Surgical Treatment of Ischemic Colitis" Report o f a Case* HARVEY LOZMAN, M . D . , t VENKAT RAO, M.D.:~
ISCHEMIC COLITIS a n d its v a r i a n t forms, r a n g i n g f r o m m i n i m a l m u c o s a l e d e m a to intestinal infarction, have b e e n associated with a wide s p e c t r u m o f etiologic factors. N o n s p e c i f i c signs a n d s y m p t o m s d e p e n d u p o n the severity o f vascular insult. A l t h o u g h visceral arterial occlusion m a y be p r e s e n t in 50 p e r cent o f cases, Williams et al. a stress that a r t e r i o g r a p h y is n o t essential f o r m a n a g e m e n t , a n d r e c o m m e n d conservative t h e r a p y in mild cases a n d intestinal resection in severe cases. T h i s is a r e p o r t o f ischemic colitis in a patient with p r o t r a c t e d lower a b d o m i n a l pain u n r e l a t e d to meals, w h o h a d i n t e r m i t t e n t b l o o d y d i a r r h e a following r i g h t h e m i c o l e c t o m y f o r s p o n t a n e o u s cecal i n f a r c t i o n . C o n s e r v a t i v e t h e r a p y failed. O u r inability to localize a specific site o f colonic i n v o l v e m e n t despite r e p e a t e d b a r i u m - e n e m a e x a m i n a t i o n s a n d e n d o s c o p i c evaluations p r e c l u d e d colonic resection. H o w e v e r , a b d o m i nal a n g i o g r a p h i c e v i d e n c e o f stenosis o f the celiac a r t e r y a n d occlusion o f the s u p e r i o r m e s e n t e r i c a r t e r y prompted an aortoceliac bypass with relief of s y m p t o m s . This case is u n u s u a l in t h a t ischemic colitis was c o r r e c t e d by a n arterial bypass p r o c e d u r e , an app r o a c h n o t p r e v i o u s l y t h o u g h t to be o f v a l u e ?
R e p o r t o f a Case A 64-year-old hypertensive Hispanic woman was first admitted to Beth Israel Medical Center in June 1977 because of severe abdominal pain unrelated to meals and intermittent rectal bleeding with mucus. She denied vomiting and weight loss. In March 1977, abdominal exploration for appendicitis at another institution revealed a cecal infarction, which was treated by right hemicolectomy. The mesenteric vessels in the specimen were patent. Five days postoperatively, an intestinal obstruction necessitated laparotomy and lysis of adhesions. Physical findings were normal except for hypertension, an epigastric bruit, and diffuse lower abdominal tenderness. Barium* Received for publication May 12, 1973. ? Attending Surgeon, Section of Vascular Surgery, Beth Israel Medical Center; Assistant Clinical Professor of Surgery, Mount Sinai School of Medicine, City University of New York. Resident, Department of Surgery, Beth Israel Medical Center; Instructor, Mount Sinai School of Medicine. Address reprint requests to Dr. Lozman: Section of Vascular Surgery, Beth Israel Medical Center, 10 Nathan D. Perlman Place, New York, New York 10003.
From the Section of Vascular Surgery, Department of Surgery, Beth Israel Medical Center, and The Mount Sinai School of Medicine, City University of New York, New York, New York enema examination, upper gastrointestinal series, sigmoido~opy, colonoscopy, and oral cholecystogram disclosed no abnormality. Abdominal angiography revealed stenosis of the celiac artery, occlusion of the orifice of the superior mesenteric artery, and renal arterial stenosis (Fig. 1). The symptoms abated and the patient was discharged. In September 1977, she was readmitted with a three-day history of severe abdominal pain, which was unrelated to meals and was associated with loose bloody bowel movement with mucus. A month prior to readmission, she had had a similar episode, lasting five days. Upper gastrointestinal series, barium-enema examination, esophagogastroduodenoscopy, and colonoscopy disclosed no abnormality. Examination of a biopsy specimen obtained via the colonoscope from the iteocolic anastomotic site revealed focal hyperemia. In spite of conservative therapy, the patient's sym proms persisted, and three weeks after admission an aortoceliac bypass was performed (Fig. 2). Postoperatively, there was no bloody diarrhea. Six months after the operation the patient is asymptomafic. Comments This was a case o f severe ischemic colitis in a patient w h o h a d s p o n t a n e o u s cecal i n f a r c t i o n followed by rec u r r e n t a b d o m i n a l pain a n d b l o o d y d i a r r h e a . E n d o scopic a n d b a r i u m - e n e m a studies failed to d o c u m e n t a specific site o f colonic i n v o l v e m e n t . A d i l e m m a in m a n a g e m e n t o c c u r r e d , since c o n s e r v a t i v e t h e r a p y failed a n d r e p o r t e d a t t e m p t s by o t h e r s to r e v e r s e the disease by c o r r e c t i o n o f vessel occlusion h a d b e e n unsuccessful? I n 1963, Boley et al. t e x p e r i m e n t a l l y p r o v e d that m e c h a n i c a l i n t e r f e r e n c e with the colonic b l o o d s u p p l y c o u l d p r o d u c e lesions c o m p a t i b l e with ischemic colitis in dogs. M y o c a r d i a l infarction, h y p o v o l e m i a , collagen disease, e m b o l i to colonic vessels, leukemia, d r u g ingestion, a n d ligation o f the i n f e r i o r m e s e n t e r i c a r t e r y d u r i n g a b d o m i n a l aortic surgical p r o c e d u r e s have all b e e n inciting factors in m a n . Since visceral arterial o c c l u s i o n is n o t a l w a y s p r e s e n t , d i m i n u t i o n o f s p l a n c h n i c p r e s s u r e to less t h a n the closing p r e s s u r e o f the colonic arterioles a p p e a r s to be the c o m m o n p r e d i s p o s i n g factor.
