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.

Chimney Technique to Preserve Visceral Flow in a Coral Reef Aorta.

The coral reef aorta (CRA) is a rare phenomenon of extreme calcification in the juxtarenal and suprarenal aorta. Open revascularization has an overall in-hospital mortality rate of 13%. We present a patient with a suprarenal CRA with colon ischemia. She has an extensive past medical history of percutaneous transluminal angioplasty and stenting of the celiac trunk (CT) and superior mesenteric artery (SMA). The computed tomography angiography showed a CRA of the suprarenal aorta with occlusion of the CT stent and near occlusion of the SMA stent. Our case illustrates that the CRA in the suprarenal part of the aorta can be treated well by chimney graft procedure, although owing to lack of long-term follow-up, it might be reserved for high-risk candidates for (thoraco)abdominal aortic surgery.

Colonic ischemia: usual and unusual presentations and their management.

PURPOSE OF REVIEW: To provide an update on the epidemiology, pathophysiology, clinical presentation, and management of colonic ischemia. RECENT FINDINGS: Formerly regarded as a rare cause of lower gastrointestinal hemorrhage, colonic ischemia is now recognized to be the most common manifestation of intestinal vascular compromise. In contrast to ischemic events in the small intestine wherein thrombotic and embolic events predominate, colonic ischemia typically results from a global reduction in blood flow to the colon and no occlusive lesion(s) are evident. Several risk factors for colonic ischemia have been identified and, together with an appropriate clinical presentation and patient demographics, create a context in which the clinician should have a high level of suspicion for its presence. Imaging with computerized tomography, in particular, may be highly supportive of the diagnosis, which where appropriate can be confirmed by colonoscopy and colonic biopsy. For most patients, management is supportive and noninterventional, and the prognosis for recurrence and survival are excellent. SUMMARY: Colonic ischemia is a common cause of lower abdominal pain and hemorrhage among the elderly typically occurring in the aftermath of an event which led to hypoperfusion of the colon. For most affected individuals the ischemia is reversible and clinical course benign.

The incidence and outcome of ischemic colitis in a population-based setting.

OBJECTIVE: Population-based studies on patients with ischemic colitis (IC) are limited. We aimed to determine the incidence, risk factors and outcome of patients with IC. METHODS: A retrospective nationwide study was conducted on adult patients with histologically confirmed IC in 2009-2013 in Iceland. IC patients were matched for age and gender with patients hospitalized with lower gastrointestinal bleeding. Data were collected on clinical presentation, comorbidities, smoking habits, management and outcome. RESULTS: Eighty-nine patients, 61 (69%) females and mean age of 65 years (±17), fulfilled the predetermined criteria. Females were older than males, 68 years (±14) vs. 59 years (±20) (p = .0170). The mean cumulative incidence was 7.3 cases per 100,000 inhabitants. A total of 57 (64%) patients presented with abdominal pain, hematochezia and diarrhea. IC was localized in the left colon in 78 (88%) patients. Overall, 62 (70%) patients had cardiovascular disease vs. 53 (60%) of control group (NS) and 55 (62%) had a history of smoking vs. 53 (60%) in control group (NS). Ten (11%) patients required surgery and/or died within 30-days from hospital admission. At the end of follow-up, 7 (9%) patients had experienced recurrence of IC with an estimated 3-year recurrence rate of 15%. CONCLUSIONS: IC is a common clinical phenomenon that affects a wide range of age groups, but is most prominent among elderly women. It typically presents with a clinical triad of abdominal pain, hematochezia and diarrhea. Most cases are mild and self-limiting with a good prognosis.

Outcomes of open and endovascular repair for ruptured and nonruptured internal iliac artery aneurysms.

