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Ischemic Bowel Disease

Bowel Ischemia

Ischemic bowel disease is caused by a compromise in the blood supply of the gut. Ischemic colitis is a relatively mild form of the condition, in which the disruption of blood flow is transient, necrosis is limited, and patients often recover in a couple of days with supportive care. Acute mesenteric ischemia can be due to either arterial or venous thrombosis and is a more serious ailment, with a relatively high rate of mortality.


Presentation

Ischemic colitis is the most frequent manifestation of ischemic bowel disease. It is caused by a temporary reduction in the blood flow in small blood vessels. The symptoms are relatively mild, necrosis is restricted and rarely affects the full thickness of the gut; however, about 15% of cases will develop transmural necrosis and, as a result, peritonitis [1]. On the other hand, acute mesenteric ischemia presents with severe pain and is often due to thrombosis or embolism. It may proceed to a compromise in the barrier function of the gut wall, leading to leakage into the peritoneum and systemic inflammation. Both ischemic colitis and mesenteric ischemia may be associated with a range of severity.

Ischemic bowel disease mainly affects the elderly. It may be induced by a variety of conditions, treatments, or medications. Physical exertion may lead to ischemia in the intestines. The ailment can follow vascular surgeries, such as aortic or cardiac bypass, and may be caused by inadequate perfusion during surgery or by ligation of the inferior mesenteric artery [2]. Colonic ischemia is observed relatively frequently in abdominal aortic aneurysm (AAA) repair surgeries [3] and has been reported after placing a stent for AAA [4]. Ischemic colitis can be a consequence of carcinoma or diverticulitis. Deficiencies of coagulation inhibitors (for example protein C) and other hypercoagulation disorders (factor V mutations, the antiphospholipid syndrome) occur in a high proportion of patients with colon ischemia [5]. A large number of medications (for example antihypertensive drugs) may result in or contribute to ischemic colitis. Both arterial and venous thrombosis can be the main pathology responsible for acute mesenteric ischemia.

The initial symptoms of ischemic colitis are abdominal cramps (mainly on the left side), and an urge to defecate, followed by bloody stools - although there is no significant loss of blood. With care including bowel rest and fluid replacement, most patients recover within a couple of days. Surgery may be necessary in the presence of more advanced necrosis or if strictures develop. Severe necrosis will lead to the appearance of signs of peritonitis. Nausea, vomiting and some other findings indicate the development of ileus. Mesenteric ischemia begins with serious abdominal discomfort in the absence of any striking abnormality during a physical exam. Later in the course of the disease, features of peritonitis develop.

