International Journal of Cardiology 185 (2015) 50–51
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Ischemic colitis as a complication of acute myocardial infarction Ruisheng Zhang a,1, Jing Ping Sun b,1, Jia Chong a, Bing Liu a, Fang Wang a,⁎, Cheuk-Man Yu b,⁎⁎ a b
Cardiology Department of Beijing Hospital, China Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
a r t i c l e
i n f o
Article history: Received 19 January 2015 Accepted 1 March 2015 Available online 3 March 2015 Keywords: Ischemic colitis Acute myocardial infarction Contrast CT
A 62 year old male was admitted for transient loss of consciousness for 4 h. The patient had percutaneous coronary intervention with stent implantation due to acute anterior myocardial infarction 6 years ago; and suffered from recurrent chest pain recently. He had a history of hypertension, dyslipidemia, paroxysmal atrial fibrillation, and being a smoker and drinker. Physical examination revealed a temperature of 35.8 °C, heart rate of 72 bpm, respiratory rate of 18 breaths/min, and BP of 150/80 mm Hg. Systemic examination was unremarkable. Laboratory results showed CK-MB of 2.07 ng/ml, myoglobin of 206 ng/ml, cTnI of 0.012 ng/ml, and BNP of 108 pg/ml, and ECG showed ST segment elevation of 0.1 mV over V2 and V3. Echocardiogram showed hypokinesia of left ventricular anterior segments, and ejection fraction was 55%. There was mild aortic valve calcification and mild mitral regurgitation. Coronary angiography was subsequently performed, which showed: the anterior descending branch of the original distal to the stent edge region lesions with 50–70% tubular stenosis and the first diagonal branch lesions with 50% stenosis. The coronary intravascular ultrasound (IVUS) examination showed a thrombus 100% block descending branch proximal to the left main artery. The patient had ventricular tachycardia, ventricular fibrillation, escape rhythm and cardiogenic shock during
⁎ Corresponding author. ⁎⁎ Correspondence to: C.-M. Yu, Institute of Vascular Medicine (IVM), Li Ka Shing Institute of Health Sciences (LiHS), S.H. Ho Cardiovascular Disease and Stroke Centre, Heart Education And Research Training (HEART) Centre and Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong. E-mail address: [email protected] (C.-M. Yu). 1 Co-first author.
http://dx.doi.org/10.1016/j.ijcard.2015.03.020 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
angiogram process. After non-synchronized cardioversion, cardiopulmonary resuscitation and endotracheal intubation, the patient obtained 3 stent implantation into the anterior descending coronary artery and the coronary flow was recovered at TIMI flow grade 3; under medicine therapy and intra-aortic balloon counterpulsation support. On the third day after coronary procedure, the patient complained of slight abdominal pain, distention and blood in stool; blood pressure dropped to 54/40 mm Hg. Physical examination revealed abdominal distension with tenderness. Urgent contrast CT scan of the abdomen suggested the diagnosis of incomplete intestinal obstruction. Mesenteric arteriography indicated that the celiac artery, superior mesenteric artery and inferior mesenteric artery had no evidence of hemorrhage and embolism. The upper endoscopy was unremarkable while colonoscopy showed petechial hemorrhages, edematous and fragile mucosa, segmental erythema, scattered erosion and ulcer surface of the ascending colon and ileocecus, and such findings were consistent with ischemic colitis. Exploratory laparotomy was performed. Mucosal and submucosal hemorrhages and edema were seen in the wall of the terminal ileum and colon (Fig. 1), and a large amount of blood clots were found in the colonic cavity. Partial resection of the terminal ileum and total resection of the (full length of 2.5 m) with ileo-rectal anastomosis were performed. After these procedures, the patient was started on a 7-day course of antibiotic therapy for the diagnosis of acute ischemic colitis. The patient was discharged home uneventfully 2 weeks after the surgery. He was in good condition at 6-month follow-up. The pathology revealed pathological colonic tissue with extensive hemorrhage and necrosis, ulceration, and acute peritonitis perforation. There was also small vessel dilatation and transparent thrombosis of the intestinal wall. The features were consistent with ischemic bowel disease (Fig. 2). 1. Discussion Ischemic colitis is a well-recognized entity generally associated with non-occlusive ischemic injury to the large bowel [1]. It must be differentiated from many other causes of abdominal pain and rectal bleeding such as infection, inflammatory bowel disease, diverticulosis and carcinoma of the colon. Although ischemic colitis may develop spontaneously, a broad spectrum of multifactorial conditions is often present. Typically, the patient is elderly and may have a past history compatible with arteriosclerosis, low flow states of any nature or congestive heart failure.
