This is a repository copy of Ischaemic colitis. White Rose Research Online URL for this paper: http://eprints.whiterose.ac.uk/111522/ Version: Published Version Article: Trotter, J.M., Hunt, L. and Peter, M.B. (2016) Ischaemic colitis. BMJ, 355. i6600. ISSN 0959-8138 https://doi.org/10.1136/bmj.i6600 Reuse Unless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version - refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher’s website. 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[email protected] https://eprints.whiterose.ac.uk/ BMJ 2016;355:i6600 doi: 10.1136/bmj.i6600 (Published 22 December 2016) Page 1 of 8 Practice PRACTICE CLINICAL UPDATES Ischaemic colitis 1 J M Trotter specialist registrar in general surgery , L Hunt specialist registrar in diabetes and 2 1 endocrinology , M B Peter consultant general surgeon 1Department of Surgery, Scarborough General Hospital, Scarborough YO12 6QL, UK; 2Department of Diabetes, Endocrinology and Metabolism, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield S10 2JF, UK The incidence of ischaemic colitis1 has risen from 6.1 cases/100 distinguishing factor between ischaemic colitis and inflammatory 000 person-years in 1976-80 to 22.9/100 000 in 2005-09.2 Acute or infective colitis, where abdominal pain often has a more gastrointestinal medical and surgical teams will see a few insidious onset.13 Symptoms of ischaemic colitis manifest in a patients with ischaemic colitis each month. Prevalence increases matter of hours and, unlike infective or inflammatory colitis, with age and comorbidity,2 which might lead to an increase in continue to worsen with systemic instability. 3 the incidence of ischaemic colitis as the population ages. A Ischaemic colitis may result in systemic inflammatory response small proportion of patients will present with a more chronic syndrome (SIRS) with associated observations of tachycardia, form of ischaemic colitis. hypotension, tachypnoea, and occasionally raised temperature This article provides practical advice to non-specialists regarding without an infective focus. Patients can present in a state of the diagnosis, management, and guideline recommendations shock, leading on to multiorgan failure if not treated correctly. for ischaemic colitis in the acute setting. Clinically, it is difficult to differentiate between patients with What is ischaemic colitis and what causes possible infective, inflammatory, or ischaemic colitis, and even it? with diagnostic tests it is not always clear. Generalists need to be equipped to recognise patients with symptoms of colitis who Ischaemic colitis and mesenteric ischaemia are different are deteriorating and refer them for specialist opinion. disorders but are often confused: table 1 highlights their differences. Ischaemic colitis occurs when there is an acute, How do you diagnose ischaemic colitis? transient compromise in blood flow, below that required for the metabolic needs of the colon. This leads to mucosal ulceration, Investigate patients with possible ischaemic colitis urgently. Computed tomography is the diagnostic investigation of choice. inflammation, and haemorrhage. The duration and severity of 4 hypoperfusion determines whether the colonic injury is Guidance from the American College of Gastroenterology predominantly ischaemic or as a consequence of recommends that computed tomography is performed within reperfusion.4Figure 1 shows the arterial supply of the colon the first few hours of admission, with care led by a senior and the most common sites for ischaemic colitis. clinician from this point. Colonoscopic evaluation is recommended within 48 hours to visualise mucosa and confirm Ischaemic colitis often has a multifactorial origin, and patients diagnosis. with extensive comorbidities are at particular risk. Box 1 lists common causes of ischaemic colitis. There is no role for abdominal plain radiographs or ultrasonography in diagnosing ischaemic colitis, though these What are the symptoms and signs of investigations often used in practice in the assessment of abdominal pain. They can give some information about ischaemic colitis? ischaemic colitis, such as thumbprinting on x ray or mural thickening and blood flow on ultrasonography and Doppler Acute presenting symptoms are commonly diarrhoea, rectal 14-17 12 ultrasound. However, the same, and more, information is bleeding, and colicky abdominal