Weight Loss
  • Systemic signs such as fever, night sweats and weight loss may be present in advanced stages . Mesenteric lymphoma may involve the small bowel by direct extension or mass effect.[aischannel.com]
  • These blood clots in the small intestine and bowels can lead to: Weight loss Pain with eating Fear of food Left untreated over time, blockages can decrease blood flow so much that the tissues in your intestines die.[upmc.com]
  • A second patient with Takayasu’s presented with a 4-month history of abdominal pain, a 50-pound weight loss, stenosis of all major mesenteric arteries, and bowel pneumatosis.[mdedge.com]
  • WEIGHT LOSS CHRONIC mesenteric ischemia sometimes leads you to lose weight because, although you may feel hungry, you eat less or less frequently to avoid the pain.[vascular.org]
  • loss and malabsorption Bloating , nausea, occasional diarrhea Abdominal bruit caused by stenosis of mesenteric vessels A patient typically presents with postprandial abdominal pain ( abdominal angina ), food aversion, and weight loss![amboss.com]
Lymphadenopathy
  • Images were evaluated for bowel wall changes, mesenteric changes, fluid collection, retroperitoneal lymphadenopathy, peritoneal enhancement, and hepatomegaly as well as for changes in other abdominal organs.[ncbi.nlm.nih.gov]
Inguinal Hernia
  • Figure 7: A 73-year-old man with an incarcerated left inguinal hernia. The covering mucosa of upper segment (arrow) is poorly enhancing on contrast-enhanced computed tomography.[ijri.org]
Hypoxemia
  • . • Generalized hypotension or hypoxemia cantherefore cause localized injury, and ischemicdisease should be considered in thedifferential diagnosis of focal colitis of thesplenic flexure or• rectosigmoid colon. 31. 2.[slideshare.net]
Whipple Disease
  • Differential diagnosis includes carcinoma , sarcoma , carcinoid tumour , tuberculosis , Whipple disease and inflammatory bowel disease .[aischannel.com]
Abdominal Pain
  • CONCLUSION: The most common CT finding in patients with SLE and acute abdominal pain is ischemic bowel disease.[ncbi.nlm.nih.gov]
  • Hallmark findings are severe abdominal pain that is out of proportion to their physical examination, nausea, vomiting, and bloody stools.[smartypance.com]
Diarrhea
  • The majority of patients presented with the triad of abdominal pain, diarrhea and vomiting. In 13 patients the diarrhea was associated with the passage of bright red blood per rectum.[ncbi.nlm.nih.gov]
  • ,Chronic ischemia may masquerade asinflammatory bowel disease, with episodes ofbloody diarrhea interspersed with periods of healing. 53.[slideshare.net]
  • […] cholesterol or peripheral artery disease) Bowel obstruction (something is stuck in the intestines) Scar tissue from surgery Tumor in the intestines Hernia The symptoms of ischemic bowel disease can include: Abdominal pain Blood in your bowel movements Diarrhea[mainlinehealth.org]
  • Her daughter says her mother also had episodes of nausea, vomiting, diarrhea, and abdominal cramps. Assessment hints Ms. Lister, who has a history of atrial fibrillation and peripheral vascular disease, has been recovering from a recent splenectomy.[americannursetoday.com]
Constipation
  • He declined to eat and reported constipation.[theexpertinstitute.com]
  • Frequent constipation, hardening of the arteries, and low blood pressure are all conditions that may occur more often in old age and simultaneously increase your risk of ischemic colitis. High cholesterol can also be a factor.[doctorshealthpress.com]
  • Constipation is a more rare symptom compared todiarrhea and manifestation of this symptom depends on the allocation of ischemia.[lecturio.com]
  • Therefore, decreased blood supply to these organs cause symptoms related to eating or after-meal digestion, including: Abdominal pain after meals Weight loss Fear of eating or change in eating habits due to post-meal pain Nausea and/or vomiting Constipation[my.clevelandclinic.org]
Abdominal Distension
  • RESULTS: Abdominal pain, abdominal distension and bloody stool were major initial presentations. The mean age of the patients was 62.4 years at the time of diagnosis of ischemia.[ncbi.nlm.nih.gov]
  • distension, back pain and shock are late features indicating compromise of bowel viability Investigations WCC 15 in 75% metabolic acidosis in 50% plain AXR normal in early stages.[aic.cuhk.edu.hk]
  • Symptoms• Cramping and abdominal pain• Bloody stools• Frequent urge to defecate• Diarrhea• Nausea or vomiting• Abdominal distension 44. Ischemia bowel• acute or chronic.• arterial or venous• occlusive or nonocclusive. 45.[slideshare.net]
  • However, the test is often technically limited due to the presence of air-filled bowels, fluid and abdominal distension.[vasculardiseasemanagement.com]
  • Unfortunately, in the postoperative period, patient’s general condition was not getting better, recurred abdominal pain, vomiting and abdominal distension with radiological signs of ileus, increased inflammatory markers level.[journals.viamedica.pl]
Abdominal Cramps
  • The initial symptoms of ischemic colitis are abdominal cramps (mainly on the left side), and an urge to defecate, followed by bloody stools - although there is no significant loss of blood.[symptoma.com]
  • Her daughter says her mother also had episodes of nausea, vomiting, diarrhea, and abdominal cramps. Assessment hints Ms. Lister, who has a history of atrial fibrillation and peripheral vascular disease, has been recovering from a recent splenectomy.[americannursetoday.com]
  • Symptoms common to this group of diseases may include: Diarrhea Vomiting Abdominal Cramping Rectal Bleeding Weight loss Additionally, these illnesses may be accompanied by other problems, such as arthritis, liver disease ( primary sclerosing cholangitis[disability-benefits-help.org]
  • Symptoms can include diarrhea with or without blood, abdominal cramps, and dehydration from water loss because of numerous watery, bowel movements. Other organs can also be affected by the infection or the toxins that the bacteria can produce.[medicinenet.com]
  • Patients with MVT present with a mixture of nausea, vomiting, diarrhea, and abdominal cramping. Gastrointestinal bleeding occurs in 10% [ 22 ].[wjes.biomedcentral.com]
Hepatomegaly
  • Images were evaluated for bowel wall changes, mesenteric changes, fluid collection, retroperitoneal lymphadenopathy, peritoneal enhancement, and hepatomegaly as well as for changes in other abdominal organs.[ncbi.nlm.nih.gov]
Hypotension
  • […] mucosal: extends down to the muscularis mucosa (hypotension) mural: involves the mucosa and submucosa (hypotension) transmural: involves all 3 wall layers (acute obstruction) What are the 2 phases of intestinal response to ischemia? 1.[quizlet.com]
  • Blood volume redistribution with transient episodes of hypotension, especially during postoperative hemodialysis, may be significant.[ncbi.nlm.nih.gov]
  • Catastrophic hypotensive states naturally affect perfusion in all mesenteric vessels and atherosclerotic narrowing, when it does occur, is typically widespread and affects much of the mesenteric vasculature.[pathwaymedicine.org]
  • Some of them are obesity, prolonged smoking, colon cancer, atherosclerosis and hypotension, but also we can add some side effects from the use of medications.[ic.steadyhealth.com]
  • .– When infarction occurs, increased pain associatedwith vomiting,hypotensive and tachycardic, withloose bloody stool. 23. 4.Mesenteric venous thrombosisin a much younger patient population than other types .– acute or subacute abdominal pain involvement[slideshare.net]
Weak Pulse
  • On assessment, she has a dry mouth, skin tenting, low blood pressure, and a rapid, weak pulse. She has no bowel sounds and exhibits guarding. Her stool is guaiac-positive, and her white blood cell count is elevated at 17,000/mm3.[americannursetoday.com]
Night Sweats
  • Systemic signs such as fever, night sweats and weight loss may be present in advanced stages . Mesenteric lymphoma may involve the small bowel by direct extension or mass effect.[aischannel.com]
Responsiveness Decreasing
  • Although the CHOP regimen is considered the gold standard for treatment of patients with DLBCL, the addition of rituximab results in a significant improvement of the outcomes , with an increased rate of full response, decreased treatment failure and relapse[aischannel.com]

