and clinical course of ischemic colitis. Toursarkissian & Thompson

18 Severe: greyish gangrenous changesSevere: greyish gangrenous changes Endoscopic classification and clinical course of ischemic colitis. Toursarkissian & Thompson

19 Chronic: ulcers with granulation tissue and pseudopolyps; stricturesChronic: ulcers with granulation tissue and pseudopolyps; strictures

20 Endoscopic severity positively correlates with need for surgery and mortalityEndoscopic severity positively correlates with need for surgery and mortality Need for surgery: mild (5%); moderate (7%); severe (57%)Need for surgery: mild (5%); moderate (7%); severe (57%) Mortality: mild (2%); moderate (5%); severe (48%)Mortality: mild (2%); moderate (5%); severe (48%) Friedland S et al. Gastrointest Endosc 2007 M. Lozano-Maya et al. Rev Esp Enferm Dig 2010

21 Early colonoscopy to aid diagnosisEarly colonoscopy to aid diagnosis mucosal changes dissipate within 48 hoursmucosal changes dissipate within 48 hours Contraindicated when peritoneal signs are presentContraindicated when peritoneal signs are present Serial re-examination required to assess progressionSerial re-examination required to assess progression Avoid over-inflation / bowel preparationAvoid over-inflation / bowel preparation Consider use of CO2 insufflationConsider use of CO2 insufflation Green BT. South M ed J 2005 Baixauli J. Cleve Clin J Med 2003

22 CT is usually done at acute presentationCT is usually done at acute presentation Highly sensitive (>95%) but not specificHighly sensitive (>95%) but not specific Detect complications e.g. pneumatosis coli, perforationDetect complications e.g. pneumatosis coli, perforation Delineate the extent of colonic involvementDelineate the extent of colonic involvement Assess patency of major vesselsAssess patency of major vessels

23 What really matters when ordering investigations Barium enema not favored anymoreBarium enema not favored anymore Classical “thumbprint” sign with 75% sensitivity onlyClassical “thumbprint” sign with 75% sensitivity only Contraindicated in suspected gangrene/ perforationContraindicated in suspected gangrene/ perforation Mesenteric angiogram rarely indicatedMesenteric angiogram rarely indicated Only used in severe cases where acute mesenteric ischemia has to be ruled outOnly used in severe cases where acute mesenteric ischemia has to be ruled out

24 Colonic ischemia: what really matters 1.20% cases occur in young patients <50 years old 2.Predisposing factors should be actively sought for 3.Right colon involvement carries poor prognosis 4.Colonoscopy is the gold standard for diagnosis 5.20% cases progresses to gangrene formation

25 20% cases progresses to gangrene formation Up to 85% cases are self-limitingUp to 85% cases are self-limiting Supportive management with bowel rest, fluid resuscitation and antibioticsSupportive management with bowel rest, fluid resuscitation and antibiotics 20% cases progress to gangrenous change which mandates urgent laparotomy20% cases progress to gangrenous change which mandates urgent laparotomy Close monitoring of clinical signs and laboratory results (WCC, HCO3, lactate)Close monitoring of clinical signs and laboratory results (WCC, HCO3, lactate) Indications for laparotomyIndications for laparotomy Signs of sepsis, peritonismSigns of sepsis, peritonism Laboratory / imaging / endoscopic evidence of bowel infarction / perforationLaboratory / imaging / endoscopic evidence of bowel infarction / perforation Gandhi SK et al. Dis Colon Rectum. 1996

26 Issues when performing laparotomyIssues when performing laparotomy Segmental resection of affected bowelSegmental resection of affected bowel Judicious consideration of primary anastomosisJudicious consideration of primary anastomosis Use of intra-operative colonoscopy to assess mucosal conditionUse of intra-operative colonoscopy to assess mucosal condition Resected segment should be opened up and examined to confirm inclusion of healthy colonic marginsResected segment should be opened up and examined to confirm inclusion of healthy colonic margins

27 Colonic ischemia: what really matters 1.20% cases occur in young patients <50 years old 2.Predisposing factors should be actively sought for 3.Right colon involvement carries poor prognosis 4.Colonoscopy is the gold standard for diagnosis 5.20% cases progresses to gangrene formation

28 Thank you C Grames and CSB-caban. Case report: Ischemic colitis in an endurance runner. Case Reports in Gastrointestinal Medicine, Vol 2012, Article ID 356895C Grames and CSB-caban. Case report: Ischemic colitis in an endurance runner. Case Reports in Gastrointestinal Medicine, Vol 2012, Article ID 356895 DC Cohen et al. Marathon-induced ischemic colitis: why running is not always good for you. American Journal of Emergency Medicine (2009) 27, 255.e5-e7DC Cohen et al. Marathon-induced ischemic colitis: why running is not always good for you. American Journal of Emergency Medicine (2009) 27, 255.e5-e7 CJ O’Neill, J Gan. Ischemic colitis in an ironman triathlete: A case report and review of the literature. Surgical Practice (2008), 12, 71-72CJ O’Neill, J Gan. Ischemic colitis in an ironman triathlete: A case report and review of the literature. Surgical Practice (2008), 12, 71-72 F Paterno, WE Longo. Ischemic colitis: risk factors for eventual surgery. The American Journal of Surgery (2010) 200l 646-650F Paterno, WE Longo. Ischemic colitis: risk factors for eventual surgery. The American Journal of Surgery (2010) 200l 646-650 C Reissfelder, M Koch et al. Ischemic colitis: Who will survive? Surgery (April 2011) Vol 149 Number 4C Reissfelder, M Koch et al. Ischemic colitis: Who will survive? Surgery (April 2011) Vol 149 Number 4 C Ryan, John RT, et al. Is Ischemic Colitis Ischemic? Diseases of the Colon & Rectum (March 2011), Vol 54(3), pp 370-373C Ryan, John RT, et al. Is Ischemic Colitis Ischemic? Diseases of the Colon & Rectum (March 2011), Vol 54(3), pp 370-373 PM Glauser, CA Maurer et al. Ischemic Colitis: clinical presentation, localization in relation to risks factors, and long-term results. World J Surg (2011) 35:2549-2554PM Glauser, CA Maurer et al. Ischemic Colitis: clinical presentation, localization in relation to risks factors, and long-term results. World J Surg (2011) 35:2549-2554 JA Bailey, WE Longo et al. Endovascular Treatment of Segmental Ischemic Colitis.Digestive Diseases and Sciences (April 2005) Vol 50, Number 4, pp 774-779JA Bailey, WE Longo et al. Endovascular Treatment of Segmental Ischemic Colitis.Digestive Diseases and Sciences (April 2005) Vol 50, Number 4, pp 774-779 T Mohanapriya et al. Ischemic Colitis. Indian J Surg (September-October 2012) 74(5): 396-400T Mohanapriya et al. Ischemic Colitis. Indian J Surg (September-October 2012) 74(5): 396-400


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