Gastrointestinal involvement of passenger lymphocyte syndrome followed by minor ABO-incompatible renal transplantation: A case report.

BACKGROUND: People with group O blood are considered universal organ donors compatible with any other blood group. However, in the case of minor ABO-incompatible transplantation, immune-mediated hemolysis may occur due to concomitant transfer of donor B lymphocytes together with the allograft. These passenger lymphocytes can produce antibodies in the recipients erythrocytes, causing hemolytic anemia known as passenger lymphocyte syndrome (PLS). METHODS: A retrospective chart review was performed. RESULTS: A 6-year-old boy (A+) underwent transplantation of a kidney from his father (O+). On postoperative day (POD) 6, the patient developed fever with no explainable causes. On POD 11, he presented with abdominal pain, hematochezia, and severe diarrhea, with sudden hemolytic anemia. Since then, GI symptoms have continued. On POD 20, direct antiglobulin test (DAT) was positive, and the anti-A IgM/G titer was 2/32. The results of the anti-A antibody elution test were strongly positive (3+). These findings highly suggested PLS. On the same day, the GI symptoms suddenly worsened, and laboratory findings showed hemolysis and thrombocytopenia with disseminated intravascular coagulation (DIC). Abdominal computed tomography (CT) scans suggested ischemic colitis of venous origin, and the patient underwent segmental colectomy with ileostomy formation on POD 23. To remove the anti-A antibodies, the patient underwent therapeutic plasma exchange (TPE) five times until the DAT and anti-A elution test were negative. CONCLUSIONS: We report a case of gastrointestinal involvement of PLS that occurred after minor ABO-incompatible kidney transplantation. This is the first report of ischemic colitis as an atypical manifestation of PLS.

Primary Epiploic Appendagitis: A Mimicker of Abdominal Pain.

Epiploic appendagitis is a rare cause of acute lower abdominal pain. Epiploic appendices are fat-filled serosal outpouchings of the cecum and sigmoid colon. Primary epiploic appendagitis (PEA) is characterized by epiploic inflammation caused by torsion of the appendage leading to ischemia or thrombosis of the appendage draining vein. Secondary epiploic appendagitis occurs in association with other inflammatory conditions of the abdomen or pelvis, most commonly diverticulitis. PEA is an important clinical mimicker of more severe causes of acute abdominal pain, such as diverticulitis, appendicitis, or gynaecological causes. The ease of access to computed tomography (CT), the diagnostic test of choice, has resulted in increased recognition of PEA. The classic CT findings of PEA are an ovoid mass measuring between 1.5 and 3.5 cm surrounded by a hyperattenuating/hyperdense ring with a centrally located hyperdense area. It is important to diagnose PEA as it is self-limiting and the correct diagnosis can prevent unnecessary hospital admission, antibiotic use, or even surgical intervention. We present a case of a 65-year-old male with a history of diverticulitis, presenting with left lower quadrant abdominal pain who was diagnosed with PEA based on CT and successfully managed with conservative treatment.

Outcomes of patients with ischemic colitis causing severe hematochezia managed medically or surgically.

PURPOSE: To compare short- and long-term outcomes of hospitalized patients with ischemic colitis (IC) presenting with severe hematochezia and treated medically or colectomy and also those with inpatient vs. outpatient start of hematochezia. METHODS: A retrospective analysis of prospectively collected data for IC patients hospitalized for severe hematochezia from two teaching hospitals was done from 1994 to 2020, with the diagnosis of IC made colonoscopically and confirmed histologically. RESULTS: Ninety-seven patients initially all had medical management for IC. Seventy-two (74.2%) were stable and had no further bleeding; 17 (17.5%) had colon resection; and 8 were critically ill and not surgical candidates. Surgical patients and non-surgical candidate had higher comorbidity scores; received more red blood cell (RBC) transfusion (median (IQR) 5 (3-10) vs. 4.5 (3-6.5) vs. 1 (0-4) units, p < 0.001); had significantly longer hospital and ICU days; had higher severe complication rates (35.3% vs. 100%. vs. 5.6%, p < 0.001); and had higher 30-day all-cause mortality rates (23.5% vs. 87.5% vs. 0, p < 0.001). Inpatients developing IC hemorrhage had more RBC transfusions, more complications, longer hospital stays, and higher mortality than patients whose IC bleeding started as outpatients. CONCLUSIONS: The majority of IC patients hospitalized for severe hematochezia were successfully treated medically. Patients who were not surgical candidate had the highest rates of severe complications and mortality. Surgical patients and those who were not surgical candidate had worse outcomes than the medical group. Patients with inpatient start of bleeding from IC had significantly worse outcomes than those with outpatient start of bleeding.