R. Zhang et al. / International Journal of Cardiology 185 (2015) 50–51
51
Fig. 1. A. The normal intestinal compared with the ischemia and necrosis of intestinal during surgery. B. The intestinal cavity with ulcer in excision of the specimen.
Fig. 2. Microscope photos: A. Transmural necrosis of intestine; B. intestinal epithelial necrosis (arrow), abscission and new epithelial formation; C. the muscle layer of significant edema; D. in the small blood vessels of the bowel with visible hyaline thrombi (arrow), congested serosa, with edema and necrosis.
Patients with this condition often complain of acute onset of abdominal pain, bloody diarrhea and vomiting. Signs of systemic inflammatory response syndrome associated with distension and tenderness of the abdomen are common on clinical examination. Clinically, two distinct forms of acute presentation occur, i.e., a benign transient form that responds to clinical management and a more severe form requiring surgery [2]. The pattern of acute ischemic colitis dictates proper management and prognosis. Transient ischemic colitis is the most common form of presentation. It accounts for 80% to 85% of all cases and is generally managed conservatively with good prognosis [3]. In gangrenous type which encompasses the remaining 15% to 20% of cases, surgery is mandatory and mortality is much higher. Surgery is also required in non-gangrenous ischemic colitis when supportive measures fail. Ischemic colitis was the second most common cause of lower gastrointestinal tract bleeding [4]. Moreover, most cases of ischemic colitis were undetected because of its short and mild clinical course. Clinical suspicion is often low for this disease as the clinical presentation of ischemic colitis can be very heterogeneous [5]. Our patient with acute myocardial infarction complicated with cardiogenic shock, application of vasoconstrictor during cardiopulmonary resuscitation; all of these conditions might result in acute ischemic colitis, even though the mesenteric angiography had no evidence of thrombus in situ. In over 50% of cases, symptoms of ischemic colitis were resolved within 48 h of onset [6]. Some cases are associated with a poorer outcome with a higher number of complications and
irreversible disease. These patients may require surgical resection of the involved bowel. Clinical vigilance on the possibility of acute ischemic colitis is important when patients with vulnerable risk factors presented with acute abdominal pain, as timely and appropriate management is crucial in altering the outcome.
Conflict of interest None.
References [1] L.F. Williams Jr., M.A. Bosniak, J. Wittenberg, B. Manuel, E.T. Grimes, J.J. Byrne, Ischemic colitis, Am. J. Surg. 117 (2) (1969) 254–264. [2] F. Paterno, E.A. McGillicuddy, K.M. Schuster, W.E. Longo, Ischemic colitis: risk factors for eventual surgery, Am. J. Surg. 200 (5) (2010) 646–650. [3] W.E. Longo, G.C. Oliver, Less common benign disorders of the colon and rectum, in: B.G. Wolff, J.W. Fleshman, D.E. Beck, J.H. Pemberton, S.D. Wexner (Eds.), ASCRS Textbook of Colorectal Surgery, Springer-Verlag, New York, 2007, pp. 601–621. [4] J.R. Newman, M.A. Cooper, Lower gastrointestinal bleeding and ischemic colitis, Can. J. Gastroenterol. 16 (9) (Sep 2002) 597–600. [5] M.A. Montoro, L.J. Brandt, S. Santolaria, et al., Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study), Scand. J. Gastroenterol. 46 (2) (Feb 2011) 236–246. [6] W.K. Chan, N. Fu, M. Alsahafi, T. Yung, E. Yoshida, Ischemic colitis: a clinical case and concise review, Univ. Tor. Med. J. 90 (4) (May 2013) 163–165.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Ischemic colitis as a complication of acute myocardial infarction Ruisheng Zhang a,1, Jing Ping Sun b,1, Jia Chong a, Bing Liu a, Fang Wang a,⁎, Cheuk-Man Yu b,⁎⁎ a b
Cardiology Department of Beijing Hospital, China Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
a r t i c l e
i n f o
Article history: Received 19 January 2015 Accepted 1 March 2015 Available online 3 March 2015 Keywords: Ischemic colitis Acute myocardial infarction Contrast CT
