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[How and how far to investigate ischemic colitis?]
... Elle n'a, en revanche, pas d'intérêt dans le diagnostic d'ischémie du territoire mésentérique supérieur, car le grêle n'est pas accessible à cet examen. Trois stades endoscopiques sont décrits [50] : • stade 1 : oedème et érythème de la muqueuse ; • stade 2 : ulcérations non nécrotiques, reposant sur une muqueuse oedématiée ; • stade 3 : nécrose extensive avec aspect gris-noir du côlon. ...
L'ischémie mésentérique aiguë est une urgence médicochirurgicale dont le pronostic est sombre. Différentes causes diminuant ou interrompant le flux sanguin veineux ou artériel sont responsables d'ischémie mésentérique aiguë. La cause la plus fréquente est l'embolie artérielle suivie par la thrombose artérielle. L'ischémie mésentérique chronique est une pathologie pouvant conduire à une ischémie aiguë par thrombose artérielle. L'ischémie mésentérique non occlusive est liée à une baisse de la perfusion mésentérique sans lésion anatomique. Le syndrome du compartiment abdominal est une des causes de l'ischémie non occlusive. Le phénomène d'ischémie-reperfusion est responsable de la défaillance multiviscérale aggravée parfois par une péritonite par perforation intestinale. Le diagnostic est difficile et basé sur la tomodensitométrie spiralée avec injection de produit de contraste. La prise en charge est réanimatoire et chirurgicale. La stabilisation de l'état hémodynamique réalisée par l'équipe d'anesthésie-réanimation est un point clé. Le pronostic est lié aux défaillances d'organes, aux antécédents du patient et à la rapidité de la prise en charge.
... In this group, although many major predisposing factors are recognised, such as aortic surgery and obstructing colonic lesions, most cases are idiopathic and arise in the absence of a proven precipitating event. In younger cases, an increasing number of predisposing causes are being found, including vasculitis [14], both hereditary and acquired thrombotic risk factors [15], oral contraceptive use [16], medications (for example, sumatriptan [17], pseudoephedrine [18], psychotropic drugs [19], alosetron [20]), combination chemotherapy regimens [21], long distance running [22], air travel [23], illicit drug use (cocaine and amphetamines) [13] and infection with the enterotoxigenic Escherichia coli 0157:H7 [24]. ...
Rofecoxib is a selective cyclooxygenase-2 inhibitor that has been approved for the treatment of osteoarthritis and management of acute pain. Recent debate has emerged regarding the prothrombotic potential and the cardiovascular safety of this new drug, especially at doses greater than 25mg. We describe two extensively investigated cases of self-limited ischemic colitis in patients who were briefly treated with 50mg rofecoxib daily for acute pain. In both cases, the onset of symptoms correlated temporally with rofecoxib use and symptoms abated with drug discontinuation. There was no evidence of other possible causes of colon ischemia. A causal relationship between the start of rofecoxib treatment and the colon ischemia cannot be definitely established on the basis of the evidence, but the temporal relationship is striking and the pathophysiological rationale could be founded.
Background
The consequences of cardiac arrest (CA) on the gastro-intestinal tract are poorly understood. We measured the incidence of ischemic injury in the upper gastro-intestinal tract after Out-of-hospital CA (OHCA) and determined the risk factors for and consequences of gastrointestinal ischemic injury according to its severity.
Methods
Prospective, non-controlled, multicenter study in nine ICUs in France and Belgium conducted from November 1, 2014 to November 30, 2018. Included patients underwent an esophago-gastro-duodenoscopy 2 to 4 d after OHCA if still intubated and the presence of ischemic lesions of the upper gastro-intestinal tract was determined by a gastroenterologist. Lesions were a priori defined as severe if there was ulceration or necrosis and moderate if there was mucosal edema or erythema. We compared clinical and cardiac arrest characteristics of three groups of patients (no, moderate, and severe lesions) and identified variables associated with gastrointestinal ischemic injury using multivariate regression analysis. We also compared the outcomes (organ failure during ICU stay and neurological status at hospital discharge) of the three groups of patients.
Results
Among the 214 patients included in the analysis, 121 (57%, 95% CI 50–63%) had an upper gastrointestinal ischemic lesion, most frequently on the fundus. Ischemic lesions were severe in 55/121 (45%) patients. In multivariate regression, higher adrenaline dose during cardiopulmonary resuscitation (OR 1.25 per mg (1.08–1.46)) was independently associated with increased odds of severe upper gastrointestinal ischemic lesions; previous proton pump inhibitor use (OR 0.40 (0.14–1.00)) and serum bicarbonate on day 1 (OR 0.89 (0.81–0.97)) were associated with lower odds of ischemic lesions. Patients with severe lesions had a higher SOFA score during the ICU stay and worse neurological outcome at hospital discharge.
Conclusions
More than half of the patients successfully resuscitated from OHCA had upper gastrointestinal tract ischemic injury. Presence of ischemic lesions was independently associated with the amount of adrenaline used during resuscitation. Patients with severe lesions had higher organ failure scores during the ICU stay and a worse prognosis.
Clinical Trial Registration NCT02349074 .
