Colon ischemia. ACG Clinical Guideline; Am J Gastroenterol 2015

Transcription

1 Colon ischemia ACG Clinical Guideline; Am J Gastroenterol 2015

2 Manifestations Acute, reversible Irreversible : gangrene, fulminant colitis/stricture formation, chronic ischemic colitis Recurrent sepsis due to bacterial translocation-in irreversible damaged bowel

3 Pathopysiology of colon ischemia Alterations in the systemic circulation anatomic/functional changes in the mesenteric vasculature LOCAL HYPOPERFUSION AND REPERFUSION

4 RISK FACTORS Comorbid cardiovascular disease and diabetes mellitus Diseases with cardiac source of embolism Chronic kidney diseases and COPD-increased mortality from colonic ischemia Thrombophylia-young patients Surgical operations on the abdomen-especially abdominal aortic aneurysm repair Drugs

5 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

6 Clinical presentation Sudden mild abdominal pain, urgent desire to defecate, passage within 24 hours of bright red or marroon blood per rectum or bloody diarrhea 9.9% gangrenous colitis, 2.5% fulminant colitis Summary statement CI isolated to the right colon is associated with higher mortality rates

7 Segmental nature Left colon most affected -32.6% Regions particularly susceptible to ischemia:splenic flexure, sigmoid colon Rectum-uncommonly affected (dual supply-splanhnic and systemic) Isolated right colon ischemia: more frequently atrial fibrillation, coronary artery disease, chronic kidney disease on hemodyalisis and worse outcomes

8 Recommended laboratory tests Serologic 1. Albumin 2. Amylase 3. Complete blood count 4. Comprehensive electrolyte panel 5. CK 6. Lactate 7. LDH Stool tests-cl.difficile assay, culture, ova and parasites

9 Predictors of severity(summary statements) Decreased Hb level Low serum albumin Metabolic acidosis

10 Plain radiography(thumbprinting sign)

11 Imaging CT with iv and oral contrast Multiphasic CT angiography(suspected IRCI or AMI) MR angiography Splanchnic angiography

12 CT in severe cases

13 Recommendations CT with iv and oral contrast first imaging modality of choice for patients suspected for colonic ischemia Early colonoscopy(within 48h of presentation) should be performed in suspected CI to confirm diagnosis

14 Colonoscopy in the diagnosis Early colonoscopy (within 48 h of presentation) should be performed in suspected CI cases to confirm the diagnosis The endoscopic procedure should be stopped at the distal-most extent of the disease Contraindicated: acute peritonitis, gangrene, pneumatosis

15 Endoscopic images

16 Endoscopic imaging

17 Histopathology Infarction and ghost cells-pathognomonic Other histologic signs: mucosal and submucosal hemorrhage, edema, capillary fibrin thrombi

18 Classification of disease severity Mild no risk factors Moderate- any patient with CI with three risk factors Severe- any patient with CI with more than three risk factors or any of the following-peritoneal signs, pneumatosis or portal gas at imaging, gangrene on colonoscopy, pancolonic distribution/irci

19 Risk factors to predict severity of colonic ischemia Male gender TA<90mm HR> 100/mi/dl Abdominal pain without rectal bleeding BUN>20mg/dl Hb<12g/dl LDH>350U/l Na<136 WBC> Colonic mucosal ulcerations at endoscopy

20 Severity and treatment-recommendations 1. most cases do not require specific therapy 2. surgical intervention 3. antibiotic therapy in moderate or severe disease

21 Ischemic colitis mortality index Risk factors for perioperative mortality 1. Low output heart failure 2. Acute kidney injury 3. Subtotal or total colectomy 4. Lactate > 2.5mmol/l 5. Pre and intraoperative catecholamine administration

22 Risk factors Mortality % Ichemic Colitis Mortality Risk Score % % % % 5 100%

23 Antibiotic therapy In moderate or severe disease Recommendation is based upon expert opinion considering murine models, retrospective human studies,personal experience of experts Broad antimicrobial regimens, 7 days

24 Management

25 Surgical indications Acute indications: peritoneal signs, massive bleeding, fulminant colitis with or without toxic megacolon, portal venous gas or pneumatosis intestinalis, deteriorating clinical condition Subacute indications: failure to respond to treatment within 2-3 weeks with continued symptoms or a protein-losing colopathy Chronic indications: symptomatic colon stricture, symptomatic segmental ischemic colitis