Case Of Ischemic Colitis Research Articles

Ischemic Colitis Revealing Polyarteritis Nodosa

Ischemic colitis is one of the most common intestinal ischemic injuries. It results from impaired perfusion of blood to the bowel and is rarely caused by vasculitis. We report a case of ischemic colitis revealing polyarteritis nodosa (PAN) in a 55-year-old man. Histological examination of the resected colon led to the diagnosis of PAN.

Lubiprostone induced ischemic colitis

Ischemic colitis accounts for 6%-18% of the causes of acute lower gastrointestinal bleeding. It is often multifactorial and more commonly encountered in the elderly. Several medications have been implicated in the development of colonic ischemia. We report a case of a 54-year old woman who presented with a two-hour history of nausea, vomiting, abdominal pain, and bloody stool. The patient had recently used lubiprostone with close temporal relationship between the increase in the dose and her symptoms of rectal bleeding. The radiologic, colonoscopic and histopathologic findings were all consistent with ischemic colitis. Her condition improved without any serious complications after the cessation of lubiprostone. This is the first reported case of ischemic colitis with a clear relationship with lubiprostone (Naranjo score of 10). Clinical vigilance for ischemic colitis is recommended for patients receiving lubiprostone who are presenting with abdominal pain and rectal bleeding.

PEG 4L with Bisacodyl 20 mg is Superior to PEG 4L Alone for Colonoscopy Preparation

Purpose: Combination bisacodyl plus polyethylene glycol (PEG) is being used less frequently due to available alternatives and the concern for ischemic colitis. The purposes of our study were to identify whether the addition of bisacodyl 20mg to 4L PEG results in a better preparation than 4L PEG alone as a single dose preparation for colonoscopy and to review its safety in a large group of patients. Methods: We identified all outpatient colonoscopy exams performed between January 1, 2010 and July 1, 2011. We excluded cases in which the preparation was not 4L PEG alone or 4L PEG + 20mg bisacodyl. We recorded patient characteristics, preparation quality on a 5-point scale, procedure duration, and adenoma detection rate. Results: After screening 1,644 exams, 938 patients were identified (4L PEG n=574, 4L PEG + 20mg bisacodyl n=364). There was a marked difference in the proportion of individuals who had a good or excellent preparation in the 4L PEG + 20 mg bisacodyl group compared to the group receiving 4L PEG alone (88.5 vs. 77.4%). In a multivariate analysis, lower BMI (≤30) and use of 4L PEG + 20mg bisacodyl (OR=2.49;1.64-3.79) were independently associated with a good or excellent preparation. No cases of ischemic colitis were identified due to bisacodyl. Adenoma detection rate did not differ between preps (33.7 vs. 31.4% for PEG alone; P=0.47) Conclusion: Use of 4L PEG + 20mg bisacodyl results in a better preparation for colonoscopy than 4L PEG alone when using a day before single preparation approach. This did not affect the adenoma detection rate however. Although we saw no cases of ischemic colitis, we suggest using a 5mg dose of bisacodyl with 4L PEG which is consistent with FDA recommendations.

Ischemic Colitis: A Case Study Highlighting A Unique Association

Purpose: A 27-year-old male with no significant medical history presented with a two-day history of lower abdominal pain and hematochezia. Abdominal pain was characterized as cramping and located in the bilateral lower quadrants. Pain was associated with a large, bloody bowel movement and patient denied any other associated symptoms. On physical exam, patient was tachycardic and abdomen was tender diffusely with voluntary guarding. Lab work was significant only for a leukocytosis of 13. CT A/P w/ contrast illustrated diffuse bowel wall thickening from the mid- transverse colon to the distal sigmoid colon and possibly involving the rectum. The descending colon was well circumscribed and demonstrated loss of haustration with concordant target sign. Pericolonic fat stranding was seen in the region of the splenic flexure and proximal descending colon. Colonoscopy revealed discontinuous areas of polypoid, cobblestoned, nonbleeding serpintine ulcerated mucosa in the transverse colon. An area of mucosa in the terminal ileum was nodular. Based on the radiologic and colonoscopy findings, a presumptive diagnosis of IBD was made while we awaited biopsy results. Colonoscopic biopsies were significant for necrosis of superficial mucosal layer with relative sparing of the deeper portion. The lamina propria in the involved areas appeared hyalinized with hemorrhage - findings all characteristic of ischemic colitis. History taking had also revealed a 5 month history of taking Adderall and urine toxicology also confirmed amphetamine usage. Ischemic colitis is a common cause of lower gastrointestinal bleeding leading to approximately 10% to 19% of hospital admissions. Most patients with colon ischemia are older with atherosclerotic disease or diabetes mellitus. Several conditions, as well as a wide variety of medications, are known to predispose to colonic ischemia. Many of these medications are under-recognized. Adderall is a prescription stimulant which has gained popularity for labeled or unlabeled use among the younger population. We report a case of ischemic colitis in a young patient linked to the use of Adderall. Adderall consists of a mixture of dextroamphetamine and amphetamine salts and is a prescription drug for attention deficit/hyperactivity disorder (ADHD) and narcolepsy. The association of ischemic colitis with dextroamphetamine has only been documented in the literature in one published case report from 1991. This case illustrates the potential for severe vascular ischemia with use of prescription stimulants such as Adderall. It also highlights the value of a complete history in young patients presenting with colitis.

