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