OBJECTIVE: To evaluate outcomes of open (OR) and endovascular repair (II-EVAR) of internal iliac artery aneurysms (IIAAs) with or without preservation of internal iliac artery (IIA) flow. METHODS: We reviewed the clinical data of consecutive patients treated for IIAAs between 2001 and 2012. End-points were morbidity, mortality, graft patency, and freedom from pelvic ischemic symptoms (buttock claudication, ischemic colitis, and spinal cord injury). RESULTS: There were 97 patients, 87 male and 10 female, with mean age of 74 ± 8 years. A total of 125 IIAAs (71 unilateral and 27 bilateral) with mean diameter of 3.6 ± 2 cm were treated. Eighty-two patients (86%) had elective repair and 15 (14%) required emergent repair (mean size, 6.7 ± 2.4 cm; range, 3.6-10 cm). OR in 60 patients (62%; 49 elective, 11 emergent) included IIA bypass in 36 (60%) patients and endoaneurysmorrhaphy in 24 (40%). II-EVAR in 37 patients (38%; 30 elective, 4 emergent) required IIA embolization in 29, iliac branch device in five or open IIA bypass in three, combined with bifurcated aortic stent grafts in 17. Early mortality was 1% for elective (1/49 open, 0/33 endovascular) and 7% for emergent repair (1/11 open, 0/4 endovascular). Early morbidity (43% vs 8%; P < .001) and length of stay (9 vs 1 day; P < .001) were significantly higher for OR as compared with II-EVAR. Pelvic ischemic complications occurred in 25 patients (26%), including hip claudication in 23, ischemic colitis in two, and paraplegia in one. Freedom from buttock claudication at 2 years was 25% in patients with no IIA preserved, 68% with preservation of one, and 95% with preservation of both IIAs (P = .002). Freedom from buttock claudication was higher after OR than after II-EVAR (79% vs 59%; P = .05). Primary and secondary patency rates of IIAA bypasses were 95%, and 80% at 1 and 3 years, respectively. CONCLUSIONS: II-EVAR of IIAAs is associated with fewer complications and shorter hospital stay compared with OR. Open and endovascular IIA reconstructions have very good long-term patency, and preservation of IIA flow is associated with higher freedom from buttock claudication.

Adipose-derived stem cells on the healing of ischemic colitis: a therapeutic effect by angiogenesis.

BACKGROUND: There has been no specific treatment for ischemic colitis. We verified the effects of adipose-derived stem cells (ASCs) on ischemia-induced colitis in a rat model. METHODS: Forty male Sprague-Dawley rats (10 weeks old; weight, 350 ± 20 g) were divided into two groups: a control group (only fibrinogen and thrombin injected, n = 20) and an ASC group (local implantation of ASCs mixed with thrombin and fibrinogen, n = 20). An ischemic colitis model was established by modifying Nagahata's methods with double-blind randomization. ASCs (1 × 10(6) cells) were implanted intramurally into the ischemic area using a fibrin glue mixture. The severity of adhesion, degree of ileus, the number and size of the ulcers, Wallace macroscopic and microscopic scores, and microvascular density were measured. RESULTS: The degree of ileus was significantly lower, and significantly fewer and smaller ulcerations were found in the ASC group than those in the control group. Wallace macroscopic and microscopic scores were lower in the ASC group than in the control group (1.90 ± 1.22 versus 3.25 ± 1.83, p < 0.01 and 1.55 ± 1.88 versus 2.84 ± 1.89, p < 0.05, respectively). Microvascular density was higher in the ASC group than in the control (54.45 ± 19.45 versus 26.54 ± 13.14, p < 0.01, respectively). CONCLUSIONS: Local implantation of ASCs into an ischemic-injured colonic wall reduced the grade of ischemic injury and enhanced tissue healing by promoting angiogenesis.

Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study).