Randomised clinical trial: alosetron improves quality of life and reduces restriction of daily activities in women with severe diarrhoea‐predominant IBS

BackgroundPatients with irritable bowel syndrome with diarrhoea (IBS-D) experience restriction in daily activities and decreased health-related quality of life (QOL).AimTo investigate effects of alosetron on patient-reported health-related QOL, satisfaction and productivity in women with severe IBS-D.MethodsA total of 705 women (severe IBS-D, Rome II criteria) randomised to alosetron 0.5 mg QD, 1 mg QD, 1 mg BID, or placebo for 12 weeks were studied. IBSQOL, treatment satisfaction, daily activities, and lost workplace productivity (LWP) were evaluated at randomisation and Week 12.ResultsOne or more doses of alosetron significantly improved all IBSQOL domains except for sexual function from baseline vs. placebo. The magnitude of IBSQOL changes was consistent with a clinically meaningful effect. Alosetron 0.5 mg QD and 1 mg BID significantly reduced IBS interference with social/leisure activities and LWP from baseline vs. placebo [social/leisure (mean ±S.E.) days lost: −6.7 ± 0.8, −7.0 ± 0.9, P < 0.01; LWP (mean ± S.E.) h lost: −11.0 ± 3.3, −21.1 ± 4.1, P < 0.05 respectively]. Significantly more patients treated with alosetron reported satisfaction vs. placebo. Improvements in IBSQOL, LWP, and treatment satisfaction significantly correlated with global improvement of IBS symptoms. The incidence of adverse events with alosetron was low with constipation being the most commonly reported event. A single case of ischaemic colitis occurred, in a patient receiving alosetron 0.5 mg QD.ConclusionsIn women with severe IBS-D, alosetron treatment, including 0.5 mg QD, resulted in statistically significant and clinically relevant improvements in health-related QOL, restriction of daily activities and treatment satisfaction over placebo. IBS symptom improvement corresponded with positive changes in IBSQOL, LWP and treatment satisfaction.

Irritable bowel syndrome and ischemic colitis: evidence supporting the increased use of alosetron

Alosetron, a 5-hydroxytryptamine 3 (5-HT3) receptor antagonist, was approved by the US Food and Drug Administration (FDA) for the treatment of diarrhea-predominant irritable bowel syndrome (IBS-D) in women in February 2000. Initial clinical trials demonstrated significant efficacy, particularly in improving fecal urgency, stool frequency and consistency [Camilleri et al. 2001]. In a recent review and systematic meta-analysis of eight alosetron clinical trials, the number needed to treat (NNT) was reported to be 7.5 [Shah et al. 2012]. Although its efficacy was never questioned, safety became a concern as cases of ischemic colitis (IC) were reported, leading to voluntary withdrawal of alosetron by GlaxoSmithKline in November 2000. Alosetron was reintroduced in 2002 as a result of patient advocacy, with a risk management plan (RMP) designed to limit availability to women with severe IBS-D [Chang et al. 2010; Lewis, 2011].

Ischaemic colitis associated with bortezomib: case report

BackgroundTreatment with bortezomib is frequently associated with haematological toxicity. In addition infrequent gastrointestinal disorders such as ischaemic colitis, irritable bowel syndrome and paralytic ileus are described, among others.PurposeTo describe a...