Chronic obstructive pulmonary disease is associated with worse outcomes in ischemic colitis: a nationwide retrospective study.

BACKGROUND: Ischemic colitis (IC) occurs when the blood supply of the large intestine becomes compromised. Several cardiovascular conditions, such as coronary artery disease, congestive heart failure, and atrial fibrillation, are well-established risk factors for the development of IC. The effects of pulmonary conditions, namely chronic obstructive pulmonary disease (COPD), on IC have not been well studied. AIMS: Our aim was to elucidate if the presence of COPD worsened outcomes in patients with IC. METHODS: Retrospective analysis of patients hospitalized with IC in 2016 was evaluated using the National Inpatient Sample database. Baseline demographic data, length of hospital stay (LOS), total hospital cost/charge, rates of colectomy, and in-hospital mortality were extracted from the database. Categorical variables were compared using the chi-square test and continuous variables were compared using the t-test. RESULTS: A total of 25,035 patients with IC were identified while 4482 of these patients also had COPD. We found that IC patients with COPD had a longer LOS (5.8 days vs 4.4 days; P<0.01), higher total hospital charge ($56,682 vs $42,365; P<0.01), higher total hospital cost ($13,603 vs $10,238; P<0.01), higher mortality rate (6.5% vs 3.1%; P<0.01), and higher colectomy rate (5.1% vs 3.7%; P<0.01). CONCLUSIONS: The presence of COPD portends poor outcomes in patients with IC. This was evidenced by increased risk of death and increased risk of undergoing colectomy. Given these findings, patients with COPD warrant closer observation. We advocate that COPD be considered as part of the risk assessment of patients with acute IC who need surgical intervention.

SARS-CoV-2 Related Ischemic Colitis in an Adolescent With Trisomy 21: Diagnostic Pitfalls and Considerations.

Millions of patients seek medical attention for diarrhea, vomiting, nausea, and abdominal pain. In the current environment, it is important to recognize that these symptoms may be the only manifestation or may precede more serious systemic complications of COVID-19. Herein, we describe the first case of ischemic colitis (IC) in a young adult who presented with diarrhea and highlight the laboratory pitfalls for patients with COVID-19 presenting with gastrointestinal (GI) symptoms.

Rare Clinical Association between Clostridioides difficile Infection and Ischemic Colitis: Case Report and Literature Review.

Background and Objectives: Gut microbiota plays an important role in the wellbeing of the host through different interactions between microflora constituents. In certain instances, Clostridioides difficile may pullulate, causing infection with associated colitis that may vary in terms of severity from mild disease to severe colitis, with increased associated mortality due to its complications. However, there are few literature data regarding the association between Clostridioides difficile and ischemic colitis. Case report: We report the case of a 30-year-old male patient, overweight, with impending dehydration, who presented with hematochezia and colicky abdominal pain, with positive fecal tests for the detection of Clostridioides difficile infection and endoscopic appearance suggesting ischemic colitis in the sigmoid and left colon, confirmed by computed tomography and histology. The patient was treated with oral Vancomycin, with resolution of symptoms, and was reevaluated through colonoscopy eight weeks after discharge, with endoscopic mucosal normalization and histological scarring process on biopsy samples. Conclusion: We report one of the few cases in the literature of ischemic colitis associated with Clostridioides difficile infection, with resolution of clinical, endoscopic, and histologic changes after specific treatment with oral Vancomycin suggesting a possible association between the two diseases. We also review the existing literature data regarding this comorbid association.

Recurrent stent thrombosis in a patient with acute coronary syndrome and ischemic colitis: between life-threatening thrombosis and life-threatening bleeding.

Complete blood count should always be considered to tailor diagnosis and appropriate management in patients with acute ischemic heart disease. We present a challenging case of recurrent acute coronary syndrome, in the context of very high thrombotic risk due to concomitant inflammatory disease. Although no general guidelines exist for the switch between antiplatelet agents, particularly in the acute setting, in specific cases, the availability of different orally- and i.v.-acting agents and platelet function tests may allow to discriminate among multiple possible mechanisms of drug failure or side effects in the individual patient.

Myxedema ascites complicated by ischemic colitis.

Myxedema Ascites is a rare finding of primary hypothyroidism, thereby leading to delayed diagnosis. However, prompt treatment with levothyroxine leads to complete resolution of the condition. We present a rare case of myxedema ascites in an elderly female and highlight the importance of early diagnosis and management. We also present ischemic colitis in the same patient, which has not been reported thus far in literature as a complication of myxedema ascites.

