Ischemic colitis medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Ischemic colitis is usually treated with supportive care. Treatment is determined by its severity and include [[intravenous fluids]], [[Intestine|bowel]] rest, nasogastric tube, and [[total parenteral nutrition]]. Patients with [[Megacolon|colonic dilatation]] are managed with insertion of a [[rectal]] tube or [[Endoscopy|endoscopic]] [[decompression]]. There is no evidence about the role of [[Anticoagulant|anticoagulation]] or [[Antiplatelet drug|antiplatelet]] therapy. [[Steroid|Steroids]] have not been shown to improve outcomes. | |||
==Medical Therapy== | ==Medical Therapy== | ||
The medical therapy for ischemic colitis is as follows:<ref>PATH, EJ, McCLURE, JN Jr. Intestinal obstruction; the protective action of sulfasuxidine and sulfathalidine to the ileum following vascular damage. Ann Surg 1950; 131:159.</ref><ref>{{cite journal | author = Plonka A, Schentag J, Messinger S, Adelman M, Francis K, Williams J | title = Effects of enteral and intravenous antimicrobial treatment on survival following intestinal ischemia in rats. | journal = J Surg Res | volume = 46 | issue = 3 | pages = 216-20 | year = 1989 | id = PMID 2921861}}</ref><ref>{{cite journal | author = Bennion R, Wilson S, Williams R | title = Early portal anaerobic bacteremia in mesenteric ischemia. | journal = Arch Surg | volume = 119 | issue = 2 | pages = 151-5 | year = 1984 | id = PMID 6696611}}</ref><ref>{{cite journal | author = Redan J, Rush B, Lysz T, Smith S, Machiedo G | title = Organ distribution of gut-derived bacteria caused by bowel manipulation or ischemia. | journal = Am J Surg | volume = 159 | issue = 1 | pages = 85-9; discussion 89-90 | year = 1990 | id = PMID 2403765}}</ref><ref>Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., 2002 Saunders, p. 2334.</ref><ref name="NikolicKeck2017">{{cite journal|last1=Nikolic|first1=Amanda L.|last2=Keck|first2=James O.|title=Ischaemic colitis: uncertainty in diagnosis, pathophysiology and management|journal=ANZ Journal of Surgery|year=2017|issn=14451433|doi=10.1111/ans.14237}}</ref> | The medical therapy for ischemic colitis is as follows:<ref>PATH, EJ, McCLURE, JN Jr. Intestinal obstruction; the protective action of sulfasuxidine and sulfathalidine to the ileum following vascular damage. Ann Surg 1950; 131:159.</ref><ref>{{cite journal | author = Plonka A, Schentag J, Messinger S, Adelman M, Francis K, Williams J | title = Effects of enteral and intravenous antimicrobial treatment on survival following intestinal ischemia in rats. | journal = J Surg Res | volume = 46 | issue = 3 | pages = 216-20 | year = 1989 | id = PMID 2921861}}</ref><ref>{{cite journal | author = Bennion R, Wilson S, Williams R | title = Early portal anaerobic bacteremia in mesenteric ischemia. | journal = Arch Surg | volume = 119 | issue = 2 | pages = 151-5 | year = 1984 | id = PMID 6696611}}</ref><ref>{{cite journal | author = Redan J, Rush B, Lysz T, Smith S, Machiedo G | title = Organ distribution of gut-derived bacteria caused by bowel manipulation or ischemia. | journal = Am J Surg | volume = 159 | issue = 1 | pages = 85-9; discussion 89-90 | year = 1990 | id = PMID 2403765}}</ref><ref>Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., 2002 Saunders, p. 2334.</ref><ref name="NikolicKeck2017">{{cite journal|last1=Nikolic|first1=Amanda L.|last2=Keck|first2=James O.|title=Ischaemic colitis: uncertainty in diagnosis, pathophysiology and management|journal=ANZ Journal of Surgery|year=2017|issn=14451433|doi=10.1111/ans.14237}}</ref> | ||
* Treatment is determined by its severity | * Treatment is determined by its severity | ||
**Sepsis, hypotension, poor cardiac function, | **[[Sepsis]], [[hypotension]], poor cardiac function, [[hypovolemia]] and [[Hypoxemia|hypoxia]] should be addressed, and precipitating [[:Category:Drugs|drugs]] withdrawn. | ||
* Patients with colonic dilatation are managed with insertion of a rectal tube or endoscopic decompression. | * Patients with [[Gastrointestinal perforation|colonic]] [[Dilation|dilatation]] are managed with insertion of a [[rectal]] tube or [[Endoscopy|endoscopic]] decompression. | ||