Workup

Laboratory tests show signs of ischemia, such as elevated lactic acid levels and acidosis, but these may develop too late for diagnosis.

Among the imaging techniques, plain abdominal radiography is not sensitive enough to detect ischemic colitis but may indicate towards mucosal edema (thumbprinting), and intramural gas, as well as intraperitoneal gas if there is a perforation. It is also useful for ruling out other conditions. Barium enema also detects thumbprinting in the large majority of patients with ischemic colitis [6], but the technique is not widely used anymore. The techniques of choice are colonoscopy and computed tomography (CT). In the early stages, colonic edema with pale mucous membranes, and capillary hemorrhages are found by colonoscopy. In later stages, a single linear ulcer may be detected [7]. In severe cases, the membranes look blue, gray or black. CT will show, among other features, symmetrical thickening of the wall, uneven narrowing of the lumen, and edema. A segmental distribution of anomalies is also characteristic of ischemic colitis [8], and is one of the features that tend to occur less in inflammatory bowel disease; thus it may be used to distinguish the two conditions. Ultrasound is not widely used but may indicate luminal thickening, edema, hemorrhage, and intramural gas [9].

Timely identification is crucial in the case of acute mesenteric ischemia because of the high mortality rates. Angiography is useful, but the clinical assessment is of primary importance.

Pneumoperitoneum
  • […] portalis : gas in the portal vein or in mesenteric vein can be differentiated by pneumobilia because gas usually reaches the periphery of the liver while pneumobilia is usually about 2 cm short of external liver border, and is more clustered at the hilum pneumoperitoneum[radiopaedia.org]
  • […] non-specific findings, such as: bowel wall thickening, bowel dilation, mesenteric edema, ascites *pitfall : to assume alternate Dx like infectious colitis when you get the non-specific early findings of mesenteric ischemia Late CT Findings: pneumatosis, pneumoperitoneum[emergencymedicinecases.com]
  • […] patients (27%) The serum bicarbonate level was less than 24 mmol/L in 26 patients (36%) Plain X-rays are often normal or show non-specific findings. [25] In a series of 73 patients, plain abdominal radiography (56%) showing colic distension in 53% or a pneumoperitoneum[en.wikipedia.org]
  • […] intra-abdominal (eg, appendicitis, diverticulitis, or abscess) Venous congestion from cirrhosis (portal hypertension) Venous trauma from accidents or surgery, [38, 39, 40, 41, 42] especially portacaval surgery Increased intra-abdominal pressure from pneumoperitoneum[emedicine.medscape.com]
ST Elevation
  • A 64-year-old man with acute ST-elevation myocardial infarction complicated by cardiogenic shock was treated with percutaneous angioplasty and intra-aortic balloon percutaneous counterpulsation.[ncbi.nlm.nih.gov]
Colitis
  • Ischemic colitis can be a consequence of carcinoma or diverticulitis.[symptoma.com]
  • What Is the Difference between Ischemic Colitis and Ulcerative Colitis? Ischemic colitis vs. ulcerative colitis. What is the difference? While both affect the bowel regions, the two different types of colitis do have some major differences.[doctorshealthpress.com]
  • How to Diagnose Ischemic Colitis Your doctor will utilize several different tests to properly diagnose ischemic colitis.[belmarrahealth.com]
  • Colonoscopy showed signs referring to acute ischemic colitis. Computed tomography detection of hepatic portal venous gas has permitted the non-invasive diagnosis of bowel necrosis.[ncbi.nlm.nih.gov]
Hepatocellular Carcinoma
  • Carcinoma 739 Metastatic Cancer of the Liver 744 Laparoscopic Cholecystectomy 748 Acute and Chronic Cholecystitis 753 Cholelithiasis 759 Biliary Strictures and Neoplasms 763 Endoscopic Management of Bile Duct Obstruction and Sphincter of Oddi Dysfunction[books.google.com]
  • Venous thrombosis• Hypercoagulable states induced, for example, by oral contraceptive or antithrombin III deficiency,• intraperitoneal sepsis,• the postoperative state,• vascular invasive neoplasm (particularly hepatocellular carcinoma),• cirrhosis,•[slideshare.net]
  • Examples are cases of cirrhosis-induced portal hypertension, invasion of the portal vein by hepatocellular carcinoma, encasement of the SMV by pancreatic carcinoma, vascular encasement by various degrees of mesenteric fibrosis in carcinoid or retractile[ijri.org]

