Epidemiology, Clinical Features, High-Risk Factors, and Outcome of Acute Large Bowel Ischemia

doi:10.1016/j.cgh.2009.05.026

Clinical Gastroenterology and Hepatology

Volume 7, Issue 10, October 2009, Pages 1075-1080.e2

https://doi.org/10.1016/j.cgh.2009.05.026 Get rights and content

Background & Aims

Only a limited amount of important information is available on acute lower bowel ischemia (ALBI). We investigated the epidemiology, clinical aspects, high-risk factors, and outcome of ALBI.

Methods

We retrospectively analyzed data collected from 401 patients with 424 hospitalizations with ALBI in a prepaid health system for 7 years.

Results

The estimated annual incidence of ALBI was 15.6/100,000 patient-years (22.6 female, 8.0 male), with a marked age-related increase. ALBI preceded 400 admissions (94%) and followed surgery or medical admission of 24 patients (6%); 307 (72%) had rectal bleeding and abdominal pain. In 417 episodes, left-sided or transverse (368, 88%) exceeded right-sided or bilateral ALBI (49, 12%). Thirty-one patients (8%) had resection; 15 died (4%). Factors that were independently associated with resection and/or death included right-sided or bilateral distribution (adjusted odds ratio [AOR], 14.64; 95% confidence interval [CI], 4.82–44.50; P < .001), onset after admission (AOR, 7.48; 95% CI, 2.19–25.54; P < .005), hypotension (AOR, 4.45; 95% CI, 1.18–16.76; P < .05), tachycardia (AOR, 4.40; 95% CI, 1.46–13.26; P < .01), warfarin use (AOR, 4.33; 95% CI, 1.21–15.47; P < .05), antibiotic therapy (AOR, 3.94; 95% CI, 1.23–12.64; P < .05), male sex (AOR, 2.65; 95% CI, 1.00–7.05; P = .05), nonsteroidal anti-inflammatory drug use (AOR, 0.15; 95% CI, 0.04–0.53; P < .005), and rectal bleeding (AOR, 0.24; 95% CI, 0.09–0.65; P < .005). During a mean of 2.6 ± 1.9 years, no patient developed chronic colitis, and 1 (<1%) had stricture dilation. Estimated ALBI recurrence was 3%, 5%, 6%, and 10% at years 1, 2/3, 4, and 5/6, respectively.

Conclusions

ALBI is common and agerelated and predominates in female patients. Demographic and clinical variables predict severe ALBI. Chronic sequelae are rare. Recurrence is substantial.

Section snippets

Population, Hospitals, and Inclusion Criteria

We studied the membership of the San Diego area of the Kaiser Permanente Medical Care Program (KPMCP), a capitated, integrated health care system serving about 500,000 people. Most are treated at the San Diego KPMCP hospital, some are treated at a contract hospital, and fewer are hospitalized elsewhere. In 2007 and 2008, we identified all members ≥20 years of age who were discharged from any hospital from January 1, 2000 to December 31, 2006, with an International Classification of Diseases,

Incidence, Diagnostic Evidence, and Anatomic Distribution

There were 424 hospitalizations among 401 patients (303 women and 98 men); 381 had 1 admission, 17 had 2 admissions, and 3 had 3 admissions. Age was 69 years (25–97). ALBI caused admission in 400 (94%) hospitalizations and developed after surgery or admission for another medical disorder in the remaining 24 (6%): ruptured or elective AAA repair, 9; other vascular surgery, 2; nonvascular surgery, 4; and medical disorders, 9.

The estimated annual incidence rates were 16.4 hospitalizations/100,000

Discussion

This large, population-based study of ALBI provides important epidemiologic and clinical information. Data on incidence, clinical features, history, treatment, hospitalization outcome, and factors predictive of severity expand knowledge. Long-term follow-up allowed novel observations on chronic sequelae and ALBI recurrence.

We found a higher incidence than reported preliminarily from a Minnesota medical records survey¹² and one¹³ of two13, 14 national insurance claims–based surveys.

