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CLINICAL FEATURES OF A LONG-COURSE ISCHEMIC COLITIS

Autor:

Prof. Dr. Júlio César M Santos Jr.TSBCP,TCBC

 

 

 

Introduction

Abstract

Patients and methods

Results

Discussion

References

 

 

 

Abstract

Seventy-six patients with ischemic colitis whose symptoms began an average of 42 days before admission, and a 9 days delay in diagnosis were analyzed to determine the clinical patterns of a long-course disease. Diagnosis was made based on clinical, endoscopic, roentgenologic and pathologic criteria. All but 3 patients were divided into two groups, one treated operatively(58%) and the other non-operatively(42%). Sixty-one patients (83%) had associated medical disease and 53% had Chagas’ megacolon. Severe hipoproteinemia was seen in almost all patients, and 57% of them had edema. Abdominal pain (94%) and diarrhea (85%) or bloody diarrhea (68%) were the most common symptoms. The ischemic lesion affected the left side of the colon in all cases (100%). Mortality was 33% for operatively managed cases and 16 % for non-operatively managed cases. Ischemic colitis affects chagasic megacolon and is a severe disease with high mortality rate, especially in older patients, and is frequently associated with several medical illnesses.
Key words: Ischemic colitis, delay in diagnosis, clinical pattern, Chagas’ megacolon

Key words: Ischemic colitis, delay in diagnosis, clinical pattern, Chagas’ megacolon

 

INTRODUCTION
Ischemic colitis is a common well-defined vascular disorder of the large bowel in the elderly, and perhaps the most frequent form of intestinal inflammation in patients more than 50 years without identifiable cause(1-3). Usually three types of ischemic colon injury have been described: a transient reversible form, a chronic form, and a gangrenous form. Boyle(4) pointed out that over a half of the patients have a transient form of disease, and 20% each have evidence of persistent chronic colitis with different features of clinical presentation depending on the extend of the affected colon segment (2,4). The objectives of the present report were 1) to review the clinical course and patterns of persistent ischemic colitis in patients with a long- course disease and delay diagnosis and medical care, and 2) to describe the association of ischemic lesions in patients with Chagas’ megacolon frequently misdiagnosed as infectious colitis(5,6).

 

PATIENTS AND METHODS
The study was conducted on patients with a definitive diagnosis of ischemic colitis selected from all patients with "colitis" admitted to University Hospital, Medical School of Ribeirao Preto, SP-Brazil, from 1976 to 1995. Diagnosis of ischemic colitis was made based on clinical, endoscopic with biopsy, or roentgenologic criteria for cases medically managed and on clinical, endoscopic with biopsy, and pathologic criteria for cases underwent operative treatment. The criteria adopted was the same describe by Brandt and col (2). Patients with intestinal ischemia due mesenteric arterial thrombosis, large bowel obstruction secondary to colon carcinoma, intestinal volvulus or those that not satisfied the diagnosis criteria were excluded. Age, sex, physical findings, associated medical problem, presence of symptoms, duration of disease, delay in diagnosis, white blood cells count (WBC), hemoglobin (HB), total serum protein(TSP), albumin (ALB), treatment and outcome were reviewed. Patients were allocated in two groups (operated and non-operated) according to severity of the ischemic lesion and proposed treatment.

 

 

RESULTS

We identified 76 patients with ischemic colitis admitted to the University Hospital over a period of 16 years. In three patients the diagnosis was made at autopsy. Seventy-three patients were treated: 31 (42%) non-operatively and 42 (58%) operatively. There were 46 men and 27 women ranging in age from 23 to 88 years (mean = 61.4 yr.). Fourteen patients (19%) were less than 50 years of age, and 24(33%) were 70 years or older. Duration of disease, delay in diagnosis, number of patients with associated illnesses are shown in Table 1.