Treatment

  • It has a high mortality rate of 59 to 93% and patient survival is highly dependent on a timely diagnosis and treatment.[websurg.com]
  • Anything that can produce such disturbing symptoms must require a relatively disturbing treatment, right? Actually, most of the treatment options for ischemic colitis are fairly mundane.[doctorshealthpress.com]
  • CT is useful for detecting the primary cause of gastrointestinal symptoms, planning treatment, and monitoring for infarction or perforation.[ncbi.nlm.nih.gov]
  • Although the CHOP regimen is considered the gold standard for treatment of patients with DLBCL, the addition of rituximab results in a significant improvement of the outcomes , with an increased rate of full response, decreased treatment failure and relapse[aischannel.com]
  • Presentation Pearls Diagnosis Treatment Picmonic Patient will present as a 71-year-old male with a history of atrial fibrillation with a sudden onset of severe abdominal pain occurring 10 minutes after eating.[smartypance.com]

Prognosis

  • Colonic ischemia is the commonest of these disorders and has a favorable prognosis in most cases. In contrast, acute mesenteric ischemia, most commonly caused by a superior mesenteric artery embolus, is a disease with a poor prognosis.[ncbi.nlm.nih.gov]
  • Prognosis? 4. When do symptoms develop? 1. Usually can elicit a history of chronic mesenteric ischemia 2. Usual site of blockage is the -origin of the SMA or -celiac axis 3. Less favorable prognosis 4.[brainscape.com]
  • For the patient's prognosis, however, it is crucial to make a diagnosis before bowel damage develops.[sciencedaily.com]

Etiology

  • Acute Vasoocclusive Etiologies Acute vasoocclusive etiologies of ischemic bowel injury arise from sudden occlusion of mesenteric vasculature which can affect arteries or veins.[pathwaymedicine.org]
  • CONCLUSIONS: Intestinal angiocentric T-cell lymphoma represents a distinct etiology of bowel ischemia. The condition should be taken into consideration, particularly in young adults with ischemic bowel disease.[ncbi.nlm.nih.gov]
  • See also acute abdomen Prognosis References: [1] [5] [6] [4] Acute mesenteric ischemia Etiology Acute arterial embolism ; ( 50% of cases ): generally resulting from atrial fibrillation , myocardial infarction , valvular heart disease, or endocarditis[amboss.com]
  • Just six cases of mesenteric ischemia have been diagnosed at Indiana University in young adults over the last 16 years, with Takayasu’s arteritis the most common etiology, he noted.[mdedge.com]