* There is no evidence about the role of anticoagulation or antiplatelet therapy. | * There is no evidence about the role of [[Anticoagulant|anticoagulation]] or [[Antiplatelet agent|antiplatelet]] therapy. | ||
* Steroids have not been shown to improve outcomes. | * [[Steroid|Steroids]] have not been shown to improve outcomes. | ||
===Intravenous Fluids=== | ===Intravenous Fluids=== | ||
* Fluid resuscitation | * [[Fluid replacement|Fluid resuscitation]] with: | ||
** Intravenous fluids | ** [[Intravenous fluids]] | ||
** Bowel rest | ** [[Intestine|Bowel]] rest | ||
** Nasogastric tube | ** Nasogastric tube | ||
** Total parenteral nutrition if prolonged bowel rest | ** [[Total parenteral nutrition]] if prolonged bowel rest | ||
===Optimize Cardiac Output=== | ===Optimize Cardiac Output=== | ||
* If possible, cardiac function and oxygenation should be optimized to improve oxygen delivery to the ischemic bowel. | * If possible, [[Heart|cardiac]] function and [[oxygenation]] should be optimized to improve [[oxygen]] delivery to the [[Ischemia|ischemic]] [[Intestine|bowel]]. | ||
===Nasogastric Tube=== | ===Nasogastric Tube=== | ||
| Line 28: | Line 28: | ||
===Antibiotics=== | ===Antibiotics=== | ||
* Antibiotic use in animal studies has demonstrated reduced duration and severity of ischemic colitis, and prevention of bacterial translocation through damaged mucosa. | * [[Antibiotic]] use in animal studies has demonstrated reduced duration and severity of ischemic colitis, and [[Prevention (medical)|prevention]] of [[Bacteria|bacterial]] translocation through damaged [[Mucous membrane|mucosa]]. | ||
** A study involving dogs demonstrated reduction in vessel thrombosis and increased survival. | ** A study involving dogs demonstrated reduction in [[Blood vessel|vessel]] [[thrombosis]] and increased survival. | ||
* The role of antibiotic therapy in humans requires further research. | * The role of [[antibiotic]] therapy in humans requires further research. | ||
====Contraindicated medications==== | ====Contraindicated medications==== | ||
* Alosetron | * [[Alosetron]] | ||
==Algorithm== | ==Algorithm of management of ischemic colitis == | ||
*The following algorithm represents the management of ischemic colitis. | *The following algorithm represents the management of ischemic colitis. | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | | | | | A01 | | | | | |A01=Abdominal pain, diarrhea, lower GI bleeding}} | {{familytree | | | | | | | | | A01 | | | | | |A01=[[Abdominal pain]], [[diarrhea]], [[lower GI bleeding]]}} | ||
{{familytree | | | | | | | | | |!| }} | {{familytree | | | | | | | | | |!| }} | ||
{{familytree | | | | | | | | | A01 | | | | | |A01=Diagnosis by CT scan or | {{familytree | | | | | | | | | A01 | | | | | |A01=Diagnosis by [[CT scan]] or [[colonoscopy]]}} | ||
{{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }} | {{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }} | ||
{{familytree | | B01 | | | | | B02 | | | | | B03 |B01=Stable or improving| B02=Peritonitis signs or gangrenous bowel| B03=Continuation of symptoms}} | {{familytree | | B01 | | | | | B02 | | | | | B03 |B01=Stable or improving| B02=[[Peritonitis]] signs or [[gangrenous]] bowel| B03=Continuation of symptoms}} | ||
{{familytree | | |!| | | | | | |!| | | | | | |!| |}} | {{familytree | | |!| | | | | | |!| | | | | | |!| |}} | ||
{{familytree | | C01 | | | | | C02 | | | | | C03 |C01=Repeat colonoscopy after 2 weeks|||||||||||C02=Emergency laparatomy|C03=Resection of diseased bowel}} | {{familytree | | C01 | | | | | C02 | | | | | C03 |C01=Repeat [[colonoscopy]] after 2 weeks|||||||||||C02=Emergency laparatomy|C03=Resection of diseased bowel}} | ||
{{familytree | |,|^|-|.| |}} | {{familytree | |,|^|-|.| |}} | ||
{{familytree | C01 | | C02 | |C01= Normal | |C02= Segmental colitis}} | {{familytree | C01 | | C02 | |C01= Normal | |C02= Segmental [[colitis]]}} | ||