Case finding

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Ischemic colitis (IC) is a condition that arises when blood flow in the colon is reduced such that it is insufficient for maintaining adequate cellular metabolic function. Microscopic colitis (MC) is a chronic disease characterized by colon mucosa that has a normal appearance on an endoscopy, watery diarrhea, and distinctive histologic features. The pathophysiology of IC is not clearly established. The etiopathogenesis of MC is considered multifactorial and not clearly known; genetic and luminal factors as well as a component of abnormal immune regulation have been described. The symptoms and severity of IC are highly variable, although the classic clinical symptoms consists of abdominal pain, fecal urgency, and, subsequently, rectorrhagia. The most characteristic manifestation of MC is watery diarrhea. The diagnostic test of choice for IC is computed tomography, while for MC it is a colonoscopy with biopsy collection. Most cases of IC require conservative management with a liquid diet, fluid replacement therapy, and empiric antibiotic therapy. In regard to the treatment of MC, drugs with a temporal relationship should be suspended and oral budesonide is the treatment of choice.
A comparison of open or laparoscopic colectomy outcomes for the management of ischemic colitis using the ACS-NSQIP database
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Ischemic colitis is a common manifestation of intestinal ischemia and is potentially a surgical emergency. Although such surgical emergencies were historically approached via open exploration, it is uncertain if there is a role for minimally invasive techniques. This study compares open vs laparoscopic colectomy techniques in the management of ischemic colitis.
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7,928 patients had ischemic colitis with 7,209 undergoing open colectomy and 719 undergoing laparoscopic colectomy. The mortality rate was significantly lower using a laparoscopic approach compared to open (6.4% vs 26%, p=<0.001) and associated with a lower odd of mortality (OR 0.58; 95% CI [0.35, 0.95]). Procedure related reoperation was lower in the laparoscopic group (6.5% vs 11%, p<0.001), but multivariate analysis was not significant (OR 0.65; 95% CI [0.43,1]). Readmission rates were not statistically different (12% vs 10%, p = 0.2). Postoperative length of stay (7 vs 12 days, p=<0.001), septic shock (6.7% vs 27%, p=<0.001), and organ space SSI (3.2% vs 6.9%, p=<0.001) were significantly decreased using a laparoscopic approach.
30-day postoperative mortality was significantly lower using a laparoscopic. Patients that had a laparoscopic colectomy had shorter hospital stays. While patients that underwent laparoscopic procedures tended to be less sick, multivariate analysis showed decreased rates of sepsis and surgical site infections compared to open colectomies when correcting for these factors.
Laparoscopic colectomy may be a better surgical approach for patients with ischemic colitis compared to open colectomy.
A case report of transmural rectosigmoid ischemia in an elderly patient
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While acute colonic ischemia is frequently observed in the elderly, rectal ischemia is a rare occurrence. We presented a case of transmural rectosigmoid ischemia in a patient who had not undergone any significant interventions and had no underlying diseases. Conservative treatment methods were unsuccessful, and surgical resection was necessary to prevent the development of gangrene or sepsis.
Upon arrival at our health center, a 69-year-old man reported experiencing left lower quadrant pain and rectorrhagia. The CT scan revealed thickening in the sigmoid and rectum. Subsequent colonoscopy revealed circumferential ulcers, severe edema, erythema, discoloration, and ulcerative mucosa in both the rectum and sigmoid. Due to persistent severe rectorrhagia and worsening pathologic parameters, another colonoscopy was performed three days later.
Initially, conservative treatments were administered, but as the tenderness worsened, surgical exploration of the abdomen was necessary. During the procedure, a large ischemia from the sigmoid to the rectal dentate line was observed, and the lesion was resected. A stapler was then inserted into the rectum, followed by the use of the Hartman pouch method to deviate the tract. Finally, colectomy, sigmoidectomy, and rectal resection were performed.
Due to the worsening pathological condition of our patient, surgical resection was necessary. It is important to note that rectosigmoid ischemia, although rare, can develop without a known underlying cause. Therefore, it is crucial to consider and evaluate potential causes beyond the most common ones. Furthermore, any pain or rectorragia should be assessed immediately.
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La mayoría de los pacientes con colitis isquémica tienen una evolución favorable; sin embargo, se ha relacionado la localización en el colon derecho con un peor pronóstico. El propósito de este estudio es comparar la presentación clínica y los resultados de la colitis isquémica del colon derecho (CICD) con la colitis isquémica de otros segmentos del colon (no CICD).
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A total of 204 patients were identified, 61 (30%) with CICD; 61% of CICD patients required surgery compared to 22% of non-CICD patients (P < 0.001). Post-surgical mortality (32 vs. 55%) and overall mortality (20 vs. 15%) differences were not statistically significant. CICD patients had more commonly unfavourable outcomes than non-CICD patients (61 vs. 25%, P < 0.001). The odds ratio (OR) for surgery was 5.28 and 4.47 for unfavourable outcomes for patients with CICD.
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: This article has an accompanying continuing medical education activity on page 1023. Learning Objectives—At the end of this activity the learner should understand the most common distribution of colonic ischemia, recognize the differing prognosis based on time of occurrence of acute large bowel ischemia, and appreciate the long-term outcome of acute colonic ischemia.

: To view this article's video abstract, go to the AGA's YouTube Channel.

: Conflicts of interest The authors disclose no conflicts.

: Funding This research was conducted with support from the Investigator-Sponsored Study Program of AstraZeneca.

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Original article—alimentary tractEpidemiology, Clinical Features, High-Risk Factors, and Outcome of Acute Large Bowel Ischemia

Background & Aims

Methods

Results

Conclusions

Section snippets

Population, Hospitals, and Inclusion Criteria

Incidence, Diagnostic Evidence, and Anatomic Distribution

Discussion

Gastroenterology

Gastroenterol Clin N Am

Am J Med

Am J Gastroenterol

Am J Gastroenterol

Am J Gastroenterol

Am J Surg

Am J Gastroenterol

Gastrointest Endosc

Gastroenterology

Ischaemic colitis

Ischemic colitis

Dis Colon Rectum

Risk factors for colon ischemia

Am J Gastroenterol

Assessment of potential risk factors associated with ischemic colitis

Neurogastroenterol Motil

Pharmacologically mediated colon ischemia

Am J Gastroenterol

Aggressive management of nonocclusive ischemic colitis following aortic reconstruction

Arch Surg

Ischemic proctosigmoiditis

Am J Gastroenterol

Systematic review: the epidemiology of ischemic colitis

Aliment Pharmacol Ther

Original article—alimentary tract
Epidemiology, Clinical Features, High-Risk Factors, and Outcome of Acute Large Bowel Ischemia