A 62 year old male was admitted for transient loss of consciousness for 4 h. The patient had percutaneous coronary intervention with stent implantation due to acute anterior myocardial infarction 6 years ago; and suffered from recurrent chest pain recently. He had a history of hypertension, dyslipidemia, paroxysmal atrial fibrillation, and being a smoker and drinker. Physical examination revealed a temperature of 35.8 °C, heart rate of 72 bpm, respiratory rate of 18 breaths/min, and BP of 150/80 mm Hg. Systemic examination was unremarkable. Laboratory results showed CK-MB of 2.07 ng/ml, myoglobin of 206 ng/ml, cTnI of 0.012 ng/ml, and BNP of 108 pg/ml, and ECG showed ST segment elevation of 0.1 mV over V2 and V3. Echocardiogram showed hypokinesia of left ventricular anterior segments, and ejection fraction was 55%. There was mild aortic valve calcification and mild mitral regurgitation. Coronary angiography was subsequently performed, which showed: the anterior descending branch of the original distal to the stent edge region lesions with 50–70% tubular stenosis and the first diagonal branch lesions with 50% stenosis. The coronary intravascular ultrasound (IVUS) examination showed a thrombus 100% block descending branch proximal to the left main artery. The patient had ventricular tachycardia, ventricular fibrillation, escape rhythm and cardiogenic shock during
⁎ Corresponding author. ⁎⁎ Correspondence to: C.-M. Yu, Institute of Vascular Medicine (IVM), Li Ka Shing Institute of Health Sciences (LiHS), S.H. Ho Cardiovascular Disease and Stroke Centre, Heart Education And Research Training (HEART) Centre and Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong. E-mail address: [email protected] (C.-M. Yu). 1 Co-first author.
http://dx.doi.org/10.1016/j.ijcard.2015.03.020 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
angiogram process. After non-synchronized cardioversion, cardiopulmonary resuscitation and endotracheal intubation, the patient obtained 3 stent implantation into the anterior descending coronary artery and the coronary flow was recovered at TIMI flow grade 3; under medicine therapy and intra-aortic balloon counterpulsation support. On the third day after coronary procedure, the patient complained of slight abdominal pain, distention and blood in stool; blood pressure dropped to 54/40 mm Hg. Physical examination revealed abdominal distension with tenderness. Urgent contrast CT scan of the abdomen suggested the diagnosis of incomplete intestinal obstruction. Mesenteric arteriography indicated that the celiac artery, superior mesenteric artery and inferior mesenteric artery had no evidence of hemorrhage and embolism. The upper endoscopy was unremarkable while colonoscopy showed petechial hemorrhages, edematous and fragile mucosa, segmental erythema, scattered erosion and ulcer surface of the ascending colon and ileocecus, and such findings were consistent with ischemic colitis. Exploratory laparotomy was performed. Mucosal and submucosal hemorrhages and edema were seen in the wall of the terminal ileum and colon (Fig. 1), and a large amount of blood clots were found in the colonic cavity. Partial resection of the terminal ileum and total resection of the (full length of 2.5 m) with ileo-rectal anastomosis were performed. After these procedures, the patient was started on a 7-day course of antibiotic therapy for the diagnosis of acute ischemic colitis. The patient was discharged home uneventfully 2 weeks after the surgery. He was in good condition at 6-month follow-up. The pathology revealed pathological colonic tissue with extensive hemorrhage and necrosis, ulceration, and acute peritonitis perforation. There was also small vessel dilatation and transparent thrombosis of the intestinal wall. The features were consistent with ischemic bowel disease (Fig. 2). 1. Discussion Ischemic colitis is a well-recognized entity generally associated with non-occlusive ischemic injury to the large bowel [1]. It must be differentiated from many other causes of abdominal pain and rectal bleeding such as infection, inflammatory bowel disease, diverticulosis and carcinoma of the colon. Although ischemic colitis may develop spontaneously, a broad spectrum of multifactorial conditions is often present. Typically, the patient is elderly and may have a past history compatible with arteriosclerosis, low flow states of any nature or congestive heart failure.