Acute ischemic colitis with hematochezia related to baloxavir marboxil treatment for influenza A.

Oseltamivir, an established oral anti-influenza medication, increases the risk of ischemic colitis. Baloxavir marboxil is a novel oral anti-influenza medication, and few studies have evaluated its potential side effects, including ischemic colitis. Moreover, as influenza A can also induce ischemic colitis, drug-induced colitis associated with anti-influenza medication is not clearly understood. In this report, we describe the case of a 62-year-old Japanese woman who developed acute ischemic colitis after taking baloxavir for influenza A. The day after taking baloxavir (day 2), the patient experienced abdominal pain, diarrhea, and nausea. On day 3, she had developed hematochezia and decided to visit our hospital. Upon presentation, inflammation of the descending and sigmoid colon was detected by abdominal echography and computed tomography. Fluid replacement therapy and dietary restrictions were initiated. On day 4, the inflammation of the descending colon and marked intestinal edema were confirmed by colonoscopy. She was clinically diagnosed with ischemic colitis, from which she recovered completely by day 9. This case suggests that patients taking baloxavir may be at risk of developing ischemic colitis with hematochezia and underscores the need to further study the induction of this condition by commonly used oral anti-influenza agents.

Severe ischemic cytomegalovirus proctocolitis with multiple perforation.

Cytomegalovirus (CMV) typically causes gastrointestinal infections in immunocompetent patients. Colonic perforations secondary to CMV are exceeding rare. We describe a 88-year-old male presenting with a week-long history of intractable abdominal discomfort, bloating, nausea and diarrhea. Flexible sigmoidoscopy revealed significant ulceration with yellowish slough. Emergency surgery was performed subsequently in view of multiple perforations in the rectosigmoid junction. CMV gastrointestinal infections demonstrated an ischemic process secondary to vasculitis, which accelerated the pathway to colonic perforation. CMV gastrointestinal infection should be considered as a differential diagnosis in patients with colonoscopy findings similar to ischemic colitis and Clostridium difficile infections.

Stercoral colitis complicated with ischemic colitis: a double-edge sword.

BACKGROUND: Stercoral colitis is a rare inflammatory process involving the colonic wall secondary to fecal impaction with high morbidity and mortality; especially if complicated with ischemic colitis, stercoral ulcer formation and subsequent perforation. There are several case reports published on abdominal perforation resulting from stercoral colitis. However, stercoral colitis complicated by ischemic colitis is rare. The purpose of this case report is to describe the potential challenges in the diagnosis and management of stercoral colitis with ischemic colitis. CASE PRESENTATION: An 87 years old male with history of chronic constipation presents with severe abdominal pain to the emergency department. The patient was hemodynamically stable. On physical examination, the abdomen was mildly distended with moderate tenderness. Lab work was significant for leukocytosis and lactic acidosis. Abdominal CT scan revealed large amount of retained stool in the colon, bowel wall thickening and infiltration of peri-colonic fat, which were suggestive for stercoral colitis. Patient was started on IV fluids and antibiotics. He was given an enema, followed by laxative and manual disimpaction of stool. Colonoscopy was performed and biopsies were obtained. Tissue biopsy was significant for focal active colitis with regenerative glandular changes and neural hyperplasia. CONCLUSION: Elevated lactic acid level secondary to ischemia of the bowel wall with CT scan findings aid in establishing the diagnosis of stercoral colitis complicated with ischemic colitis. Urgent treatment with laxatives and fecal disimpaction is indicated to prevent perforation and peritonitis.

Fulminant gangrenous ischemic colitis: is it the solely severe type of ischemic colitis?

PURPOSE: The purposes of the study are to evaluate the characteristics of gangrenous colitis and to identify clinicobiological factors. METHODS: We performed a retrospective study of 75 patients in whom the diagnosis was made endoscopically and confirmed pathologically, between March 2004 and March 2010 at a tertiary teaching hospital. We classified ischemic colitis into the reversible and irreversible types (gangrenous colitis). The influence of factors, such as medical history, symptoms, physical examination, laboratory abnormalities, endoscopic findings, abnormalities on computed tomography, perioperative issues, complications, and several scoring systems, on gangrenous ischemic changes and mortality was evaluated by univariate and multivariate analyses. RESULTS: Ischemic colitis was classified as gangrenous ischemic type in 19 patients. The sigmoid colon was the most common site of involvement. However, the disease distribution was significantly different between the two groups. Pancolitis was most commonly observed for fulminant gangrenous colitis. A difference between the two groups was detected for several factors: age, mortality, physiologic score, APACHE II, mean arterial pressure at the time of admission, heart rate, albumin level, and sodium bicarbonate concentration. Multivariate analysis indicated four factors predictive of gangrenous colitis: absence of hematochezia, abdominal tenderness, absence of diarrhea, and albumin level. Another multivariate analysis excluding gangrenous change factors for mortality indicated four factors: arterial pH, serum sodium bicarbonate (metabolic acidosis), albumin (<3.0), and arterial oxygenation. CONCLUSION: Absence of diarrhea and hematochezia, presence of abdominal tenderness, and hypoalbuminemia could be the predictors for development of gangrenous changes of ischemic colitis.