Ischemic colitis during interferon-ribavirin therapy for chronic hepatitis C: A case report

Ischemic colitis is a rare complication of interferon administration. Only 9 cases in 6 reports have been described to-date. This report describes a case of ischemic colitis during pegylated interferon and ribavirin treatment for chronic hepatitis C, and includes a review of the relevant literature. A 48-year-old woman was treated with pegylated interferon α-2a and ribavirin for chronic hepatitis C, genotype Ib. After 19 wk of treatment, the patient complained of severe afebrile abdominal pain with hematochezia. Vital signs were stable and serum white blood cell count was within the normal range. Abdominal computed tomography showed diffuse colonic wall thickening from the splenic flexure to the proximal sigmoid colon, which is the most vulnerable area for the development of ischemic colitis. Colonoscopy revealed an acute mucosal hyperemic change, with edema and ulcerations extending from the proximal descending colon to the sigmoid colon. Colonic mucosal biopsy revealed acute exudative colitis. Polymerase chain reaction and culture for Mycobacterium tuberculosis were negative and the cultures for cytomegalovirus, Salmonella and Shigella species were negative. After discontinuation of interferon and ribavirin therapy, abdominal pain and hematochezia subsided and, following colonoscopy showed improvement of the mucosal ulcerations. Ischemic colitis cases during interferon therapy in patients with chronic hepatitis C reported so far have all involved the descending colon. Ischemic colitis is a rarely encountered complication of interferon administration in patients with chronic hepatitis C and should be considered when a patient complains of abdominal pain and hematochezia.

A case of ischemic colitis associated with metabolic acidosis

A case of ischemic colitis associated with metabolic acidosis

A Case of Ischemic Colitis Associated with Adult Intestinal Malrotation

A Case of Ischemic Colitis Associated with Adult Intestinal Malrotation

Report of a case of ischemic colitis with bilaterally patent internal iliac arteries after endovascular abdominal aneurysm repair

During endovascular aneurysm repair (EVAR), interruption of the internal iliac arteries (IIAs) or the inferior mesenteric artery by stents or embolization is thought to cause colon ischemia. To minimize this risk, attempts have been made to preserve the IIAs using iliac branch devices or IIA revascularization. Here we present our experience of colon ischemia after EVAR in a patient with bilaterally patent IIAs without evidence of embolism. A 70-year-old man had abdominal pain and a ruptured abdominal aortic aneurysm was found. We performed EVAR with custom-made tube grafts preserving the bilateral IIAs. On postoperative day 2, the patient complained of abdominal pain, a sigmoidoscopy was performed revealing colon ischemia. On laparotomy, transmural infarction of the sigmoid colon was found and resected. Because IIA preservation cannot guarantee protection against colon ischemia, surgeons should maintain a high level of suspicion and use surveillance liberally after EVAR for early diagnosis of colon ischemia, even if both IIAs are preserved.

Ischaemic colitis during interferon treatment for chronic hepatitis C: report of two cases and literature review

Ischaemic colitis is known to be a severe emergency complication of interferon (IFN) therapy. However, as ischaemic colitis is an infrequent complication of IFN therapy, limited information is available regarding the safety of resuming IFN therapy after resolution of ischaemic colitis and subsequent recurrence. Here, we report two cases of ischaemic colitis during IFN therapy for chronic hepatitis C. Ischaemic colitis was fully healed within 1 week after its onset and IFN withdrawal, and IFN therapy was resumed following patients' wishes to do so. Ischaemic colitis did not recur after the resumption of IFN therapy, and sustained virological response was achieved in both patients. In this report, we also summarize the findings of 11 cases of IFN-associated ischaemic colitis (nine previously published cases plus our two cases) and review the clinical characteristics of ischaemic colitis during IFN therapy in patients with chronic hepatitis C.

Ischemic colitis due to a dissecting aneurysm of the superior rectal artery

Ischemic injury to the bowel is a disease entity that has a wide spectrum of pathological and clinical findings. Patients with chronic ischemia present with colicky abdominal pain, obstructive symptoms and signs of ischemic colonic stricture. We reported the first case of ischemic colitis arising from a superior rectal artery (SRA) aneurysm. Colonoscopy showed non-resolving colitis complicated by sigmoid stricture. CT angiogram with 3D reconstruction showed a dissecting SRA aneurysm measuring 2 cm by 1.2 cm by 1.3 cm. The patient underwent laparoscopic-assisted low anterior resection, which was converted to open because of adhesions and made a full recovery.

Ischemic colitis masquerading as colonic tumor: Case report with review of literature

Ischemic colitis can mimic a carcinoma on computed tomographic (CT) imaging or endoscopic examination. A coexisting colonic carcinoma or another potentially obstructing lesion has also been described in 20% of the cases of ischemic colitis. CT scan can differentiate it from colon cancer in 75% of cases. However, colonoscopy is the preferred method for diagnosing ischemic colitis as it allows for direct visualization with tissue sampling. Varied presentations of ischemic colitis have been described as an ulcerated or submucosal mass or as a narrowed segment of colon with ulcerated mucosa on colonoscopy. Awareness and early recognition of such varied presentations of a common condition is necessary to differentiate from a colonic carcinoma, and to avoid unnecessary surgery and related complications.