R. Zhang et al. / International Journal of Cardiology 185 (2015) 50–51
51
Fig. 1. A. The normal intestinal compared with the ischemia and necrosis of intestinal during surgery. B. The intestinal cavity with ulcer in excision of the specimen.
Fig. 2. Microscope photos: A. Transmural necrosis of intestine; B. intestinal epithelial necrosis (arrow), abscission and new epithelial formation; C. the muscle layer of significant edema; D. in the small blood vessels of the bowel with visible hyaline thrombi (arrow), congested serosa, with edema and necrosis.
Patients with this condition often complain of acute onset of abdominal pain, bloody diarrhea and vomiting. Signs of systemic inflammatory response syndrome associated with distension and tenderness of the abdomen are common on clinical examination. Clinically, two distinct forms of acute presentation occur, i.e., a benign transient form that responds to clinical management and a more severe form requiring surgery [2]. The pattern of acute ischemic colitis dictates proper management and prognosis. Transient ischemic colitis is the most common form of presentation. It accounts for 80% to 85% of all cases and is generally managed conservatively with good prognosis [3]. In gangrenous type which encompasses the remaining 15% to 20% of cases, surgery is mandatory and mortality is much higher. Surgery is also required in non-gangrenous ischemic colitis when supportive measures fail. Ischemic colitis was the second most common cause of lower gastrointestinal tract bleeding [4]. Moreover, most cases of ischemic colitis were undetected because of its short and mild clinical course. Clinical suspicion is often low for this disease as the clinical presentation of ischemic colitis can be very heterogeneous [5]. Our patient with acute myocardial infarction complicated with cardiogenic shock, application of vasoconstrictor during cardiopulmonary resuscitation; all of these conditions might result in acute ischemic colitis, even though the mesenteric angiography had no evidence of thrombus in situ. In over 50% of cases, symptoms of ischemic colitis were resolved within 48 h of onset [6]. Some cases are associated with a poorer outcome with a higher number of complications and
irreversible disease. These patients may require surgical resection of the involved bowel. Clinical vigilance on the possibility of acute ischemic colitis is important when patients with vulnerable risk factors presented with acute abdominal pain, as timely and appropriate management is crucial in altering the outcome.
Conflict of interest None.
References [1] L.F. Williams Jr., M.A. Bosniak, J. Wittenberg, B. Manuel, E.T. Grimes, J.J. Byrne, Ischemic colitis, Am. J. Surg. 117 (2) (1969) 254–264. [2] F. Paterno, E.A. McGillicuddy, K.M. Schuster, W.E. Longo, Ischemic colitis: risk factors for eventual surgery, Am. J. Surg. 200 (5) (2010) 646–650. [3] W.E. Longo, G.C. Oliver, Less common benign disorders of the colon and rectum, in: B.G. Wolff, J.W. Fleshman, D.E. Beck, J.H. Pemberton, S.D. Wexner (Eds.), ASCRS Textbook of Colorectal Surgery, Springer-Verlag, New York, 2007, pp. 601–621. [4] J.R. Newman, M.A. Cooper, Lower gastrointestinal bleeding and ischemic colitis, Can. J. Gastroenterol. 16 (9) (Sep 2002) 597–600. [5] M.A. Montoro, L.J. Brandt, S. Santolaria, et al., Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study), Scand. J. Gastroenterol. 46 (2) (Feb 2011) 236–246. [6] W.K. Chan, N. Fu, M. Alsahafi, T. Yung, E. Yoshida, Ischemic colitis: a clinical case and concise review, Univ. Tor. Med. J. 90 (4) (May 2013) 163–165.
