Ischemic Dilatation of the Colon

ERNEST F. ROSA~IO, MD, FRAnCiS E. ROSATO, MD,* .[on~x SCOTT, MD,

HARTE CROW, MD, and '~VALL.-KCE T. ,'~[II.I.ER, MD

A TTENTION WAS FOCUSED on ischemic lesions of the colon by Mars ton et al. ~ T h e y descr ibed three var ian ts of this syndrome, which were the results

of a difference in the site and size of the vessel occhtded, in the status of the

col la tera l c i rcu la t ion , in the degree and d u r a t i o n of hypotens ion , and in the

status of the bowel flora: (1) i schemic colit is wi th g a n g r e n e - - r e q u i r i n g im-

med ia t e ope ra t ion ; (2) ischemic s t r i c t u r e - - a r ap id ly d e v e lo p in g stricture,

i n v o l v i n g m a i n l y the splenic f lexure region; and (3) T r a n s i e n t ischemic

c o l i t i s I s u b s i d e s w i t h o u t specific t r e a t m e n t and with no sequelae.

A l t h o u g h genera l ly a sel f - l imited disease, wh ich progresses to e i ther s t r i c tme

f o r m a t i o n or to comple t e r e s to ra t ion of n o r m a l colonic archi tec ture , ischemic

colitis may proceed to gangrene over a pro trac ted per iod of t ime , wi thou t

s t r ik ing change in the c o n d i t i o n of the pa t ien t . Delay in diagnosis and treat-

m e n t will resul t in increased m o r t a l i t y as shown by the fo l lowing cases.

Case 1

R.M., a 73-,,ear-old woman, developed a hypotensive episode while receiving heparin for superficial phlebitis. A diagnosis of retroperitoneal hematoma was established, and she promptly responded to blood administration. She complained thereafter of constant, dull, lower abdominal pain. Her temperature remained below 100" rectally, and her WBC count was between 8,000 and 13,000. A needle aspiration of the four quadrants of the abdomen was negative. About 8 days after the onset of the pain, she had liquid, grossly bloody, bowel movements. Proctoscopy showed diffuse mt, cosal bleeding and several areas of ulceration.

A plain film of the abdomen showed marked dilatation of the transverse colon (Fig 1), and a subsequent barium enema revealed mucosal abnormality with several ulcerations (Fig 2), most marked in the distal transverse colon; there was an associated fistula.

Upoia operation immediately thereafter, the entire transverse colon had undergone full thickness necrosis--without perforation. There was diffuse mucosal ulceration of the ascending and descending colon, although the serosa and muscularis seemed intact. Resection with ileostomy and sigmoid colostomv (mucous fistula) was performed. The patient died on the third postoperative clay with gram negative septicemia. At autopsy, there were superficial ulcerations of the residual sigmoid and entire rectal mucosa. The surgical pathologic specimen re~ealed extensive mucosal ulceration throughout, with full

From the Departments of Surgery and Radiology, School of Medicine, University of Pennsylvania, Philadelphia, 19104.

Address for reprint requests: Dr. F. E. Rosato. Hospital of the IT of Pa, 1000 I. S. Ravdin Institute, Philadelphia, Pa 19104.

*Advanced Clinical Fellow, Americau Cancer Society.

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Ischeml¢ Dilatation

th ickness necrosis of the transverse colon and adjacent por t ions of the ascending and descending colon.

Case 2 H.E., an 89-year-old man , was admi t t ed to the Hospi ta l of the Univers i ty of Pennsy lvan ia

wi th a 10-day history of lower abdomi na l pa in and diarrhea. Pr ior to this, he had been in excel lent heal th , and denied any previous s imilar episodes. He was afebrile, had occasional p r e m a t u r e cardiac beats, and all pe r iphera l pulses were p resen t and normal . His bowel sounds were hyperact ive and there was no abdomina l dis tent ion, en la rged organs, or abnorma l masses.

