Colon ischemia. Bible class 12 September Stefan Christen. ACG Clinical Guideline: Am J Gastroenterol 2015
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1 Colon ischemia Bible class 12 September 2018 Stefan Christen ACG Clinical Guideline: Am J Gastroenterol 2015
2 Definition
3 Definition Imbalance between blood supply and metabolic demands of the colonocytes
4 Definition Imbalance between blood supply and metabolic demands of the colonocytes A complete stop of the blood flow is not necessarily, sometimes only significantly reduction
5 Definition Imbalance between blood supply and metabolic demands of the colonocytes A complete stop of the blood flow is not necessarily, sometimes only significantly reduction Injury depends on acuteness of the event, degree of preexisting vascular collateralization, length of time
6 Definition Imbalance between blood supply and metabolic demands of the colonocytes A complete stop of the blood flow is not necessarily, sometimes only significantly reduction Injury depends on acuteness of the event, degree of preexisting vascular collateralization, length of time Reperfusion injury may produce more damage than just reduction of blood flow without reperfusion
7 Definition Imbalance between blood supply and metabolic demands of the colonocytes A complete stop of the blood flow is not necessarily, sometimes only significantly reduction Injury depends on acuteness of the event, degree of preexisting vascular collateralization, length of time Reperfusion injury may produce more damage than just reduction of blood flow without reperfusion -> local hypoperfusion and reperfusion injury
8 Definition Imbalance between blood supply and metabolic demands of the colonocytes A complete stop of the blood flow is not necessarily, sometimes only significantly reduction Injury depends on acuteness of the event, degree of preexisting vascular collateralization, length of time Reperfusion injury may produce more damage than just reduction of blood flow without reperfusion -> local hypoperfusion and reperfusion injury In most cases, no specific cause for ischemia is identified
9 Manifestations (clinical)
10 Manifestations (clinical) Sudden (mild) abdominal pain
11 Manifestations (clinical) Sudden (mild) abdominal pain Urgent desire to defecate
12 Manifestations (clinical) Sudden (mild) abdominal pain Urgent desire to defecate Within 24 hours bright red marroon blood per rectum or bloody diarrhea
13 Manifestations (clinical) Sudden (mild) abdominal pain Urgent desire to defecate Within 24 hours bright red marroon blood per rectum or bloody diarrhea Hb often stable (<5% transfusion)
14 Manifestations (clinical) Sudden (mild) abdominal pain Urgent desire to defecate Within 24 hours bright red marroon blood per rectum or bloody diarrhea Hb often stable (<5% transfusion) Symptomes often resolve within 2 3 days
15 Manifestation II
16 Manifestation II Reversible: - Colopathy with subepithelial hemorrhage, edema and ulcerations -Resorption usually within 3 day (Ulcerations may persist for several months)
17 Manifestation II Reversible: - Colopathy with subepithelial hemorrhage, edema and ulcerations -Resorption usually within 3 day (Ulcerations may persist for several months) Irreversible: (up to 9%) - Gangrene, fulminant colitis - Chronic ischemic colitis (rare) - Stricture (rare)
18 Manifestation II Reversible: - Colopathy with subepithelial hemorrhage, edema and ulcerations -Resorption usually within 3 day (Ulcerations may persist for several months) Irreversible: (up to 9%) - Gangrene, fulminant colitis - Chronic ischemic colitis (rare) - Stricture (rare) Recurrent sepsis due to bacterial translocation
19 EPIDEMIOLOGY
20 EPIDEMIOLOGY % of all patients hospitalized for acute lower gastrointestinal Bleeding
21 EPIDEMIOLOGY % of all patients hospitalized for acute lower gastrointestinal Bleeding - Annual incidence rate of 17.7 cases/100,000 person-years
22 EPIDEMIOLOGY % of all patients hospitalized for acute lower gastrointestinal Bleeding - Annual incidence rate of 17.7 cases/100,000 person-years - Nearly four fold increase over 34 years
23 EPIDEMIOLOGY % of all patients hospitalized for acute lower gastrointestinal Bleeding - Annual incidence rate of 17.7 cases/100,000 person-years - Nearly four fold increase over 34 years - More common in women than in men (57 76%)
24 EPIDEMIOLOGY % of all patients hospitalized for acute lower gastrointestinal Bleeding - Annual incidence rate of 17.7 cases/100,000 person-years - Nearly four fold increase over 34 years - More common in women than in men (57 76%) - Mortality rate 4 to 12%