{{familytree | | | | | |!| | | |}} | {{familytree | | | | | |!| | | |}} | ||
{{familytree | | | | | C01 | |C01= Segment colectomy}} | {{familytree | | | | | C01 | |C01= Segment colectomy}} | ||
| Line 54: | Line 54: | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Gastroenterology]] | |||
[[Category:Medicine]] | |||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Up-To-Date]] | |||
Latest revision as of 14:35, 2 February 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2]
Overview
Ischemic colitis is usually treated with supportive care. Treatment is determined by its severity and include intravenous fluids, bowel rest, nasogastric tube, and total parenteral nutrition. Patients with colonic dilatation are managed with insertion of a rectal tube or endoscopic decompression. There is no evidence about the role of anticoagulation or antiplatelet therapy. Steroids have not been shown to improve outcomes.
Medical Therapy
The medical therapy for ischemic colitis is as follows:[1][2][3][4][5][6]
- Treatment is determined by its severity
- Sepsis, hypotension, poor cardiac function, hypovolemia and hypoxia should be addressed, and precipitating drugs withdrawn.
- Patients with colonic dilatation are managed with insertion of a rectal tube or endoscopic decompression.
- There is no evidence about the role of anticoagulation or antiplatelet therapy.
- Steroids have not been shown to improve outcomes.
Intravenous Fluids
- Fluid resuscitation with:
- Intravenous fluids
- Bowel rest
- Nasogastric tube
- Total parenteral nutrition if prolonged bowel rest
Optimize Cardiac Output
- If possible, cardiac function and oxygenation should be optimized to improve oxygen delivery to the ischemic bowel.
Nasogastric Tube
- A nasogastric tube may be inserted if an ileus is present.
Antibiotics
- Antibiotic use in animal studies has demonstrated reduced duration and severity of ischemic colitis, and prevention of bacterial translocation through damaged mucosa.
- A study involving dogs demonstrated reduction in vessel thrombosis and increased survival.
- The role of antibiotic therapy in humans requires further research.
Contraindicated medications
Algorithm of management of ischemic colitis
- The following algorithm represents the management of ischemic colitis.
| Abdominal pain, diarrhea, lower GI bleeding | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Diagnosis by CT scan or colonoscopy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Stable or improving | Peritonitis signs or gangrenous bowel | Continuation of symptoms | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Repeat colonoscopy after 2 weeks | Emergency laparatomy | Resection of diseased bowel | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Normal | Segmental colitis | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Segment colectomy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
References
- ↑ PATH, EJ, McCLURE, JN Jr. Intestinal obstruction; the protective action of sulfasuxidine and sulfathalidine to the ileum following vascular damage. Ann Surg 1950; 131:159.
- ↑ Plonka A, Schentag J, Messinger S, Adelman M, Francis K, Williams J (1989). "Effects of enteral and intravenous antimicrobial treatment on survival following intestinal ischemia in rats". J Surg Res. 46 (3): 216–20. PMID 2921861.
- ↑ Bennion R, Wilson S, Williams R (1984). "Early portal anaerobic bacteremia in mesenteric ischemia". Arch Surg. 119 (2): 151–5. PMID 6696611.
- ↑ Redan J, Rush B, Lysz T, Smith S, Machiedo G (1990). "Organ distribution of gut-derived bacteria caused by bowel manipulation or ischemia". Am J Surg. 159 (1): 85–9, discussion 89-90. PMID 2403765.
- ↑ Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., 2002 Saunders, p. 2334.
- ↑ Nikolic, Amanda L.; Keck, James O. (2017). "Ischaemic colitis: uncertainty in diagnosis, pathophysiology and management". ANZ Journal of Surgery. doi:10.1111/ans.14237. ISSN 1445-1433.