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Colonic IschemiaColonic Ischemia - A Diagnostic - A Diagnostic ChallengeChallenge
Joint Hospital Surgical Grand Joint Hospital Surgical Grand RoundRound
Dr. Nerissa MakDr. Nerissa MakDepartment of SurgeryDepartment of SurgeryNorth District HospitalNorth District Hospital
Why is it difficult to Why is it difficult to diagnose?diagnose? UncommonUncommon
– incidence rate of 7.2 per 100,000 person-years in the general population1
Non-specificInsidious
Up to 85% of patients completely resolving their illness within 1-2 days2
1. Cole JA, et al. Am J Gastroenterol 2004;99:486-912. Williams, Lester F. et al. Ann of Sur. 182(4):439-448,
October 1975
Why is it difficult to Why is it difficult to diagnose?diagnose?
UncommonUncommon incidence rate of 7.2 per 100,000
person-years in the general population1
Non-specific Insidious
Up to 85% of patients completely resolving their illness within 1-2 days2
1. Cole JA, et al. Am J Gastroenterol 2004;99:486-912. Williams, Lester F. et al. Ann of Sur. 182(4):439-448,
October 1975
Why is it difficult to Why is it difficult to diagnose?diagnose?
Uncommon incidence rate of 7.2 per 100,000
person-years in the general population1
Non-specific Insidious
– 80 -85% of patients completely resolving their illness within 1-2 days2
1. Cole JA, et al. Am J Gastroenterol 2004;99:486-912. Williams, Lester F. et al. Ann of Sur. 182(4):439-448,
October 1975
Why is it important?Why is it important?
15 -20% 15 -20% Gangrenous ischemiaGangrenous ischemia– 50 -75% mortality even after surgical resection50 -75% mortality even after surgical resection11
20% chronic colitis20% chronic colitis Recurrent bacteremia or persistent fever even Recurrent bacteremia or persistent fever even
without GI symptomswithout GI symptoms22
Misdiagnosed as inflammatory bowel Misdiagnosed as inflammatory bowel diseasedisease Responds poorly to immunosuppressive therapyResponds poorly to immunosuppressive therapy
Increased risk of perforation on steroidsIncreased risk of perforation on steroids
1. Parish KL, et al. Am Surg 1991 Feb;57(2):118-212. Cappell MS, Gastroenterol Clin North Am 1998 Dec;27(4):827-60, vi
Why is it important?Why is it important? 15 -20% Gangrenous ischemia15 -20% Gangrenous ischemia
50 -75% mortality even with surgical 50 -75% mortality even with surgical resectionresection11
20% 20% chronic colitischronic colitis– Symptomatic stricture, bloody diarrhoeaSymptomatic stricture, bloody diarrhoea– Recurrent bacteremia or persistent fever Recurrent bacteremia or persistent fever
even without GI symptomseven without GI symptoms22
Misdiagnosed as inflammatory bowel Misdiagnosed as inflammatory bowel diseasedisease Responds poorly to immunosuppressive Responds poorly to immunosuppressive
therapytherapy Increased risk of perforation on steroidsIncreased risk of perforation on steroids1. Parish KL, et al. Am Surg 1991 Feb;57(2):118-21
2. Cappell MS, Gastroenterol Clin North Am 1998 Dec;27(4):827-60, vi
Why is it important?Why is it important?
15 -20% Gangrenous ischemia15 -20% Gangrenous ischemia 50 -75% mortality even with surgical resection50 -75% mortality even with surgical resection11
20% chronic colitis20% chronic colitis Recurrent bacteremia or persistent fever even Recurrent bacteremia or persistent fever even
without GI symptomswithout GI symptoms22
Misdiagnosed as inflammatory bowel Misdiagnosed as inflammatory bowel diseasedisease– Responds poorly to immunosuppressive Responds poorly to immunosuppressive
therapytherapy– Increased risk of perforation on steroidsIncreased risk of perforation on steroids
How to diagnose?How to diagnose?