BACKGROUND: There is a lack of prospective studies evaluating the natural history of colonic ischaemia (CI). We performed such a study to evaluate the clinical presentation, outcome, and mortality as well as clinical variables associated with poor prognosis. METHODS: An open, prospective, and multicentre study was conducted in 24 Spanish hospitals serving a population of 3.5 million people. The study included only patients who met criteria for definitive or probable CI. A website (www.colitisisquemica.org) provided logistical support. RESULTS: A total of 364 patients met criteria for inclusion. CI was suspected clinically in only 24.2% of cases. The distribution of clinical patterns was as follows: reversible colopathy (26.1%), transient colitis (43.7%), gangrenous colitis (9.9%), fulminant pancolitis (2.5%), and chronic segmental colitis (17.9%). A total of 47 patients (12.9%) had an unfavorable outcome as defined by mortality and/or the need for surgery. Multivariate analysis identified the following signs as independent risk factors for an unfavorable outcome: abdominal pain without rectal bleeding [odds ratio (OR) 3.9; 95% confidence interval (CI) = 1.6-9.3], non-bloody diarrhoea (OR 10; 95% CI = 3.7-27.4), and peritoneal signs (OR 7.3; 95% CI = 2.7-19.6). Unfavorable outcomes also were more frequent in isolated right colon ischaemia (IRCI) compared with non-IRCI (40.9 vs. 10.3%, respectively; p < 0.0001). The overall mortality rate was 7.7%. CONCLUSIONS: The clinical presentation of CI is very heterogeneous, perhaps explaining why clinical suspicion of this disease is so low. The presence of IRCI, and occurrence of peritoneal signs or onset of CI as severe abdominal pain without bleeding, should alert the physician to a potentially unfavorable course.

Colon ischemia: recent insights and advances.

Ischemic colitis is the most common manifestation of ischemic injury to the gastrointestinal tract, and the variety of defined causes is increasing. Local hypoperfusion and reperfusion injury are both thought to contribute to the disease process, which manifests with a wide spectrum of injury including reversible colopathy (subepithelial hemorrhage and edema), transient colitis, chronic colitis, stricture, gangrene, and fulminant universal colitis. The distribution is typically segmental. Older studies showed that any portion of the colon can be involved; recently, it was established that the site of involvement and prognosis can be correlated. In particular, isolated involvement of the right side of the colon was shown to have a different presentation and worse outcome than ischemic colitis involving other segments. Diagnosis is usually made clinically and supported by radiologic imaging and colonoscopic evaluation. Most patients respond to conservative supportive therapy, although some with severe disease require surgical intervention.

[Clinical and morphological criteria for microscopic ischemic colitis in patients with chronic coronary heart disease of the digestive system].

We studied the clinical symptoms and functional-morphological changes of the colon in 42 patients with cardiovascular disease, impaired blood flow in the unpaired visceral branches of the abdominal aorta, clinical and instrumental signs of ischemic colon lesions (ICL). Clinical symptoms characteristic of intestinal pathology were observed in all patients, but traditionally described laboratory-instrumental signs of ischemic colitis are installed in only two of them. At the same time, the histological study of the mucosa of the sigmoid colon in 21 of 23 patients revealed necrosis of surface epithelium, reducing the number of goblet cells, focal lymphoid-cell infiltrates and microcirculatory disturbances with the development of stasis, thrombosis and microcirculatory plazmorrags of the colon mucosa. Thus, we have established a new form of ICL--microscopic ischemic colitis. It is the morphological evidence of abdominal pain syndrome, observed in most patients with chronic abdominal ischemia.

Association of decreased variation of coefficient R-R interval with ischemic colitis and small bowel obstruction.

BACKGROUND: The parasympathetic nervous system exerts and controls intestinal tone. Several studies have suggested that the coefficient of the R-R intervals (CVRR) is useful for evaluating the parasympathetic nervous system. OBJECTIVES: This study aimed to evaluate the relationship between gastrointestinal emergencies, specifically ischemic colitis (IC) and small bowel obstruction (SBO), and the autonomic nervous system. METHODS: In this retrospective study, a total of 13 patients with IC or SBO aged ≧65 years were analyzed. CVRR was measured in patients with IC and SBO and controls. RESULTS: CVRR averaged to 8.8% ± 2.5% in controls, 1.4% ± 0.4% in patients with IC, and 2.4% ± 1.0% in SBO groups (p < 0.001). CVRR was significantly lower in patients with IC and SBO than that in controls. CONCLUSION: The results of this study demonstrate the possibility that CVRR may serve as a clinical index for assessing the functioning of the parasympathetic nervous system in patients with IC or SBO.

Lower gastrointestinal distress in endurance athletes.