Epidemiology

  • A clinical review of recent findings in the epidemiology of inflammatory bowel disease. Clin Epidemiol. 2013 ; 5:237–247.[jaha.ahajournals.org]
  • Definition / general Ischemic changes may be mucosal, mural (due to hypoperfusion) or transmural (major vessels involved) Chronic ischemia may produce similar changes as acute ischemia, may be segmental and patchy Epidemiology Usually age 50 years but[pathologyoutlines.com]
  • Epidemiology The incidence of ischaemic colitis has risen from 6.1 cases/100 000 person-years in 1976-80 to 22.9/100 000 in 2005-09 [ 5 ]. Many mild cases may go unreported.[patient.info]
  • Epidemiology, clinical features, high-risk factors, and outcome of acute large bowel ischemia”. Clin Gastroenterol Hepatol. vol. 7. 2009. pp. 1075-80.[clinicaladvisor.com]
  • […] flow to the small intestine (arterial or venous) that can result in bowel infarction Chronic mesenteric ischemia : constant or episodic hypoperfusion of the small intestine, usually due to atherosclerosis References: [1] [2] [3] [4] Ischemic colitis Epidemiology[amboss.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology• Arterial sources v.s. venous sources:proximately 9:1.[slideshare.net]
  • The pathophysiology of the ischemic event usually will determine the management approach used.[link.springer.com]
  • Pathophysiology Intestinal blood flow of the superior mesenteric artery ( SMA ) and/or inferior mesenteric artery ( IMA ) is suddenly compromised (see “Etiology” for causes) intestinal hypoxia intestinal wall damage mucosal inflammation possibly bleeding[amboss.com]
  • This discussion will focus on the etiology, pathophysiology, diagnosis, and management of acute mesenteric ischemia. Table 86–1. Potential Causes of Acute Mesenteric Ischaemia[accessmedicine.mhmedical.com]

Prevention

  • Ischemic colitis prevention It is difficult to prevent ischemic colitis as there are many factors that can contribute to its onset.[belmarrahealth.com]
  • Gastrointestinal Bleeding 584 Transcatheter Management of Upper and Lower Gastrointestinal Tract Bleeding 590 Diverticular Disease of the Colon 597 Laboratory Evaluation and Liver Biopsy Assessment in Liver Disease 604 Acute Hepatitis Management and Prevention[books.google.com]
  • Prevention, diet and feeding for intestinal ischemia It is possible to reduce the risk of intestinal ischaemia with some changes in lifestyle that help prevent atherosclerosis: Choose a diet rich in fruits, vegetables, nuts and seeds.[hickeysolution.com]
  • CHICAGO – Early recognition of mesenteric ischemia in young adults and children is essential to prevent bowel loss and other serious consequences associated with this rare condition, Dr. Michael Dalsing said at a vascular surgery symposium.[mdedge.com]
  • Your doctor may prescribe blood-thinning medications to prevent future blood clots. Angioplasty is another treatment option for narrowed arteries. A mesh tube called a stent is inserted into the narrowed artery to hold it open.[healthline.com]

References

Article

  1. Cappell MS. Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia. Gastroenterol Clin North Am. 1998 Dec;27(4):827-860.
  2. Brewster DC, Franklin DP, Cambria RP, et al. Intestinal ischemia complicating abdominal aortic surgery. Surgery. 1991 Apr;109(4):447-454.
  3. Piotrowski JJ, Ripepi AJ, Yuhas JP, Alexander JJ, Brandt CP. Colonic ischemia: the Achilles heel of ruptured aortic aneurysm repair. Am Surg. 1996 Jul;62(7):557-60; discussion 560-561.
  4. Jaeger HJ, Mathias KD, Gissler HM, Neumann G, Walther LD. Rectum and sigmoid colon necrosis due to cholesterol embolization after implantation of an aortic stent-graft. J Vasc Interv Radiol. 1999 Jun;10(6):751-755.
  5. Koutroubakis IE, Sfiridaki A, Theodoropoulou A, Kouroumalis EA. Role of acquired and hereditary thrombotic risk factors in colon ischemia of ambulatory patients. Gastroenterology. 2001 Sep;121(3):561-565.
  6. Iida M, Matsui T, Fuchigami T, Iwashita A, Yao T, Fujishima M. Ischemic colitis: serial changes in double-contrast barium enema examination. Radiology. 1986 May;159(2):337-341.
  7. Zuckerman GR, Prakash C, Merriman RB, Sawhney MS, DeSchryver-Kecskemeti K, Clouse RE. The colon single-stripe sign and its relationship to ischemic colitis. Am J Gastroenterol. 2003 Sep;98(9):2018-2022.
  8. Balthazar EJ, Yen BC, Gordon RB. Ischemic colitis: CT evaluation of 54 cases. Radiology. 1999 May;211(2):381-388.
  9. Ripollés T, Simó L, Martínez-Pérez MJ, Pastor MR, Igual A, López A. Sonographic findings in ischemic colitis in 58 patients. AJR Am J Roentgenol. 2005 Mar;184(3):777-785.

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Last updated: 2019-06-28 10:41