1 / 28

Colonic Ischemia: What really matters?

Colonic Ischemia: What really matters?. Clinical pitfalls in acute management Dr. Stewart Chan Kwong Wah Hospital. Case Scenario. M/31 Good past heath Amateur Marathon runner Sudden onset left-sided abdominal pain and mild per rectal bleeding after a Marathon race

chelsa
Download Presentation

Colonic Ischemia: What really matters?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


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

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

  3. PE: afebrile, stable vitals • Soft abdomen with mild LLQ tenderness • PR: small amount of altered blood • WCC16.3 • Amylase / ABG normal • CXR: no free gas • AXR: 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 • 3rd most frequent cause of per-rectal bleeding • 15% develops life-threatening gangrenous changes • 60% perioperative mortality • 30% develops chronic complications • Chronic colitis, ulcers, stricture, recurrence Brandt LJ et al. Surg Clin North Am. 1992

  7. Colonic ischemia: what really matters • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 20% cases progresses to gangrene formation

  8. Colonic ischemia: what really matters • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 20% cases progresses to gangrene formation

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

  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 factors • Age >60 • Hemodialysis • Hypertension • DM • Hypoalbuminemia • Constipation Park CJ et al. Dis Colon Rectum 2007

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

  12. Colonic ischemia: what really matters • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 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 well • Right colonic involvement carries 2x higher mortality (23%) and 5x higher risk requiring laparotomy (60%) • Need to rule out acute mesenteric ischemia • Associates with general hypoperfusion state, NSAID use • Red flags • Right sided abdominal pain • Absence of per rectal bleeding • 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 • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 20% cases progresses to gangrene formation

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

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

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

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

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

  20. Endoscopic severity positively correlates with need for surgery and mortality • Need for surgery: mild (5%); moderate (7%); severe (57%) • 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 diagnosis • mucosal changes dissipate within 48 hours • Contraindicated when peritoneal signs are present • Serial re-examination required to assess progression • Avoid over-inflation / bowel preparation • Consider 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 presentation • Highly sensitive (>95%) but not specific • Detect complications e.g. pneumatosis coli, perforation • Delineate the extent of colonic involvement • Assess patency of major vessels

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

  24. Colonic ischemia: what really matters • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 20% cases progresses to gangrene formation

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

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

  27. Colonic ischemia: what really matters • 20% cases occur in young patients <50 years old • Predisposing factors should be actively sought for • Right colon involvement carries poor prognosis • Colonoscopy is the gold standard for diagnosis • 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 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-e7 • CJ O’Neill, J Gan. Ischemic colitis in an ironman triathlete: A case report and review of the literature. Surgical Practice (2008), 12, 71-72 • F 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 4 • C 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) 35:2549-2554 • JA Bailey, WE Longo et al. Endovascular Treatment of Segmental Ischemic Colitis.Digestive Diseases and Sciences (April 2005) Vol 50, Number 4, pp 774-779 • T Mohanapriya et al. Ischemic Colitis. Indian J Surg (September-October 2012) 74(5): 396-400

More Related