Risk factors for ischaemic colitis after surgery for abdominal aortic aneurysm: a systematic review and observational meta-analysis.

BACKGROUND: Ischaemic colitis is an infrequent but serious complication following repair of abdominal aortic aneurysm (AAA), with high mortality rates. This systematic review set out to identify risk factors for the development of ischaemic colitis after AAA surgery. METHODS: A systematic search of the MEDLINE, EMBASE and CINAHL databases was performed. This search was limited to studies published in the English language after 1990. Abstracts were screened by two authors. Eligible studies were obtained as full text for further examination. Data was extracted by two authors, and any disputes were resolved via consensus. Extracted data was pooled using Mantel-Haenszel random effects models. Bias was assessed using two Cochrane-approved tools. Effect sizes are expressed as relative risk ratios alongside the 95 % confidence interval. Statistical significance was defined at the level of p < 0.05. RESULTS: From 388 studies identified in the initial search, 33 articles were included in the final synthesis and analysis. Risk factors were grouped into patient (female gender, disease severity) and operative factors (peri-procedural hypotension, operative modality). The risk of ischaemic colitis was significantly higher when undergoing emergency repair versus elective (risk ratio (RR) 7.36, 3.08 to 17.58, p < 0.001). Endovascular repair reduced the likelihood of ischaemic colitis (RR 0.22, 0.12 to 0.39, p < 0.001). DISCUSSION: The quality of published evidence on this subject is poor with many retrospective datasets and inconsistent reporting across studies. Despite this, emergency presentation and open repair should prompt close monitoring for the development of IC.

The predictors of the severity of ischaemic colitis: a systematic review of 2823 patients from 22 studies.

AIM: The study reviews the literature related to ischaemic colitis (IC) as the evidence base to identify factors predicting severity. METHOD: A systematic review of the literature was conducted on the predictors of the severity of IC. Severe IC or adverse outcome of IC was defined as a patient requiring surgery or who died. MEDLINE, Embase and Cochrane Library databases were searched from inception to 15 January 2015. Manual searches of reference lists from potentially relevant papers and meetings were also performed. RESULTS: In all, 22 studies involving 2823 patients were identified; 19 were case series, two were case-control studies and one was a cohort study. The overall adverse outcome rate was 22.0% (620/2823). The prognostic predictors for surgery or mortality which were most frequently reported included right sided IC, peritonitis, shock or arterial hypotension (< 90 mmHg), male gender, tachycardia and lack of rectal bleeding. Thirteen studies relating to the right colon from which data could be extracted were further analysed. The right colon was involved in 277 cases, with an incidence of adverse outcomes of 48.4% (134/277), while in the non-right colonic involvement group the incidence was significantly lower at 12.1% (142/1175) (P = 0.000). CONCLUSION: The incidence of adverse outcome in patients with IC remains high. Male gender, tachycardia, lack of rectal bleeding, peritonitis, shock or arterial hypotension (< 90 mmHg) and right sided IC are predictors of poor prognosis. Right-sided IC, shock or arterial hypotension (< 90 mmHg) and signs of peritonitis may be the most significant predictors of severity.

Origin, Clinical Characteristics and 30-Day Outcomes of Severe Hematochezia in Cirrhotics and Non-cirrhotics.