A Case of Oral-contraceptive Related Ischemic Colitis in Young Woman.

Ischemic colitis is generally considered a disease of the elderly. The causes of ischemic colitis include low-flow states due to cardiac dysfunction or hypovolemia and certain medications including estrogen. Here we report a case of ischemic colitis in a 26-year-old woman. She had no specific medical history except taking oral-contraceptives for a long time. The mechanism of estrogen-induced ischemic colitis is not clearly understood. But we recommend that oral-contraceptives should be considered as a cause of ischemic colitis in young women.

Ischemic Colitis as Initial Presentation of Factor V Leiden Deficiency

Purpose: Colitis in young individuals is usually either infectious or inflammatory in nature. Ischemia as a cause of colitis in the young patient is rare unless underlying factors exist. We report an unusual case of ischemic colitis in a young male who presented with chronic diarrhea and weight loss and was subsequently found to have factor V Leiden deficiency. A 42 year old male presented to our clinic with complaints of abdominal pain and bloating for 1 month. He also reported mucous in stool for the past 5 days, without significant diarrhea or hematochezia. Physical Exam and laboratory testing, including leukocyte count, and stool analysis were normal. A CT scan was performed for persistent abdominal pain and showed thickening of the descending and sigmoid colon consistent with either infectious or inflammatory colitis. Subsequent colonoscopy revealed a diffusely edematous but non-friable colonic mucosa. Biopsies of the colon were normal. A provisional diagnosis of infectious colitis was made and the patient was treated conservatively. Three months later the patient presented with 40 lbs weight loss and diarrhea upto 25 times with hematochezia but without abdominal pain. Physical Exam was again benign. Laboratory testing including leukocyte count were within normal limits. The patient underwent flexible sigmoidoscopy which now showed severe ulceration, granularity and friablilty of the mucosa with contact bleeding in the descending and the sigmoid colon. Biopsies were taken. In view of the clinical picture the patient was thought to have infectious colitis or inflammatory bowel disease. However, pathology revealed extensive lamina propria necrosis, fibrin thrombi and gland atrophy, findings consistent with ischemic colitis. Given this unusual clinical presentation of ischemic colitis in a young patient, he underwent an evaluation for clotting diseases and was found to have a positive factor 5 leiden mutation. The patient also underwent CT angiogram of the mesenteric vessels which showed a “water halo” pattern of enhancement in the post contrast images which may be indicative of inflammatory or ischemic bowel, but no obvious arterial occlusion. Although considered a disease of the elderly, as our case demonstrates, young, apparently healthy adults can present with ischemic colitis which is typically related to underlying diseases of the clotting cascade. Furthermore, the time course and presentation in young patients may be atypical.

T1069 Appropriateness for Ordinary Hospital Admission of Patients With Nonvariceal Upper Gastrointestinal Haemorrhage

GIB was matched in 77.2% (3057/3960) of cases. Mean age was 58.5y (range 12-103y) and 66.5% were males. Upper GIB (UGIB) accounted for 1911 (66.7%) cases. The top 3 causes were: 1. Peptic ulcer disease (54.1%), 2. Gastroduodenitis (16.3%) and 3. Mallory Weiss Tear (13.4%). Variceal UGIB (VUGIB) accounted for 7.5% of UGIB events. The proportion of UGIB fell from 69.4% in 2004 to 67.0% in 2008 (p=0.038,R2=0.96). Mortality rates for non-VUGIB fell from 2.5% to 2.1% (p=0.356,R2=0.28) while VUGIB mortality rates fell from 14.9% to 9.0% (p=0.356,R2=0.28). Endoscopic hemostasis rates rose from 97.6% to 99.0% (p=0.093,R2=0.67). Angiotherapy rate was 0.9% with no change over the 5 years. Significant risk factors for mortality among UGIB were: age (odds ratio (OR):1.04; 95% confidence interval (CI):1.02-1.06), number of comorbidities (OR:1.59; 95% CI:1.32-1.90) and ICU admission (OR:17.0; 95% CI:6.5-44.4). Lower GIB (LGIB) accounted for 954 (33.3%) cases. The top 3 causes were: 1. Piles (39.6%), 2. Diverticular disease (29.8%) and 3. Colorectal cancer (14.0%). The proportion of LGIB cases rose from 30.6% in 2004 to 33.0% in 2008 (p=0.032,R2=0.83) and this was contributed by a rise in ischemic colitis cases from 1.2% to 5.9% (p=0.024,R2=0.98). Mortality rate for LGIB was 2.3% with no significant change over the 5 years. Therapeutic colonoscopy rates dropped from 15.2% to 10.3% (p=0.043,R2=0.96) while angiotherapy rates rose from 1.8% to 4.9% (p=0.278,R2= 0.37). Surgical rate was 4.7% without significant change over the 5 years. Significant risk factors for mortality among LGIB were: age (OR:1.07; 95% CI:1.03-1.12), number of comorbidities (OR:1.52, 95% CI:1.14-2.03) and surgery (OR:4.51; 95% CI:1.20-17.0). Conclusions: ED admission diagnosis of acute GIB was correctly matched by in-patient discharge diagnosis in 77.2% of cases. Trend of UGIB was falling with reduction in mortality and surgical rates. There was a rising trend in LGIB, contributed by a rise in ischemic colitis events over the same period. Mortality and surgical rates remained unchanged for LGIB while colonoscopic intervention rates fell and angiotherapy rates rose.

