Information about Ischemic Colitis by Dr. Dhaval Mangukiya.
Details of Ischaemic colitis, Colonic circulation, CT diagnosis of colonic ischemic, Management of colonic ischaemia, Dignosis of colonic ischaemia, Colours of ischaemia, cleveland clinic guidelines, Indications for surgery in colonic ischaemia, Surgery for colonic ischaemia, Outcome of ischaemic colitis.
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2. ISCHAEMIC COLITIS
Relatively common in the elderly
Commonest form of ischaemic injury to the GI tract
Spectrum of disease from transient mucosal inflammation to
gangrene
Real incidence is uncertain:
(1.7 cases per 1000 autopsies in Sweden)
Scand J Gastro 2006
5. PATHOPHYSIOLOGY OF COLONIC
ISCHAEMIA
Occlusion of main vessels is rare
Transient low flow state with degenerative narrowing of small
vessels in the elderly
Vasoconstriction & increased metabolic requirements in some
cases
6. SPECIFIC CAUSES OF COLONIC
ISCHAEMIA
After AAA repair
AMI & shock, cardiopulmonary bypass (high mortality)
Hypercoagulable states
Vasculitis
Marathon running
Cocaine
7. COLONIC ISCHAEMIA AFTER
AORTIC ANEURYSM REPAIR
Occurs in 5% of cases
High index of suspicion & early colonoscopy
Trial of implantation of IMA after repair: 128 patients with patent
IMA randomised - ischaemia in 6 patients after implantation & 10
patients without implantation (NS)
Austria, J Vasc Surg, 2006
8. HYPERCOAGULABLE STATES
Coagulation abnormalities in 28% of patients with colonic
ischaemia compared with 8.4% of general population
Coagulation abnormalities included factor V & activated protein C
resistance, protein S deficiency, anticardiolipin antibody
Canton Ohio, Southern Medical Journal 2004
10. DISTRIBUTION OF ISCHAEMIC
CHANGES
Most commonly splenic flexure & descending colon
After AAA repair & IMA ligation usually involves sigmoid colon
Embolic disease causes right colon ischaemia
15. SYMPTOMS & SIGNS OF COLONIC
ISCHAEMIA
Left sided cramping pain with or without faecal urgency
Rectal bleeding
Diarrhoea
Signs of peritonitis
Clinical context – post AAA repair
21. COLONOSCOPIC MANAGEMENT BASED
ON COLOUR
(CLEVELAND CLINIC GUIDELINES):
Red mucosa – repeat 4-5 days
Yellow mucosa – repeat 2-3 days
Green mucosa – repeat next day
Grey mucosa – repeat in 12 hours
Black mucosa - laparotomy
22. INDICATIONS FOR SURGERY IN
COLONIC ISCHAEMIA
Peritonitis – at presentation or after
observation
Free gas, intramural gas,
intraportal gas on X-ray
Infarction at colonoscopy – lack of bleeding
Colonic stricture
23. SURGERY FOR COLONIC
ISCHAEMIA
Resect ischaemic bowel – normal mucosa at resection margins
Hartmann’s procedure or anterior resection/left hemicolectomy &
loop ileostomy for left sided ischaemia
Right hemi-colectomy for right sided ischaemia
Low Hartmann’s for rectal ischaemia
25. OUTCOME OF ISCHAEMIC COLITIS
129 patients studied 1992-2002, mean age 66 (29-98), 47% male
54 in hospital at presentation
43 patients (33 percent) had peritonitis & required immediate
surgery (51% mortality)
70 patients treated non operatively – 17 required subsequent
surgery (24%)
Longo et al, St. Louis, Surgery 2003