COLONIC ISCHEMIA AS AN EARLY MARKER OF ACUTE MESENTERIC ISCHEMIA
Introduction: Acute mesenteric ischemia (AMI) and colonic ischemia (CI) may be quite intricate and appear in the same patient simultaneously or in different time frames. However, in the majority of patients with CI a specific occlusive vascular lesion cannot be identified, as opposed to AMI. According to the American College of Gastroenterology (ACG), CT angiography should be performed in all patients with severe CI in order to exclude AMI. The main purposes of this study were to stratify CI severity to determine if there was an association with the presence of AMI, and to identify determinants of AMI in severe CI.
Methods: The clinical data of all patients admitted with the diagnosis of CI from 2010 to 2014 were retrospectively reviewed.
Results: A total of 241 patients were included, 213 with isolated CI and 28 with CI+AMI. CI was stratified according to ACG severity classification. No cases of concomitant AMI were found in mild CI, 1.5% of patients with moderate CI and 56.8% of patients with severe CI had simultaneously AMI. The severe isolated CI was compared with the severe CI+AMI group. Hematochezia was found more frequently in isolated CI (p<0.001) whereas constipation and isolated right CI were more common in the CI+AMI group (p=0,021). At admission haemoglobin level was significantly higher in the CI+AMI (13.8±1.9 Vs 11.4±2.2; p<0.001) as was lactate level (7.6±4.6 Vs 2.4±1.3; p=0.001). Atrial fibrillation, coronary disease and isolated right colon ischemia were more common in the CI+AMI group (p<0.05). Other clinical findings were evaluated with no significant difference between groups.
Conclusions: The knowledge of an association between CI and AMI prompts to look for underlying occlusive disease in patients with severe CI. Our results based on the analysis of 241 patients with CI support the ACG recommendation for CT angiography in all patients with severe CI. Elevated lactate level, right isolated CI, atrial fibrillation and coronary disease are predictors of AMI in patients with severe CI in this study.
2. Anatomic patterns, patient characteristics, and clinical outcomes in ischemic colitis: a study of 313 cases supported by histology. Brandt, LJ; Feuerstadt, P; Blaszka,M; Am J Gastroenterol; 2010; 105(10):2245–52;
3. Epidemiology, clinical features, high risk factors, and outcome of acute large bowel ischemia. Longstreth, GF: Yao, JF; Clin Gastroenterol Hepatool; 2009 Oct;7(10):1075-80.e1–2;
4. A population-based study of incidence, risk factors, clinical spectrum, and outcomes of ischemic colitis. Yadav, S; Dave,M; Edakkanambeth, V; et.al. Clin Gastroenterol Hepatol. 2015 Apr;13(4):731-8.e1–6;
5. Clinical patterns and outcomes of ischaemic colitis: results of the working group for the study of ischamic colitis in Spain. Montoro, MA; Brandt,LJ; Santolaria,S; et.al. Scand J Gastroenterol. 2011 Feb;46(2):236–46.
6. Ischemic colitis: risk factors for eventual surgery. Paterno, F; McGillicuddy EA; Schuster KM; et.al. Am J Surg.
7. Risk factors associated with the developmentof ischemic colitis. Fernandez, C; Núñez, L; González, E; et.al. World J Gastroenterol. 2010 Nov;200(5):646–50.
8. Epidemiology, risk and prognostic factors in mesenteric venous thrombosis. Acosta, S; Alhadad A, Svensson P; et.al. Br J Surg. 2008 Oct;95(10):1245–51.
9. A population-based study of incidence, risk factors, clinical spectrum, and outcomes of ischemic colitis. Yadav, S; Dave,M; Edakkanambeth, V; et.al. Clin Gastroenterol Hepatol. 2015 Apr;13(4):731-8.e1-6;
10. Acute intestinal ischaemia. Lock, G. Best Pract Res Clin Gastroenterol. 2001 Feb;15(1):83–98.
11. AGA technical review on intestinal ischemia. Brandt, LJ; Boley, SJ; Gastroenterology. 2000 May;118(5):954–68.
12. Colonic ischemia. Greewald, DA; Brandt, LJ; J Clin Gastroenterol. 1998 Sep;27(2):122–8.
13. Cecal necrosis: infrequent variant os ischemic colitis. Report of five cases. Scheler, JG; Hudlin, MM; Dis Colon Rectum. 2000 May;43(5):708–12.
14. ACG Clinical Guideline: Epidemiology, Risk Factors, Patterns of Presentation, Diagnosis, and Management of Colon Ischemia (CI). Brandt, LJ; Feuerstadt, P; Longstreth, GF; et.al. Am J Gastroenterol. 2015 Jan;110(1):18–44;
15. Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis. Flobert, C. Cellier, C; Berger,A; et.al. Am J Gastroenterol. 2000 Jan;95(1):195–8.
16. Epidemiology, clinical features, high-risk factors and outcome of acute large bowel ischemia. Longstreth, G; Yao, JF; Clin Gastroenterol Hepatol. 2009 Oct;7(10):1075–80
17. ESTES guidelines: acute mesenteric ischaemia. Tilsed, JVT; Casamassima, A; Kurihara,H; et.al. Eur J Trauma Emerg Surg. 2016 Apr;42(2):253–70.
18. Editor's Choice — Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). Bjorck M, Koelemay M, Acosta S, European journal of vascular and endovascular surgery. 2017;53(4):460–510