No widely accepted diagnostic No widely accepted diagnostic criteriacriteria
Colonic IschemiaColonic Ischemia - A Diagnostic - A Diagnostic ChallengeChallenge
Xiaoping Zou, et al. Dig Dis Sci (2009) 54:2009–2015
Clinical Symptoms
Radiological Findings
Endoscopic Findings
Classical triad: Classical triad: – Crampy abdominal painCrampy abdominal pain– DiarrhoeaDiarrhoea– HematocheziaHematochezia
Clinical Symptoms
Reinus JF, et al. Gastroenterol Clin North Am l990;19:319-343
Any precipitating factors or risk
factors?
Profound ShockProfound Shock11
Vascular Vascular – IatrogenicIatrogenic22
– Major artery occlusionMajor artery occlusion– Venous thrombosisVenous thrombosis
InflammatoryInflammatory Hypercoagulable states Hypercoagulable states
– Small artery occlusionSmall artery occlusion Atherosclerotic, diabetesAtherosclerotic, diabetes VasculitisVasculitis
Colonic obstruction/ dilatationColonic obstruction/ dilatation– MechanicalMechanical– Pseudo-obstruction Pseudo-obstruction
MedicationsMedications Others (airplane flights, marathon running)Others (airplane flights, marathon running)
Etiology for Ischemic Colitis
1. Gandhi SK, et al. Dis Colon Rectum 1996;39:88-100
2. Zelenock GB, et al. Surgery 1989;106:771-9
Profound ShockProfound Shock11
Vascular Vascular – IatrogenicIatrogenic22
– Major artery occlusionMajor artery occlusion– Venous thrombosisVenous thrombosis
InflammatoryInflammatory Hypercoagulable states Hypercoagulable states
– Small artery occlusionSmall artery occlusion Atherosclerotic, diabetesAtherosclerotic, diabetes VasculitisVasculitis
Colonic obstruction/ dilatationColonic obstruction/ dilatation– MechanicalMechanical– Pseudo-obstruction Pseudo-obstruction
MedicationsMedications Others (airplane flights, marathon running)Others (airplane flights, marathon running)
Etiology for Ischemic Colitis
1. Gandhi SK, et al. Dis Colon Rectum 1996;39:88-100
2. Zelenock GB, et al. Surgery 1989;106:771-9
Profound ShockProfound Shock11
Vascular Vascular – IatrogenicIatrogenic22
– Major artery occlusionMajor artery occlusion– Venous thrombosisVenous thrombosis
InflammatoryInflammatory Hypercoagulable states Hypercoagulable states
– Small artery occlusionSmall artery occlusion Atherosclerotic, diabetesAtherosclerotic, diabetes VasculitisVasculitis
Colonic obstruction/ dilatationColonic obstruction/ dilatation– MechanicalMechanical– Pseudo-obstruction Pseudo-obstruction
MedicationsMedications Others (airplane flights, marathon running)Others (airplane flights, marathon running)
Etiology for Ischemic Colitis
1. Gandhi SK, et al. Dis Colon Rectum 1996;39:88-100
2. Zelenock GB, et al. Surgery 1989;106:771-9
Profound ShockProfound Shock11
Vascular Vascular – IatrogenicIatrogenic22
– Major artery occlusionMajor artery occlusion– Venous thrombosisVenous thrombosis
InflammatoryInflammatory Hypercoagulable states Hypercoagulable states
– Small artery occlusionSmall artery occlusion Atherosclerotic, diabetesAtherosclerotic, diabetes VasculitisVasculitis
Colonic obstruction/ dilatationColonic obstruction/ dilatation– MechanicalMechanical– Pseudo-obstruction Pseudo-obstruction
MedicationsMedications Others (airplane flights, marathon running)Others (airplane flights, marathon running)
Etiology for Ischemic Colitis
1. Gandhi SK, et al. Dis Colon Rectum 1996;39:88-100
2. Zelenock GB, et al. Surgery 1989;106:771-9
Suspected for ischemic colitis if Suspected for ischemic colitis if – older than 60older than 60– HemodialysisHemodialysis– HypertensionHypertension– HypoalbuminemiaHypoalbuminemia– diabetes mellitusdiabetes mellitus– constipation-inducing medications constipation-inducing medications
The presence of The presence of four or more risk four or more risk factorsfactors was was 100 percent predictive100 percent predictive of of ischemic colitis.ischemic colitis.