Fig 1. Plain abdomina l films showing marked di la t ion of transverse colon.

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Rosafo et al

A proctoscopic e x a m i n a t i o n 3 days after admiss ion showed ery thema, edema, and friability, wi th mul t ip l e mucosal b leeding points . A plain film of tile a b d o m e n showed di lated loops (~f small bowel, wi th air p resent in the transverse colon. A ba r i um enema, on the same day, showed mu l t i p l e potypoid filling defects (Fig 3) in the transverse colon, with loss of n o r m a l mucosa l markings . Stool specimens were negat ive for ova and parasites, and there was no growth of Salmonella , Shigella, Staphylococci, or )'east. T h e hemoglob in was

Fig 2. B a r i u m ene ma in Case 1. Note deep ulcer in distal transverse colon wi th associated

listula (ar row).

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Ischemlc Dila~a÷[on

9.0 g%, and the WBC count was 6,600 wi th 69% nonf i l amen ted forms and 17% poly- m o r p h o n u c l e a r leukocytes.

On the 10th hospital day, he I)egan to ha~e grossly bloody stools, and t ransfus ion therapy was begun, A plain lilm of the a b d o m e n the following day, showed marked di la ta t ion of the transverse colon, and tile next day, ha ' . ing received 6 nul l s of whole blood, he was taken to lhe ()pt'rating room.

At ]aparotomy the transxerse colon was ent i re ly necrotic, and there were also ischemic

Fig 3. Barium enema in Case 2. Note pseudopolypoid formation in transverse colon.

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Rosato ef al

changes of the entire ascending and descending colon. A subtotal colectomy, ileostomy, and" exteriorization of the sigmoid remnant was performed. His postoperative course included acute renal failure and aspiration pneumonia. He died on the eighth postoperative day. The surgically resected specimen showed nmcosal ulceration with full thickness necrosis of the transverse colon. The ileal line of resection appeared normal.

DISCUSSION

Ischemic colitis usually occurs in the sixth or seventh decades, and is characterized by the abrupt onset of abdominal pain and rectal bleeding, accompanied by fever and leukocytosis. Peritoneal signs in the left lower abdomen often suggest sigmoid diverticulitis, while the bloody diarrhea makes one consider ulcerative colitis. T h e diagnosis may be made by sigmoidoscopy and radiologic examination.

Rectal involvement was initially thought not to occur, 1 but has subsequently been described, particularly after surgery on the abdominal aorta. 2, a, 7 When present, sigmoidoscopic findings are usually diffuse, and vary from edema and friability to large, discrete ulcers. Rectal biopsy may show mucosal infarction 7 and fresh fibrin thrombi in arterioles, a

T h e characteristic barium enema with transient ischemic colitis consists of smooth submucosal defects, due to hemorrhage into the bowel wall ("thumb- pr in t ing") . These particular changes indicate reversible disease. With gangrenous ischemic colitis, as seen in our cases, there are multiple, large ulcerations in the mucosa and pseudopolypoid filling, defects caused by the remaining mucosa, following partial slough. Th e major area of involvement is characteristically the splenic flexure.

T h e radiographic picture as seen on barium enema resembles ulcerative colitis, amoebic colitis, or granulomatous colitis, but can usually be dif- ferentiated from these lesions by the large, deep ulcerations, the distribution of involvement, and the clinical history. Dilatation of the transverse colon, seen in plain abdominal films in both of these patients, is particularly suggestive of ulcerative colitis.

T h e first major clinical probIem then is the differentiation of ischemic colitis from acute ulcerative colitis. Advanced age, a lack of previous intestinal problems, or a previous episode of hypotension or cardiac failure (or both) suggest ischemic colitis. Therefore, a vascular origin should be suspected in all elderly patients with what appears to be ulcerative colitis, particularly in those with short-lived or atypical disease. A radiographic appearance of dilatation of the transverse colon, coupled with barium enema findings of ulceration and pseudopolyp formation, indicate gangrenous ischemic colitis. Attempts at nonoperative management, are contraindicated in this group.