Table 1. Demographic data, duration of disease, delay diagnosis, and number of patients with associated medical disease


DATA

OPERATIVE
n=42(58)

NON-OPERATIVE
n=31(42)

TOTAL
n=73(100)

Male : Female

32:10

14:17

46:27

*Age

58.0
[23-87];16.7

63.6
[37-88];11.4

61.4
[23-88];13.9

*Duration of disease(days)

51.0
[0-183];50.6

31.0
[1-128];30.0

42.3
[0-183];43

*Delay in diagnosis(days)

9.6
[0-46];9.5

8.0
[0-33];9.4

9.0
[0-46];9.9

Patients with
associated medical
disease

 
37 (90)

 
24 (75)

 
61 (83)

* = mean, range, and standart desviation; numbers in parentheses indicate percentage
The most common presenting symptoms were abdominal pain, diarrhea with or without blood, anemia and fever (Table 2)

 

Table 2. Presenting signs and symptoms and principal diagnostic procedures  


Data

Operative
n = 42

Non-operative
n = 31

Total
n = 73

Abdominal pain

40 (97)

29 (93)

69

Diarrhea
with blood

35 (83)
29 (69)

27 (87)
21 (67)

62
50

Anemia

33 (78)

13 (42)

46

Fever

31 (74)

19 (61)

50

Weight loss

31 (74)

12 (38)

43

Edema

31 (74)

11 (37)

42

Anorexia

28 (68)

10 (32)

38

DIAGNOSIS PROCEDURE

Endoscopic examination

35

31

66(90)

a. colonoscopy
b. colonoscopy and barium enema
c. proctosigmoidoscopy

21
9
5

22
8
1

43
17
6

Surgery

7

-

7 (9)

Total

42

31

73(100)

numbers in parentheses indicate percentage

Forty-two patients (57%) had edema of lower extremities in agreement with the low levels of serum albumin (Table 2 and 3).

 

Table 3. Laboratories data of 73 for patients with ischaemic colitis  


*DATA

OPERATIVE
n = 42

NON-OPERATIVE
n = 31

TOTAL
n = 73

Hemoglobin
gm/dl

10.4
[6-17];2.4

11.8
[7-16];2.34

10.9
[6-17];2.5

WBC

8912
[1800-38200];6300

11480
[3300-29300];6486

10477
[2500-38200];6657

TSP gm/dl

5.5
[3.3-7.8];1.2

6.5
[4.9-8.7];0.98

5.9
[3.3-8.7];1.1

ALBUMIN
gm/dl

2.63
[1.0-4.3];0.74

3.1
[1.8-4.6];0.74

2.8
[1.6-4.6];0.75

* mean,[range], standard desviation; WBC= withe blood count; TSP= total serum protein


 

 Sixty-one patient (83%) had associated medical illnesses and the most frequent of them were Chagas’ disease with megacolon, arterial hypertension, alcoholism, diabetes, and chronic obstructive pulmonary disease(Table 4).

Table 4. Associated medical problems in 61 patients with ischaemic colitis  


Disease

Operative
n=37/42 (88)

Non-operative
n=24/31 (77)

Total
n=61/73 (83)

Chagas’ megacolon

29/37 (78)

10/24 (41)

39 (54)

COPD*

7(19)

1 ( 4)

8 (11)

Arterial hypertension

5 (5)

7 (29)

12 (16)

Alcoholism

4(11)

4 (16)

8 (11)

Diabetes

3 (8)

5 (8)

8 (11)

CHF**

2 (5)

2 (8)

4 (5)

Other

3 (8)

3 ( 9)

6 (8)

*COPD = Chronic obstructive pulmonary disease;** CFH = Congestive heart failure; numbers in parentheses indicate percentage
Diagnosis was made at endoscopic examination and biopsy in 67 patients (90%), by associated air contrast barium enema, colonoscopy and biopsy in 17 (23%), and by surgery in 7 patients (9%) (Table 2). The sites of ischemia within the large bowel among all patients are listed in Table 5. All but three patients (96%) had ischemia developed in left colon.