25 Classification
26 Classification Type I: Etiology not clear -> no specific therapy
27 Classification Type I: Etiology not clear -> no specific therapy Type II: Etiology identified - systemic hypotension - decreased cardiac output - aortic surgery -> treat the underlining disease
28 Risk Factors
29 Risk Factors Cardivascular RF - hypertension (57 72%), diabetes mellitus (17 28%), dyslipidemia (18 33%), renal disease (4 18%), coronary artery disease (18 37%), congestive heart failure (9 16%), peripheral vascular disease (8 21%)
30 Risk Factors Cardivascular RF - hypertension (57 72%), diabetes mellitus (17 28%), dyslipidemia (18 33%), renal disease (4 18%), coronary artery disease (18 37%), congestive heart failure (9 16%), peripheral vascular disease (8 21%) Diseases with risk of embolism/thrombosis - atrial fibrillation (9 14%), thrombophylia, hypercoagulable states (young patients!-> Further diagnostic tests)
31 Risk Factors Cardivascular RF - hypertension (57 72%), diabetes mellitus (17 28%), dyslipidemia (18 33%), renal disease (4 18%), coronary artery disease (18 37%), congestive heart failure (9 16%), peripheral vascular disease (8 21%) Diseases with risk of embolism/thrombosis - atrial fibrillation (9 14%), thrombophylia, hypercoagulable states (young patients!-> Further diagnostic tests) Chronic obstructive pulmonary disease (10 18%) (motality )
32 Risk Factors Cardivascular RF - hypertension (57 72%), diabetes mellitus (17 28%), dyslipidemia (18 33%), renal disease (4 18%), coronary artery disease (18 37%), congestive heart failure (9 16%), peripheral vascular disease (8 21%) Diseases with risk of embolism/thrombosis - atrial fibrillation (9 14%), thrombophylia, hypercoagulable states (young patients!-> Further diagnostic tests) Chronic obstructive pulmonary disease (10 18%) (motality ) Injury of the vessels: - type IIIb aortic dissection, surgery
33 Risk Factors Cardivascular RF - hypertension (57 72%), diabetes mellitus (17 28%), dyslipidemia (18 33%), renal disease (4 18%), coronary artery disease (18 37%), congestive heart failure (9 16%), peripheral vascular disease (8 21%) Diseases with risk of embolism/thrombosis - atrial fibrillation (9 14%), thrombophylia, hypercoagulable states (young patients!-> Further diagnostic tests) Chronic obstructive pulmonary disease (10 18%) (motality ) Injury of the vessels: - type IIIb aortic dissection, surgery Irritable bowel syndrome, cases of longdistance running in runners (26-42 years of age), Sickle cell crisis
34 RF Drugs
35 RF Drugs Moderate evidence:
36 RF Drugs Moderate evidence: constipation-inducing drugs, immunomodulator drugs, illicit drugs (amphetamines, cocaine)
37 RF Drugs Moderate evidence: constipation-inducing drugs, immunomodulator drugs, illicit drugs (amphetamines, cocaine) Low evidence:
38 RF Drugs Moderate evidence: constipation-inducing drugs, immunomodulator drugs, illicit drugs (amphetamines, cocaine) Low evidence: chemotherapeutic drugs, decongestants (pseudoephedrine), diuretics, ergot alcaloids, hormonal therapies, psychotropic drugs, serotoninergic drugs
39 Localisation
40 Localisation Usually segmental
41 Localisation Usually segmental Left colon most affected
42 Localisation Usually segmental Left colon most affected Rectum-uncommonly affected (dual blood supply)
43 Localisation Usually segmental Left colon most affected Rectum-uncommonly affected (dual blood supply) Isolated right colon ischemia:
44 Localisation Usually segmental Left colon most affected Rectum-uncommonly affected (dual blood supply) Isolated right colon ischemia: -more frequently atrial fibrillation (2x), coronary artery disease, chronic kidney disease on hemodyalisis - worse outcomes - only 25-46% have rectal bleeding
45
46 Watershed
47 Watershed
48 Watershed
49 Recomendet laboratory tests
50 Recomendet laboratory tests Complete blood count Electrolyt pannel Albumin Lactate LDH ph CK Amylase (assosiated with acute bowel ischemia) Exclude infectious colitis: Stool cultrue, Cl.difficile assay, ova and parasites
51 Risk factors of sever ischemia
52 Risk factors of sever ischemia Male gender Puls >100bpm Blood pressure <90 mm Hg Abdominal pain without rectal bleeding Ulcerations at endoscopy Peritoneal signs Ischemia of the right colon Free fluid on CT BUN >20mg/dl Hb <12g/dl LDH >350U/l Na<136 COPD, NI, Hepatitis C, Warfarin use WBC>15.000