pain. Examination typically provided in greater detail on computed tomography that is not reveals a soft abdomen with tenderness and voluntary guarding user dependent and is usually more readily available out of hours over the affected segment of colon. The presence of peritonitis than ultrasonography. suggests full thickness ischaemia, perforation, or alternative diagnosis. The acute onset of the symptoms is a useful Correspondence to: J M Trotter [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2016;355:i6600 doi: 10.1136/bmj.i6600 (Published 22 December 2016) Page 2 of 8 PRACTICE What you need to know Ischaemic colitis is different from mesenteric ischaemia or ischaemic bowel Ischaemic colitis is typically acute in onset and has a high mortality rate Patients with suspected ischaemic colitis need urgent admission to a gastroenterological unit with specialist surgical services Some patients with ischaemic colitis can be managed conservatively Computed tomography is the investigation of choice for initial diagnosis of ischaemic colitis, using colonoscopy within 48 hours to give further prognostic information and to confirm diagnosis Box 1: Common causes of ischaemic colitis Physiological SystemicHeart failure, systemic inflammatory response syndrome (SIRS), atherosclerosis EmbolicAtrial fibrillation ThromboticConcurrent malignancy and haematological disorders6 Iatrogenic PharmacologicalChemotherapy, sex hormones, interferon therapy, pseudoephedrine, cardiac glycosides, diuretics, statins, non-steroidal anti-inflammatory drugs (NSAIDS), immunosuppressive drugs, vasopressors6 7 SurgicalAbdominal aortic aneurysm repair8 EndoscopicColonoscopy and bowel preparation media for colonoscopy4-11 Laboratory tests Longitudinal ulcerations (colon single stripe sign) (fig 3) In the presence of rectal bleeding, perform clotting studies and A sharply defined segment of involvement.21 a haemoglobin level. Inflammatory makers such as C reactive Cyanosis and pseudo-polyps suggest a transmural ischaemia. protein and neutrophil count are likely to be raised. Check renal function as patients are at risk of acute kidney injury because Colonoscopy is advocated by most studies, and there is no of the inflammatory response in ischaemic colitis. evidence that its use in assessment of ischaemic colitis is unsafe when performed by experienced practitioners.4 22 Retrospective Serum lactate levels may be raised as a result of systemic studies of a total of 659 cases reported no cases of perforation dysfunction and hypoperfusion. The role of lactate in this secondary to colonoscopy,23 24 in data published in recent scenario is in monitoring progress during resuscitation. Raised guidance.4 serum lactate does not indicate gastrointestinal ischaemia, and a normal lactate level does not exclude full thickness ischaemia of the colon.18 What treatment is available? Initial resuscitation Contrast enhanced computed tomography There is no specific guidance for the resuscitation of patients Computed tomography gives prompt information, with positive with ischaemic colitis. General resuscitation principles apply, findings in ischaemic colitis in up to 98% of cases.19 These including include wall thickening, abnormal or absent wall enhancement, Intravenous fluid resuscitation dilatation, mesenteric stranding, venous engorgement, ascites, Fluid balance monitoring with bladder catheterisation pneumatosis (gas within the bowel wall), and portal venous gas (fig 2).19 20 The CT findings suggest a diagnosis of ischaemic Assessment of acid-base status with arterial blood gas colitis, but they can be present regardless of severity,19 limiting sampling the prognostic value. The presence of such features (particularly Blood glucose control and monitoring in diabetic patients. in the watershed between the superior and inferior mesenteric artery) will suggest a diagnosis of ischaemic colitis but cannot While there is no specific evidence regarding fluid resuscitation absolutely distinguish it from other types of colitis. CT can rule in ischaemic colitis, aggressive and prompt resuscitation of a out other diagnoses and complications such as perforation that patient with SIRS has profound effects on outcomes, and specific will change management. algorithms now exist for conditions such as sepsis and pancreatitis.25 26 Endoscopic evaluation With appropriate resuscitation measures, colonic inflammation and