Th e second clinical problem is the assessment of progression from mucosal ischemia to transmucosal necrosis, once the diagnosis of ischemic colitis has been made. Ischemic colitis is usually self-limited with eventual restoration of normal colonic structure and function. Supportive measures, antibiotics

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Ischemic Dila+ation

and nasogastric suction usually suffice, and operation can be avoided. Close observation for necrosis and perforat ion is mandatory, a Once the diagnosis of ischemic colitis has been made, a static situation with eventual resolution cannot be assumed. Spreading peritonitis, increasing toxicity and elevation of the leukocyte count indicate progression of the ischemic lesion. Equally important, the development of transmural necrosis may evolve over a long period of time, without striking changes in these clinical parameters. Both of our cases were carefully watched for many days before operation, illustrating the indolent course that colonic gangrene may follow. 2,4,6,%9 Repeated barium enemas and plain abdominal films are necessary to the management of ischemic colitis, since these are indicators of the vascular status of the colon. Th e progression from thumb print ing to ulceration and pseudo- polypoid formation on barium enema is indicative of irreversible ischemia. As seen on a plain film of the abdomen, the development of dilatation of the colon in the same segment of the bowel, previously demonstrated by a bar ium enema as an area of ischemic colitis, also indicates transmural infarction. T h e development of either of these findings indicates impending perforat ion of the colon, and requires prompt surgical treatment. By utilizing these radio- graphic criteria, an earlier diagnosis of transmuraI necrosis can be made in doubtful cases. The resultant earlier surgical t reatment will increase the survival rate in this disease.

SUMMARY

Ischemic colitis may present as dilatation of the colon, often seen in acute ulcerative colitis. Clinical history and radiographic findings usually suffice to differentiate these two lesions. Prompt surgical t reatment is indicated for ischemic dilatation.

Two cases are presented to show that ischemic colitis may progress to trans- mural gangrene, without striking clinical change. Repeated bar ium enema and plain abdominal films are required for the management of patients with ischemic colitis, who do not promptly recover. T h e progression from thumb printing to ulcerative and pseudopolypoid changes on bar ium enema, or the development of dilatation in a segment of ischemic colon, indicates necrosis and requires immediate surgical treatment.

REFERENCES

1. ]V[ARSTON, A., PnH~S, M. T., THOMAS, L., and Mo~soN, B. C. Ischemlc colitis. Gut 7:1, 1966.

2. MILLER, R. E,, KNOX, ~V. G. Colon ischemic following infrarenal aortic surgery: Report of four cases. Ann Surg 163:639, 1966.

3. BICKS, R. O., BALE. G. F., HOWARO, H., and McBL'RNFY, R. F. Acute and delayed colon ischernia after aortic aneurvsm surgery. Ann Intern Med 122:249, 1968.

4. MCCORT, J. J, Infarction of the descending colon due to vascular occlusion. New Eng ] Med 262:168, 1960.

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5. BYRD, B. F., .}R., S.'~w~lRS, J. L., BOMAR. R. L., and KLATTE, E. C. Reversible vascula: occlusion of the colon. A~zt~ Surg 167:901, 1968.

6. FARM~, J, BETAXCOCRr, E., and KXLPATRICK, Z. M. T h e radiology of ischemic proctitis. Radiology 91:302, 1968.

7. KILPATRICK, Z. M., FARMAN, J., YESNER, R., and SPIRO, H. M. Ischemic proctitis. JAMA 205:64, 1968.

8. NESCHIS, M., Sn-(;El.~t~x, S. S., and PARk~:R, J. G. Diagnosis and m a n a g e m e n t of the megacolon of ulcerat ixe colitis. Gastroe~tterology 55:251, 1968.

9. McGovERx, V. J., and GOL'LSrON, S. J. M. Ischemic enterocolit is. Gut 6:213, 1965.

928 American Journal of Digestive Diseases