53 Risk factors of sever ischemia Male gender Puls >100bpm Blood pressure <90 mm Hg Abdominal pain without rectal bleeding Ulcerations at endoscopy Peritoneal signs Ischemia of the right colon Free fluid on CT BUN >20mg/dl Hb <12g/dl LDH >350U/l Na<136 COPD, NI, Hepatitis C, Warfarin use WBC>15.000
54 Classification of disease severity
55 Classification of disease severity Mild: no risk factors
56 Classification of disease severity Mild: no risk factors Moderate: up to three risk factors
57 Classification of disease severity Mild: no risk factors Moderate: up to three risk factors Severe: more than three risk factors or -peritoneal signs - pneumatosis or portal gas at imaging - gangrene on colonoscopy - pancolonic distribution/irci
58 Imaging
59 Imaging CT with i.v. and oral contrast (first imaging modality of choice)
60 Imaging CT with i.v. and oral contrast (first imaging modality of choice) Multiphasic CT angiography, MR angiography, Splanchnic angiography
61 Imaging Plain radiography (thumbprinting sign)
62 Imaging
63 Colonoscopy
64 Colonoscopy - Early colonoscopy within 48h of presentation
65 Colonoscopy - Early colonoscopy within 48h of presentation -Typical signs disappear (47% vs 10% >5 d)
66 Colonoscopy - Early colonoscopy within 48h of presentation -Typical signs disappear (47% vs 10% >5 d) - Not too much insufflation, CO2
67 Colonoscopy - Early colonoscopy within 48h of presentation -Typical signs disappear (47% vs 10% >5 d) - Not too much insufflation, CO2 - The endoscopic procedure should be stopped at the distal-most extent of the disease (distribution of desease wit CT)
68 Colonoscopy - Early colonoscopy within 48h of presentation -Typical signs disappear (47% vs 10% >5 d) - Not too much insufflation, CO2 - The endoscopic procedure should be stopped at the distal-most extent of the disease (distribution of desease wit CT) - Contraindication acute peritonitis, gangrene, pneumatosis
69 Colonoscopy - Early colonoscopy within 48h of presentation -Typical signs disappear (47% vs 10% >5 d) - Not too much insufflation, CO2 - The endoscopic procedure should be stopped at the distal-most extent of the disease (distribution of desease wit CT) - Contraindication acute peritonitis, gangrene, pneumatosis - No biopsy in gangrene
70 single-stripe sign
71
72
73
74 Histopathology
75 Histopathology Infarction and ghost cells (pathognomonic) (8%)
76 Histopathology Infarction and ghost cells (pathognomonic) (8%) Other histologic signs: mucosal and submucosal hemorrhage, edema, capillary fibrin thrombi
77 Treatment
78 Treatment Mostly no specific therapy i.v. fluid, maybe parenteral nutrition
79 Treatment Mostly no specific therapy i.v. fluid, maybe parenteral nutrition Surgery
80 Treatment Mostly no specific therapy i.v. fluid, maybe parenteral nutrition Surgery Antibiotic therapy in moderate or severe disease Broad antimicrobial regimens for 7 days
81 Treatment Mostly no specific therapy i.v. fluid, maybe parenteral nutrition Surgery Antibiotic therapy in moderate or severe disease Broad antimicrobial regimens for 7 days Cardial work-up if a cardiac source of embolism is suspected
82 Indication for surgery Acute: Subacute: Chronic:
83 Indication for surgery Acute: peritoneal signs, massive bleeding, fulminant colitis, toxic megacolon, portal venous gas or pneumatosis intestinalis, Subacute: Chronic:
84 Indication for surgery Acute: peritoneal signs, massive bleeding, fulminant colitis, toxic megacolon, portal venous gas or pneumatosis intestinalis, Consider if hypotension, tachycardia, pain without bleeding, fluid on CT, gangrene, right sided or pancolonic Subacute: Chronic:
85 Indication for surgery Acute: peritoneal signs, massive bleeding, fulminant colitis, toxic megacolon, portal venous gas or pneumatosis intestinalis, Consider if hypotension, tachycardia, pain without bleeding, fluid on CT, gangrene, right sided or pancolonic Subacute: failure to respond to treatment within 2-3 weeks with continued symptoms or a proteinlosing colopathy Chronic:
86 Indication for surgery Acute: peritoneal signs, massive bleeding, fulminant colitis, toxic megacolon, portal venous gas or pneumatosis intestinalis, Consider if hypotension, tachycardia, pain without bleeding, fluid on CT, gangrene, right sided or pancolonic Subacute: failure to respond to treatment within 2-3 weeks with continued symptoms or a proteinlosing colopathy Chronic: symptomatic colon stricture, symptomatic segmental ischemic colitis
87 Management
88 Questions?
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