Training regimens and race days place significant demands upon both the competitive endurance athlete and the frequent-recreational runner. Lower gastrointestinal derangements, especially those involving diarrhea and rectal bleeding, are common and can impact adversely both the performance and the health of the athlete. While most cases are relatively benign, more significant and severe symptoms may not only impair sports performance, but also signify more serious disease. The sports medicine clinician should be familiar with the management of these problems in order to optimize treatment, facilitate return to play, and maximize the athlete's potential.

Acute colonic ischaemia in rats results in long-term structural changes without alterations of colonic sensitivity.

Colonic ischaemia and mast cells have been involved in the pathophysiology of the functional gastrointestinal disorder irritable bowel syndrome, although the cause-effect relationships remain unknown. We assessed long-term histopathological and functional changes associated to an acute ischaemic episode (1 h) of the colon, followed by 8-week recovery, in rats. Functional colonic alterations [sensitivity during colorectal distension (CRD), compliance and propulsive motility] were assessed regularly during the recovery. Colonic histopathology (presence of inflammation, morphometric alterations and variations in neuronal density in the enteric nervous system) 8-week postischaemia was assessed. Following ischaemia, none of the functional parameters tested (motility, sensitivity and compliance) were affected. At necropsy, the colon presented an overall normal appearance with an increase in weight of the ischaemic area (mg/cm: 99 +/- 6; P < 0.05 vs. control: 81 +/- 4 or sham ischaemia: 81 +/- 3). Histopathological evaluations revealed the presence of a local infiltrate of mast cells in the area of ischaemia (nb of mast cells: 142 +/- 50; P < 0.05 vs. control, 31 +/- 14 or sham ischaemia: 40 +/- 16), without other significant alterations. Animals subjected to colonic ischaemia and treated 8 weeks later with the mast cell degranulator, compound 48/80, showed no changes in CRD-related pain responses. These studies show that acute colonic ischaemia is associated with the presence of a long-term local infiltration of mast cells, located within the serosa and muscle layers, despite the absence of functional changes, including colonic sensitivity. Considering the important pathophysiological functions of mast cells, the observed mast cell infiltration may be involved in ischaemia-induced functional changes yet to be characterized.

Rebamipide enema therapy for left-sided ischemic colitis patients accompanied by ulcers: open label study.

AIM: To attempt rectal administration of rebamipide in the treatment of ischemic colitis patients with ulcers, and evaluate its effects. METHODS: We compared 9 ischemic colitis patients (2 men, 7 women) with ulcers treated by bowel rest only from 2000 to 2005 (conventional therapy group), with 6 patients (2 men, 4 women) treated by rebamipide enema therapy in 2006 (rebamipide enema therapy group) and analyzed the mean duration of fasting and hospitalization, degree of ulcer healing, and decrease in WBC count for the two groups. RESULTS: The mean duration of fasting and hospitalization were 2.7+/-1.8 d and 9.2+/-1.5 d in the rebamipide group and 7.9+/-4.1 d and 17.9+/-6.8 d in the control group, respectively, and significantly reduced in the rebamipide group (t= -2.915; P=0.0121 and t= -3.054; P=0.0092). As for the degree of ulcer healing at 7 d after admission, the ulcer score was reduced by 3.5+/-0.5 (points) in the rebamipide group and 2.8+/-0.5 (points) in the control group (t=1.975; P=0.0797), while the decrease in WBC count was 120.0+/-55.8 (x 10(2)/microL) in the rebamipide group and 85.9+/-56.8 (x 10(2)/microL) in the control group (t=1.006; P=0.3360). CONCLUSION: In left-sided ischemic colitis patients with ulcers, rebamipide enema therapy significantly reduced the duration of fasting and hospitalization, recommending its use as a new and effective therapeutic alternative.

Fatal intestinal ischemia after laparoscopic correction of incisional hernia.

