acg clinical guideline; am j gastroenterol 2015 · risk factors comorbid cardiovascular disease and...
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Colon ischemia
ACG Clinical Guideline; Am J Gastroenterol 2015
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Manifestations
Acute, reversible
Irreversible : gangrene, fulminant colitis/stricture
formation, chronic ischemic colitis
Recurrent sepsis due to bacterial translocation-in
irreversible damaged bowel
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Pathopysiology of colon ischemia
Alterations in the systemic circulation
anatomic/functional changes in the mesenteric
vasculature
LOCAL HYPOPERFUSION AND REPERFUSION
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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
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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
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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
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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
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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
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Predictors of severity(summary statements)
Decreased Hb level
Low serum albumin
Metabolic acidosis
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Plain radiography(thumbprinting sign)
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Imaging
CT with iv and oral contrast
Multiphasic CT angiography(suspected IRCI or AMI)
MR angiography
Splanchnic angiography
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CT in severe cases
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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
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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
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Endoscopic images
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Endoscopic imaging
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Histopathology
Infarction and ghost cells-pathognomonic
Other histologic signs: mucosal and submucosal
hemorrhage, edema, capillary fibrin thrombi
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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
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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>15.000
Colonic mucosal ulcerations at endoscopy
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Severity and treatment-Recommendations
1. most cases do not require specific therapy
2. surgical intervention
3. antibiotic therapy in moderate or severe disease
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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
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Ichemic Colitis Mortality Risk Score
Risk factors Mortality
0 10.5%
1 28.9%
2 37.1%
3 50.0%
4 76.7%
5 100%
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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
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Management
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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