 

 Table 5. Ischaemic colitis: Location in large


bowel  Location

Operative
n = 42

Non-operative
n = 31

Total
n = 73

Left colon

14 (33)

2 (6)

16 (22)

Descendent

8 (19)

15 (48)

23 (31)

Sigmoid-descendent

8 (19)

4 (13)

12 (16)

Sigmoid

6 (14)

3 (9)

9 (12)

Rectum-sigmoid

3 (7)

5 (16)

8 (11)

Descend-transv

2 (5)

-

2 (2)

Splenic flexure

1 (2)

-

1

Transverse

-

2 (6)

2 (2)

All colon

-

1 (3)

1

numbers in parentheses indecate percentage

 

 Among patients operatively managed, 24 (58%) initially underwent an intestinal stoma (colostomy or ileostomy) to improve the general condition for later elective surgical treatment. Among them there were 8 (33%)deaths, the rest 16 patients (66%) underwent elective operation with no death. Eighteen patients (43%) in the operative group were managed without a previous stoma and the surgical procedure was performed as an definitive emergency operation. Six of these patients (33%) died. The operative procedures and outcome are shown in Table 6.
Table 6. Outcome of surgery treatment among 42 patients with ischemic colitis operatively managed with performed previous stoma (elective operation) and without previous stoma (emergency operation)


Outcome

Stoma
n = 24

Without stoma
n = 18

total
n = 42

p

Alive

16*

18* 

34**

 

Death

-

p<0.05

Total

24 

18 

42 

 

Definitive surgical treatment
n = 34**

Outcome

Elective Operation
pacients with stomas
n=16*

Emergency operation
patients witout stomas
n=18*

total

p

Alive

16(100)

12(67)

28

 

Death

-

6(33)

6

p<0.05

Total

16 

18 

34

 

numbers in parentheses indicate percentage

 

There was no relevant distinguishing feature between the non-operative and operative groups determining the result of treatment, except for the severity of the lesion itself pointed out by death rate between patients operatively managed with or without stoma (Table 7). The same has occured between group of patients with acquired megacolon (Chagas's disease) and others (Table 8).

Table 7. Outcome of management, laboratory data, age, duratino of disease, delay in diagnosis, and diagnoisis at admission on 73 patients with ischemic colitis  

 

Operative

Non-operative

Data

Dead (14/42)

Alive (28/42)

Dead (5/31)

Alive (26/31)

*Age(yr.)

61

56

58.4

65

Hemoglobin gm/dl

9.6

10.9

11

12

TSP gm/dl

5.2

6.9

5.6

6.7

Albumin gm/dl

2.4

3.57

2.6

3.2

WBC

10,976

7,706

14,860

11,281

*Duration of disease(days)

30

63.3

37.2

28.7

*Delay in diagnosis(days)

9.7

9.5

9.4

9.2

Diagnosis at admission

Infectious colitis

9/14(64)

12/28(43)

3/5(60)

11/26(42)

Ischaemic colitis

3(21)

3(10)

1(20)

3(11)

* mean; TSP= total serum protein; numbers in parentheses indicate percentage

 

Table 8.  Management and outcome comparison between  chagasic patients with  megacolon and ischaemic colitis and patients
without megacolon   


Procedure

Operative(42)

Non-operative(31)

 

Outcome

Alive

Death

Aliive

Death

Total

Chagas’ megacolon

21 (50)

8 (19)

8 (26)

2 (6)

39

Others

7 (16)

6 (14)

18 (58)

3 (10)

34

Total

28 (67)

14 (33)

26 (84)

5 (16)

73

 

 

 