Background and study aims Ischemic colitis (IC) is potentially lethal. Clinical and biology information and results of computed tomography (CT) scan and/or colonoscopy are used to assess its severity. However, decision-making about therapy remains a challenge.
Patients and methods This was a retrospective, single-center study between 2006 and 2015. Patients with severe IC who underwent endoscopic evaluation were included. The aims were to determine outcomes depending on endoscopic findings and assess the role of endoscopy in the management.
Results A total of 71 patients were included (men = 48 (68%), mean age = 71 ± 13 years). There was hemodynamic instability in 29 patients (41 %) and severity signs on CT scan in 18 (38 %). Twenty-nine patients (41 %) underwent surgery and 24 (34 %) died. The endoscopic grades were: 15 grade 1 (21 %), 32 grade 2 (45 %), and 24 grade 3 (34%). Regarding patients with grade 3 IC, 55 % had hemodynamic instability, 58 % had severity signs on CT scan, 68 % underwent surgery, and 55 % died. The decision to perform surgery was based on hemodynamic status in 62 % of cases, CT scan data in 14 %, endoscopic findings in 10 %, and other in 14 %. Colectomy was more frequent in patients with grade 3 IC (P < 0.05). A mismatch between mucosal aspect (necrosis) and serous (normal) was observed in 13 patients (46 %). Risk factors for colectomy in univariate analysis were aortic aneurysm surgery, hemodynamic instability, no colic enhancement on CT scan, and endoscopic grade 3. Risk factors for mortality in multivariate analysis were hemodynamic instability, colectomy, and Charlson score > 5 (P < 0.05).
Conclusions This study suggests a low impact of endoscopy on surgical decision making. Hemodynamic instability was the first indication for colectomy. A discrepancy between endoscopic mucosal (necrosis) and surgical serous (normal) aspects was frequently noted.
The large bowel accounts for roughly half of all episodes of gastrointestinal ischemia. Three major manifestations of ischemic injury to the colon can be distinguished: massive bowel infarction (gangrenous colitis), hemorrhagic enterocolitis, and ischemic colitis (nongangrenous colitis). Ischemic colitis, usually due to subacute colonic ischemia, is the most common form. The disease can be reversible or irreversible. It affects mainly elderly, but younger patients can also show features of ischemic colitis in particular situations. It occurs on the mucosal side (ulcero-inflammatory pattern) or transmural (cobblestoning and strictures). Histology shows a characteristic picture with variable cell necrosis, minimal inflammation, and hyalinization of the stroma. © 2014 Springer International Publishing Switzerland. All rights reserved.
La isquemia mesentérica aguda es una urgencia medicoquirúrgica de pronóstico sombrío. Está provocada por diversas afecciones que disminuyen o interrumpen el flujo sanguíneo venoso o arterial. La causa más común es la embolia arterial, seguida de la trombosis arterial. La isquemia mesentérica crónica puede conducir a una isquemia aguda por trombosis arterial. La isquemia mesentérica no oclusiva se relaciona con una disminución de la perfusión mesentérica, sin lesión anatómica. El síndrome del compartimento abdominal es una de las causas de la isquemia no oclusiva. El fenómeno de isquemia-reperfusión causa insuficiencia multivisceral, en ocasiones agravada por una peritonitis consecutiva a una perforación intestinal. El diagnóstico es difícil y se basa en la tomografía computarizada (TC) helicoidal con inyección de medio de contraste. El tratamiento es médico y quirúrgico. La estabilización del estado hemodinámico por el equipo de anestesia-reanimación es un punto clave. El pronóstico depende de la insuficiencia orgánica, de los antecedentes del paciente y de la rapidez en instaurar el tratamiento.
The purpose of this study was to describe the sonographic findings of 58 patients with proven ischemic colitis and to evaluate whether any of the findings are related to the presence or development of transmural necrosis.
We reviewed the histories of patients diagnosed with ischemic colitis over a period of 5.5 years. Sixty-two patients had undergone sonographic examinations. The spectrum of sonographic findings in ischemic colitis was based on the original imaging report, with an analysis of the presence of colonic abnormalities and their associated alterations. In the second part of the study, we divided the patients into two groups according to the presence or absence of transmural necrosis, and the sonographic findings of each group were compared. Ten patients had sonographic follow-up studies during their hospital stay.
The prospective sensitivity of sonography for the characterization of colonic abnormalities was 93.5% (58/62 patients). Segmental involvement was detected in 57 of the 58 patients, with left-sided colitis in 47 (81%). The mean length of bowel involved was 19 cm, with a mean wall thickness of 7.6 mm. Colon wall stratification was preserved in 38 patients (66%). Altered pericolic fat was observed in 16 patients (28%). Absence of or barely visible color Doppler flow in the thickened bowel wall was recorded in 80% of patients. Altered pericolic fat was the only sonographic variable significantly associated with the presence of transmural necrosis (p = 0.004). Improvement as assessed on sonography was observed in all patients with a good clinical course. In patients with transmural necrosis, sonography did not show improvement.
Sonography is a valuable technique for the detection of colonic abnormalities resulting from ischemic colitis. In this study, altered pericolic fat or the absence of improvement in sonographic follow-up studies were factors associated with transmural necrosis.
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