0012-3706/78/1000/0520/$00.60 9 American Society of Colon and Rectal Surgeons
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V o l u m e 21 Number 7
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SURGICAL TREATMENT OF ISCHEMIC COLITIS
Williams et al. a r e p o r t e d 19 cases o f patients with ischemic colitis a n d reviewed the relevant medical literature. A b d o m i n a l pain was p r e s e n t in 75 per cent o f their cases. D i a r r h e a was p r e s e n t in 61 per cent. O f those 61 per cent, 69 per cent had bloody diarrhea. T h e y c o n c l u d e d that visceral arterial occlusion cannot be used to establish severity or therapy, a n d stressed that a r t e r i o g r a p h y is not essential to clinical m a n a g e ment. T h e y e m p h a s i z e d the total clinical picture in establishing a diagnosis, since neither histologic material n o r b a r i u m studies were specific. In a review of 15 cases o f patients o p e r a t e d on for chronic visceral ischemia, H e r t z e r et al. ~- r e f e r r e d to f o u r patients who h a d features o f b o t h chronic and acute ischemia. T w o distal small-intestinal resections and a right hemicolectomy for three separate episodes of infarction were necessary in one case. Abd o m i n a l a n g i o g r a p h y r e v e a l e d o c c l u s i o n o f the s u p e r i o r mesenteric a r t e r y and severe stenosis of the celiac a r t e r y and the inferior m e s e n t e r i c artery. T h e acute ischemic episodes were a t t r i b u t e d to emboli f r o m a plaque within the s u p e r i o r mesenteric artery. H o w e v e r , emboli were not d o c u m e n t e d by a b d o m i n a l
Fro. 2. Aortoceliac bypass using 6-mm wo~en Dacron.
a n g i o g r a p h y o r o p e r a t i o n . It is possible that diminished splanchnic p e r f u s i o n d u e to large-vessel occlusion with i n a d e q u a t e collaterals could have b e e n responsible for the acute ischemic episodes. O u r case could not be categorized as classic intestinal visceral ischemia, since the strict prerequisites for diagnosis, which are r e p r o d u c i b l e a b d o m i n a l pain related to meals, d i a r r h e a , a n d weight loss, were not found. T h e i n t e r m i t t e n t s y m p t o m s , a b d o m i n a l pain and bloody d i a r r h e a several m o n t h s after s p o n t a n e ous cecal infarction, a l t h o u g h atypical, are m o r e readily attributable to ischemic colitis. A b d o m i n a l a r t e r i o g r a p h y a n d correction o f occlusion o f visceral vessels m a y be o f value in ischernic colitis with p r o t r a c t e d i n t e r m i t t e n t s y m p t o m s when conservative t h e r a p y fails a n d an involved area of colon a m e n a b l e to resection c a n n o t be d e m o n s t r a t e d . References
FIG. I. Stenosis of the celiac artery; occlusion of the superior mesenteric arter?; stenosis of the renal artery.