BACKGROUND: The sites of origin, causes and outcomes of severe hematochezia have not been compared between cirrhotics and non-cirrhotics. In cirrhotics versus non-cirrhotics presenting with severe hematochezia, we aimed at (1) identifying the site and etiology of gastro-intestinal bleeding and independent predictors of bleeding from the upper gastrointestinal tract versus small bowel or the colon, (2) comparing 30-day clinical outcomes, and (3) proposing an algorithm for management of severe hematochezia. METHODS: In this cohort study from two university-based medical centers, 860 consecutive patients with severe hematochezia admitted from 1995 to 2011 were prospectively enrolled with 160 (18.6 %) cirrhotics. We studied (a) general clinical and laboratory characteristics of cirrhotics versus non-cirrhotics, (b) predictors of bleeding sites in each patient group by multiple variable regression analysis, and compared (c) 30-day outcomes, including rebleeding, surgery and deaths. RESULTS: Cirrhosis independently predicted an upper gastrointestinal source of bleeding (OR 3.47; 95 % CI 2.01-5.96) as well as history of hematemesis, melena in the past 30 days, positive nasogastric aspirate, prior upper gastrointestinal bleeding or use of aspirin or non-steroidal anti-inflammatory. The most prevalent diagnoses were esophageal varices (20 %) in cirrhotics and colon diverticular bleeding (27.1 %) in non-cirrhotics. Thirty-day rates of rebleeding, surgical interventions and deaths were 23.1 versus 15 % (P = 0.01), 14.4 versus 6.4 % (P < 0.001), and 17.5 versus 4.1 % (P < 0.001), in cirrhotics versus non-cirrhotics, respectively. CONCLUSIONS: Cirrhosis predicted an upper gastrointestinal site of bleeding in patients presenting with severe hematochezia. The 30-day rates of rebleeding, surgery, and death were significantly higher in cirrhotics than in non-cirrhotics.

Natural history of outpatient-onset ischemic colitis compared with other lower gastrointestinal bleeding: a long-term cohort study.

PURPOSES: The long-term clinical course of outpatient-onset ischemic colitis remains unknown. Our aims are to elucidate the in- and out-of-hospital clinical outcomes of ischemic colitis and compare them with those of lower gastrointestinal bleeding (LGIB). METHOD: A cohort of 370 outpatients was hospitalized for ischemic colitis (n = 57) or other LGIB (n = 313). All patients had undergone colonoscopy. During hospitalization, the need for transfusion or interventions, further bleeding, mortality, and length of hospital stay were measured. After discharge, long-term recurrence and mortality were analyzed by the Kaplan-Meier method. RESULTS: Colonoscopy revealed that 88% of ischemic colitis cases were left sided. Compared with other LGIB, ischemic colitis cases had significantly lower transfusion requirements (p < 0.01), further bleeding (p = 0.02), endoscopic intervention (p < 0.01), and shorter hospital stay (p = 0.03). No significant differences between the groups were noted in the need for surgery, angiographic procedures, or mortality during hospitalization. During a mean follow-up of 22 months, rebleeding was significantly lower (log-rank test; p < 0.01) in ischemic colitis cases (5.3%) than in other LGIB cases (19.4%) after discharge. During the mean follow-up period of 29 months, 1 patient (1.8%) with ischemic colitis and 18 patients (5.8%) with other LGIB died (log-rank test; p = 0.41). CONCLUSIONS: Outpatient-onset ischemic colitis patients usually had left-sided colitis, recovered with conservative short-term treatment and had lower transfusion requirements and further bleeding compared with other LGIB patients. After discharge, patients with outpatient-onset ischemic colitis had lower recurrence over the long term than other LGIB patients.

Systematic review of self-expanding stents in the management of benign colorectal obstruction.

AIM: Colorectal obstruction due to benign disease is likely to become more prevalent. Self-expanding stents have been shown to be effective in reducing morbidity and allowing one-stage resection or improved palliation in colorectal cancer. This review assessed the use of self-expanding stents in benign colorectal obstruction. METHOD: A systematic review was performed using PubMed, Embase and the Cochrane Library. Keywords included: 'benign disease' 'colorectal obstruction', 'stent', 'endoprosthesis' and 'prosthesis' Original articles from all relevant listings were sourced. These were hand searched for further articles of relevance. The main outcome measures assessed were technical and clinical success, perforation, reobstruction and stoma avoidance in the bridge to surgery population. RESULTS: The search strategy identified 130 articles; the 21 included studies yielded a pooled analysis of 122 patients. Diverticulitis was the predominant aetiology (66/122, 54%). Technical success was achieved in 115/122 (94%) and clinical success in 108/120 (87%) patients. Overall, the perforation rate was 12% (15/122) and the reobstruction rate was 14% (17/122). A stoma was avoided in 48% (23/48) of bridge to surgery patients. Perforation and stoma avoidance in the bridge to surgery group were worse with an aetiology of diverticulitis. CONCLUSION: Complication rates in stenting for benign colorectal obstruction are higher than for malignant obstruction. On the basis of limited published evidence, stenting cannot be recommended for benign colorectal obstruction.