Ischemic Colitis and Complications of Constipation Associated With the Use of Alosetron Under a Risk Management Plan: Clinical Characteristics, Outcomes, and Incidences

Alosetron is a potent, selective 5-HT(3) receptor antagonist prescribed for women with severe diarrhea-predominant irritable bowel syndrome (IBS-D) under a risk management plan (RMP). The RMP was implemented following cases of ischemic colitis (IC) and complications of constipation (CoC) associated with the use of alosetron. The objectives of this study were to characterize IC and CoC clinical features, outcomes, and incidence rates in the new restricted patient population to evaluate the effectiveness of the RMP in the prevention of serious outcomes. Safety data from adverse event reporting from November 2002 through June 2008 were reviewed for probable and possible IC and CoC using the US Food and Drug Administration/sponsor-defined criteria and definitions. Evidence for IC included medical documentation, colonoscopy, and sigmoidoscopy+/-biopsy. Evidence for CoC included medical history and confirmation from health-care professionals. Within the inclusion dates, 29,072 patients received 203,939 alosetron prescriptions. Although the absolute numbers of IC and CoC cases have declined, the incidence rates for IC and CoC (0.95 and 0.36 cases per 1,000 patient-years, respectively) were similar to rates during the postmarketing cycle before alosetron withdrawal. In patients with severe IBS-D receiving alosetron (n=998) or placebo (n=411) in clinical trials since reintroduction, incidence rates for IC were 4 and 2 cases per 1,000 patients, respectively. Rates for CoC were 2 and 0 cases per 1,000 patients in the alosetron and placebo groups, respectively. No mesenteric ischemia, surgeries, transfusions, or deaths occurred in patients with IC and no cases of CoC were associated with toxic megacolon, perforation, surgeries, transfusions, or deaths. IC and CoC cases were typically of short duration and all improved on prompt withdrawal of alosetron. Serious outcomes associated with IC and CoC appear to be mitigated since introduction of alosetron under the RMP.

NO-Xplode: A Case of Supplement-Associated Ischemic Colitis

The most common cause of ischemic colitis (IC) is a sudden and transient reduction in splanchnic perfusion. In the younger population, medications are an increasingly recognized cause of ischemic bowel disease. Over-the-counter supplements may also lead to the development of ischemic colitis through similar effects. We present a case of ischemic colitis in a 42-year-old active duty service member after using the performance-enhancing supplement, NO-Xplode. In this report, we review the pharmacology of this supplement and its proposed mechanism of injury.

Glutaraldehyde-Induced Chemical Colitis Versus Ischemic Colitis

To the Editor, Dr. Ahishali and colleagues have recently (Dec 2009 issue) reported on three cases of presumed glutaraldehydeinduced chemical colitis [1]. In describing glutaraldehydeinduced colitis, the authors appropriately suggest that the colonoscopic findings are nonspecific and may mimic those seen in ischemic colitis, inflammatory bowel disease, and infectious colitis. In describing case #2 (which I agree was in fact related to glutaraldehyde-induced chemical colitis), the authors suggest that transabdominal Doppler interrogation of the mesenteric artery was performed, and as no pathologic findings were noted, a diagnosis of ischemic colitis was excluded. This suggestion is both misleading and incorrect. Although Doppler interrogation of the mesenteric artery can be useful in attempting to evaluate for acute mesenteric ischemia (from, for example, thrombosis of the superior mesenteric artery), a normal result does not necessarily exclude ischemic colitis. Ischemic colitis is considered to most frequently be a spontaneous event, without major mesenteric vessel occlusion, and this disorder is believed to be ‘‘low-flow’’ and nonocclusive in nature [2]. As such, in the usual case of ischemic colitis, the results of mesenteric Doppler interrogation (or even angiography) will be normal. The authors’ thoughts in this regard would be welcome.