1. Boley SJ, Schwartz S, Lash J. et al: Reversible vascular occlusion of the colon. Surg Gynecol Obstet 116:53, 1963 2. Hertzer NR. Beven EG, Humphries AW: Chronic intestinal ischemia. Surg Gynecol Obstet 145:321, 1977 3. Williams LFJr. Wittenberg J: Ischemic colitis: An useful clinical diagnosis, but is it ischemic? Ann Surg I82: 439, i975
ISCHEMIC COLITIS a n d its v a r i a n t forms, r a n g i n g f r o m m i n i m a l m u c o s a l e d e m a to intestinal infarction, have b e e n associated with a wide s p e c t r u m o f etiologic factors. N o n s p e c i f i c signs a n d s y m p t o m s d e p e n d u p o n the severity o f vascular insult. A l t h o u g h visceral arterial occlusion m a y be p r e s e n t in 50 p e r cent o f cases, Williams et al. a stress that a r t e r i o g r a p h y is n o t essential f o r m a n a g e m e n t , a n d r e c o m m e n d conservative t h e r a p y in mild cases a n d intestinal resection in severe cases. T h i s is a r e p o r t o f ischemic colitis in a patient with p r o t r a c t e d lower a b d o m i n a l pain u n r e l a t e d to meals, w h o h a d i n t e r m i t t e n t b l o o d y d i a r r h e a following r i g h t h e m i c o l e c t o m y f o r s p o n t a n e o u s cecal i n f a r c t i o n . C o n s e r v a t i v e t h e r a p y failed. O u r inability to localize a specific site o f colonic i n v o l v e m e n t despite r e p e a t e d b a r i u m - e n e m a e x a m i n a t i o n s a n d e n d o s c o p i c evaluations p r e c l u d e d colonic resection. H o w e v e r , a b d o m i nal a n g i o g r a p h i c e v i d e n c e o f stenosis o f the celiac a r t e r y a n d occlusion o f the s u p e r i o r m e s e n t e r i c a r t e r y prompted an aortoceliac bypass with relief of s y m p t o m s . This case is u n u s u a l in t h a t ischemic colitis was c o r r e c t e d by a n arterial bypass p r o c e d u r e , an app r o a c h n o t p r e v i o u s l y t h o u g h t to be o f v a l u e ?
R e p o r t o f a Case A 64-year-old hypertensive Hispanic woman was first admitted to Beth Israel Medical Center in June 1977 because of severe abdominal pain unrelated to meals and intermittent rectal bleeding with mucus. She denied vomiting and weight loss. In March 1977, abdominal exploration for appendicitis at another institution revealed a cecal infarction, which was treated by right hemicolectomy. The mesenteric vessels in the specimen were patent. Five days postoperatively, an intestinal obstruction necessitated laparotomy and lysis of adhesions. Physical findings were normal except for hypertension, an epigastric bruit, and diffuse lower abdominal tenderness. Barium* Received for publication May 12, 1973. ? Attending Surgeon, Section of Vascular Surgery, Beth Israel Medical Center; Assistant Clinical Professor of Surgery, Mount Sinai School of Medicine, City University of New York. Resident, Department of Surgery, Beth Israel Medical Center; Instructor, Mount Sinai School of Medicine. Address reprint requests to Dr. Lozman: Section of Vascular Surgery, Beth Israel Medical Center, 10 Nathan D. Perlman Place, New York, New York 10003.
From the Section of Vascular Surgery, Department of Surgery, Beth Israel Medical Center, and The Mount Sinai School of Medicine, City University of New York, New York, New York enema examination, upper gastrointestinal series, sigmoido~opy, colonoscopy, and oral cholecystogram disclosed no abnormality. Abdominal angiography revealed stenosis of the celiac artery, occlusion of the orifice of the superior mesenteric artery, and renal arterial stenosis (Fig. 1). The symptoms abated and the patient was discharged. In September 1977, she was readmitted with a three-day history of severe abdominal pain, which was unrelated to meals and was associated with loose bloody bowel movement with mucus. A month prior to readmission, she had had a similar episode, lasting five days. Upper gastrointestinal series, barium-enema examination, esophagogastroduodenoscopy, and colonoscopy disclosed no abnormality. Examination of a biopsy specimen obtained via the colonoscope from the iteocolic anastomotic site revealed focal hyperemia. In spite of conservative therapy, the patient's sym proms persisted, and three weeks after admission an aortoceliac bypass was performed (Fig. 2). Postoperatively, there was no bloody diarrhea. Six months after the operation the patient is asymptomafic. Comments This was a case o f severe ischemic colitis in a patient w h o h a d s p o n t a n e o u s cecal i n f a r c t i o n followed by rec u r r e n t a b d o m i n a l pain a n d b l o o d y d i a r r h e a . E n d o scopic a n d b a r i u m - e n e m a studies failed to d o c u m e n t a specific site o f colonic i n v o l v e m e n t . A d i l e m m a in m a n a g e m e n t o c c u r r e d , since c o n s e r v a t i v e t h e r a p y failed a n d r e p o r t e d a t t e m p t s by o t h e r s to r e v e r s e the disease by c o r r e c t i o n o f vessel occlusion h a d b e e n unsuccessful? I n 1963, Boley et al. t e x p e r i m e n t a l l y p r o v e d that m e c h a n i c a l i n t e r f e r e n c e with the colonic b l o o d s u p p l y c o u l d p r o d u c e lesions c o m p a t i b l e with ischemic colitis in dogs. M y o c a r d i a l infarction, h y p o v o l e m i a , collagen disease, e m b o l i to colonic vessels, leukemia, d r u g ingestion, a n d ligation o f the i n f e r i o r m e s e n t e r i c a r t e r y d u r i n g a b d o m i n a l aortic surgical p r o c e d u r e s have all b e e n inciting factors in m a n . Since visceral arterial o c c l u s i o n is n o t a l w a y s p r e s e n t , d i m i n u t i o n o f s p l a n c h n i c p r e s s u r e to less t h a n the closing p r e s s u r e o f the colonic arterioles a p p e a r s to be the c o m m o n p r e d i s p o s i n g factor.