BACKGROUND AND OBJECTIVES: Intestinal ischemia is a very rare complication of laparoscopic procedures. In this report, we describe the first case of fatal large bowel ischemia in the aftermath of laparoscopic incisional hernia repair. METHODS: A literature search using PubMed was performed to identify all published cases of intestinal ischemia following laparoscopic procedures. RESULTS: Our search revealed 13 cases of intestinal ischemia following various laparoscopic procedures. Including this one, 10 of 14 cases reported on so far had impaired cardiovascular, hepatic or renal function or atherosclerosis. None of these patients-at-risk survived. In this series, no indications of faulty operative technique could be identified. CONCLUSION: Patient-related risk factors seem to play the most important role in the development of this rare but devastating complication. Preventive measures and methods to identify patients at risk for developing intestinal ischemia during and after laparoscopy are not completely clear. Patient selection, an optimal hydration status, an optimized technique with lowest insufflation pressure possible, and intermittent decompressions of the abdomen when the procedure is lengthy are the measures that have a potential to prevent this complication. Whatever laparoscopic procedure has been performed, intestinal ischemia should be considered in any patient with nonspecific abdominal symptoms.

Seasonal variation in occurrence of ischemic colitis: a retrospective study.

Objectives We aimed to identify the clinical characteristics of ischemic colitis (IC) and to investigate the occurrence of seasonal variation. Methods From January 2008 to December 2014, 368 had IC as the reason for their admission. A total of 364 patients were enrolled in this study. We investigated patient characteristics and seasonal variations in incidence. Results The mean age (±standard deviation) of patients with IC at diagnosis was 66.8 (±16.9) years. Most patients had abdominal pain (341 cases), hematochezia (337 cases), and diarrhea (199 cases) as their chief complaints. The clinical courses of the disease were classified as transient (294 cases), stricture (17 cases), gangrenous (2 cases), and indeterminate types (51 cases). Although IC tended to occur less frequently in winter, the seasonal difference was not significant. Conclusion There is currently no evidence for seasonal variation in hospital admissions for IC.

Factors predicting poor prognosis in ischemic colitis.

AIM: To determine the clinical, analytical and endoscopic factors related to ischemic colitis (IC) severity. METHODS: A total of 85 patients were enrolled in a retrospective study from January 1996 to May 2004. There were 53 females and 32 males (age 74.6+/-9.4 years, range 45-89 years). The patients were diagnosed as IC. The following variables were analyzed including age, sex, period of time from the appearance of symptoms to admission, medical history, medication, stool frequency, clinical symptoms and signs, blood tests (hemogram and basic biochemical profile), and endoscopic findings. Patients were divided in mild IC group and severe IC group (surgery and/or death). Qualitative variables were analyzed using chi-square test and parametric data were analyzed using Student's t test (P<0.05). RESULTS: The mild IC group was consisted of 69 patients (42 females and 27 males, average age 74.7+/-12.4 years). The severe IC group was composed of 16 patients (11 females and 5 males, average age of 73.8+/-12.4 years). One patient died because of failure of medical treatment (no surgery), 15 patients underwent surgery (6 after endoscopic diagnosis and 9 after peroperatory diagnosis). Eight of 85 patients (9.6%) died and the others were followed up as out-patients for 9.6+/-3.5 mo. Demographic data, medical history, medication and stool frequency were similar in both groups (P>0.05). Seriously ill patients had less hematochezia than slightly ill patients (37.5% vs 86.9%, P = 0.000). More tachycardia (45.4% vs 10.1%, P = 0.011) and a higher prevalence of peritonism signs (75% vs 5.7%, P = 0.000) were observed in the severe IC group while the presence and intensity of abdominal pain were similar between two groups. Two patients with severe IC had shock when admitted. Regarding analytical data, more seriously ill patients were found to have anemia and hyponatremia than the mildly ill patients (37.5% vs 10.1%, P = 0.014 and 46.6% vs 14.9%, P = 0.012, respectively). Stenosis was the only endoscopic finding that appeared more frequently in seriously ill patients than in slightly ill patients (66.6% vs 17.3%, P = 0.017). CONCLUSION: The factors that can predict poor prognosis of IC are the absence of hematochezia, tachycardia and peritonism, anemia and hyponatremia and stenosis.