    DISCUSSION

Severe but not fulminating ischemic colitis can result in a long-course disease with a large spectrum of symptoms including an acute stage of sudden onset of cramp, mild abdominal pain, defecation with passage of either bright red or brown blood mixed with stool. This initial phase is commonly seen in almost all patients with colonic ischemia. In two thirds of these patients the disease has a protracted course as a chronic irreversible colitis (2-4) with persistent bloody diarrhea, abdominal distention, hipoproteinemia due a protein-losing enteropathy, anemia, anorexia, weight loss and swelling (7,8). The diverse spectrum of signs and symptoms can be misdiagnosed with infectious colitis or inflammatory bowel disease(2) and depends on the severity of colon damage and on the length of the affected segment. Many cases of infectious or inflammatory colitis due secondary to modification of intestinal flora caused by chronic fecal stasis has been describe in Chagas’ megacolon(5,6). However, in our series, the extensive large bowel inflammatory damage of our patients with Chagas’ megacolon was diagnosed as secondary to ischemia, as described elsewhere(8,9).
In our identified 76 patients with ischemic colitis there were special features such as average time of evolution of disease before hospital admission, the delay in diagnosis after admission and the incidence of large bowel ischemia affecting patients with megacolon (39/73; 53%) representing 4% of our all operated cases of chagasic megacolon. Duration of disease and delay in diagnosis were  factors leading to morphologic changes of the colon and an complex clinical presentation not observed in other series. Patients with long course of untreated disease come to the hospital presenting abdominal pain, diarrhea, severe hipoproteinemia due protein-losing enteropathy, mainly from extensive damaged large bowel mucous; edema, emaciation and anemia. Despite their prolonged course and clinical picture, almost all of our patient were seen as having infectious enterocolitis. Fifty-six per cent of patients in our series had an irreversible form of ischemic colonic injury with strictured, leading us to decide for surgical treatment. They were anemic, mal-nourished, emaciated, distended diarrheic and swollen patients. Almost all of them were recovered with intestinal stoma which allowed the diseased colon rest, with improved clinical and laboratory data.
The surgical approach was also based on the evolution of the disease (10) before or after a stoma, on serial endoscopic appearance of ischemic insult, extent and depth of mucous lesion, presence of an inelastic or non-distensible colon, large scarped ulcers, strictured segment, and low total serum protein or albumin.
Ischemic colitis frequently proves to be a severe disease with high mortality rate not only to the disease itself but also the advanced age of patients who commonly present diverse and critical associated medical conditions (11,12.). It has an incidence of 4% in the population of patients with Chagas’ disease and can be misdiagnosed as inflammatory or infectious colitis in the presence of megacolon(8,9).

 

References

  1. Brandt LJ, Goldberg L, Boley SJ, Mitsudo S, and Berman A. Ulcerating colitis in the elderly. Gastroenterology(abstract) 1979;76: 1106
  2. Brandt J, Boley SJ, Goldberg L, Mitsudo S, and Berman A. Colitis in the elderly: A reappraisal. Am J Gastroenterol 1981;76:239-245.
  3. Brandt LJ and Boley SJ. Colonic ischemia. Surg Clin North Amer 1992;72:203-209.
  4. Boley SJ. Colonic ischemia - 25 years later. Am J Gastroenterol 1990;85: 931-934.
  5. Ginani FF, Rezende MS, Magalhães AV, Barbosa JA and Barbosa HB. Toxic dilatation of the colon in the chagasic megacolon. Rev Assoc Med Bras 1976;22: 32-33.
  6. Kobyasi S, Mendes EF, Rodrigues MAM and Franco MF. Toxic dilatation of the colon in Chagas’ disease. Br J Surg 1992;79:1202-3.
  7. Longo WE, Ballantyne GH, Gusberg BJ. Ischemic colitis. Patterns and prognosis. Dis Colon Rectum 1992;35:726-730.
  8. Santos Jr JCM e Guimarães AS. Colite isquêmica - Diagnóstico e Conduta Terapêutica. In: Paula-Casto L e Savassi-Rocha PR, eds. Tópicos em Gastroenterologia -1. Rio de Janeiro: Medsi, 1990:195-208.
  9. Santos Jr JCM e Guimarães AS. Colite isquêmica. In: Savassi-Rocha PR, Andrade JI e Souza C, eds. Abdômen Agudo - Diagnóstico e Tratamento. São Paulo: Medsi, 1993:509-513.
  10. Toda J, Misaki F, Kawai K. Analysis of the clinical features of ischemic colitis. Gastroenterol Jpn 1983;18:204-209.
  11. Abel ME, Russel TR. Ischemic colitis: comparison of surgical and nonoperative management. Dis Colon Rectum 1983; 26: 113-115.
  12. Guttormson N and Budrick MP. Mortality from ischemic colitis. Dis Colon Rectum 1989;32:469-472.