0012-3706/78/1000/0520/$00.60 9 American Society of Colon and Rectal Surgeons
520
V o l u m e 21 Number 7
521
SURGICAL TREATMENT OF ISCHEMIC COLITIS
Williams et al. a r e p o r t e d 19 cases o f patients with ischemic colitis a n d reviewed the relevant medical literature. A b d o m i n a l pain was p r e s e n t in 75 per cent o f their cases. D i a r r h e a was p r e s e n t in 61 per cent. O f those 61 per cent, 69 per cent had bloody diarrhea. T h e y c o n c l u d e d that visceral arterial occlusion cannot be used to establish severity or therapy, a n d stressed that a r t e r i o g r a p h y is not essential to clinical m a n a g e ment. T h e y e m p h a s i z e d the total clinical picture in establishing a diagnosis, since neither histologic material n o r b a r i u m studies were specific. In a review of 15 cases o f patients o p e r a t e d on for chronic visceral ischemia, H e r t z e r et al. ~- r e f e r r e d to f o u r patients who h a d features o f b o t h chronic and acute ischemia. T w o distal small-intestinal resections and a right hemicolectomy for three separate episodes of infarction were necessary in one case. Abd o m i n a l a n g i o g r a p h y r e v e a l e d o c c l u s i o n o f the s u p e r i o r mesenteric a r t e r y and severe stenosis of the celiac a r t e r y and the inferior m e s e n t e r i c artery. T h e acute ischemic episodes were a t t r i b u t e d to emboli f r o m a plaque within the s u p e r i o r mesenteric artery. H o w e v e r , emboli were not d o c u m e n t e d by a b d o m i n a l
Fro. 2. Aortoceliac bypass using 6-mm wo~en Dacron.
a n g i o g r a p h y o r o p e r a t i o n . It is possible that diminished splanchnic p e r f u s i o n d u e to large-vessel occlusion with i n a d e q u a t e collaterals could have b e e n responsible for the acute ischemic episodes. O u r case could not be categorized as classic intestinal visceral ischemia, since the strict prerequisites for diagnosis, which are r e p r o d u c i b l e a b d o m i n a l pain related to meals, d i a r r h e a , a n d weight loss, were not found. T h e i n t e r m i t t e n t s y m p t o m s , a b d o m i n a l pain and bloody d i a r r h e a several m o n t h s after s p o n t a n e ous cecal infarction, a l t h o u g h atypical, are m o r e readily attributable to ischemic colitis. A b d o m i n a l a r t e r i o g r a p h y a n d correction o f occlusion o f visceral vessels m a y be o f value in ischernic colitis with p r o t r a c t e d i n t e r m i t t e n t s y m p t o m s when conservative t h e r a p y fails a n d an involved area of colon a m e n a b l e to resection c a n n o t be d e m o n s t r a t e d . References
FIG. I. Stenosis of the celiac artery; occlusion of the superior mesenteric arter?; stenosis of the renal artery.
1. Boley SJ, Schwartz S, Lash J. et al: Reversible vascular occlusion of the colon. Surg Gynecol Obstet 116:53, 1963 2. Hertzer NR. Beven EG, Humphries AW: Chronic intestinal ischemia. Surg Gynecol Obstet 145:321, 1977 3. Williams LFJr. Wittenberg J: Ischemic colitis: An useful clinical diagnosis, but is it ischemic? Ann Surg I82: 439, i975