Risk factors for ischemic colitis
Park CJ, et al. Dis Colon Rectum. 2007 Feb;50(2):232-8.
High index of suspiciousHigh index of suspicious– Typical presentationsTypical presentations– Vulnerable history Vulnerable history
e.g. shock or post AAA repair; ESRF on e.g. shock or post AAA repair; ESRF on hemodialysishemodialysis
– Elderly with cardiovascular disease Elderly with cardiovascular disease
Clinical Symptoms
AXRAXR Barium enemaBarium enema CTCT AngiographyAngiography
Radiological Findings
Jordan H. Wolff, et al. J Clin Gastroenterol 2008;42:472–475
AXR
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;72:107-124
AXR
Greenwald, David A, et al. Jn of Clin Gastroent 1998: 27(2), pp 122-128
Barium enema
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: 1197-1218Sreenarasimhaiah J. BMJ. 2003;326:1372–1376
Barium enema
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: 1197-1218Sreenarasimhaiah J. BMJ. 2003;326:1372–1376
Barium enema
Karen M. Horton, et al. Radiographics 2000:3; 20:399-418
CT
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
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
Angiography
Usually NOT indicate in ischemic colitis– Majority of
ischemic colitis are non-occlusive disease
Guttormson NL, et al. Dis Col Rect 1989;32:469-72.
Angiography
Exception– ? Acute mesenteric
ischemia– in Isolated Right
Colon Ischemia Associated with
occlusion of the SMA
mortality rates mortality rates >50%>50%
Tendler DA. Semin Gastrointest Dis 2003;4:66-16
The gold standard of diagnosis
Features suggestive of ischemic Features suggestive of ischemic colitiscolitis– segmental involvement– abrupt transition between normal and
affected mucosa– rectal sparing– rapid resolution within 5-7 days within 5-7 days
Sreenarasimhaiah J. Curr Gastroenterol Rep. 2005;7:421–426Su C, et al. Am J Gastroenterol 1998;93:1055-60
Colonoscopy
Transient ischemic Transient ischemic colitiscolitis
Xiaoping Zou, et al. Dig Dis Sci 2009:54; 2009–2015
Patchy edematous &
Erythematous mucosa
longitudinal ulcerations
petechial hemorrhages interspersed with pale areas
Severe ischemic colitisSevere ischemic colitis
Xiaoping Zou, et al. Dig Dis Sci 2009:54; 2009–2015
Cyanotic, scattered
ulcerations
pseudomembranes
pseudopolyps
Severe ischemic colitisSevere ischemic colitis
Xiaoping Zou, et al. Dig Dis Sci 2009:54; 2009–2015Greenwald, David A, et al. Jn of Clin Gastroent 1998: 27(2), pp 122-128
Pseudotumor
Gangrene in dusky background
Stricture of ischemic Stricture of ischemic colitiscolitis
Xiaoping Zou, et al. Dig Dis Sci 2009:54; 2009–2015Greenwald, David A, et al. Jn of Clin Gastroent 1998: 27(2), pp 122-128
Lumen stricture & mucosa granularity
Stricture mimicking a neoplasm
The gold standard of diagnosis– InvasiveInvasive– As initial investigation in selected As initial investigation in selected
casescases Highly suspicious of acute ischemic Highly suspicious of acute ischemic
colitis with no peritoneal signcolitis with no peritoneal sign Suspicious of chronic colitis Suspicious of chronic colitis
Endoscopic Findings
Take home messageTake home message……
Think of itThink of it– High risks groupHigh risks group– Recurrent diseaseRecurrent disease
Look for itLook for it– Combination of clinical features, Combination of clinical features,
radiological & endoscopic findingsradiological & endoscopic findings– Acute and chronic colitis Acute and chronic colitis
Q&AQ&A