Imaging Pearls ❯ Colon ❯ Ischemic Bowel
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- "Rosuvastatin (Crestor, AstraZeneca) is a commonly used drug for managing hypercholesterolaemia. It is a very safe medication with mostly acceptable side effects. Rare but serious side effects are not well known. A 64-year-old woman presented with bloody diarrhoea after starting rosuvastatin for hypercholesterolaemia. Stool microscopy and culture ruled out infective causes. Abdominal CT scan revealed normal calibre celiac axis and superior mesenteric artery. Colonoscopic biopsy revealed ischaemic colitis as the final histological diagnosis. The patient is in complete remission after ceasing the medication. Rosuvastatin causing ischaemic colitis should be considered a rare but serious adverse drug reaction.”
Adverse drug reaction: Rosuvastatin as a cause for ischaemic colitis in a 64-year-old woman
Tan J et al.
BMJ Case Reports 2012 - “In conclusion, statin use was associated with a lower risk of CD, consistent with one previous observational analysis. Notwithstanding their inherent limitations, additional adequately-powered observational studies examining statin use and IBD risk would be of value. Although there is evidence to suggest the existence of a preclinical phase in CD,our ability to identify those at risk of IBD, in whom statin use could avert disease progression, remains limited. Further studies focusing on the role of statins in IBD progression are also therefore warranted.”
Association Between Statin Use and Inflammatory Bowel Diseases: Results from a Swedish, Nationwide, Population-based Case-control Study,
Paul Lochhead et al.
Journal of Crohn's and Colitis, Volume 15, Issue 5, May 2021, Pages 757–765 - Introduction: Nonocclusive Ischemic Colitis has become more prevalent and frequently of uncertain etiology. Patients infrequently experience recurrence. The author cared for a 63 year old female who had 4 episodes over a 14 month period. She was hypertensive but otherwise in good health. Review of her medications was remarkable for pravastatin use for more than 10 years. Because isolated cases have been reported while on rosuvastatin, it was elected to discontinue the pravastatin and perform a case control .
Conclusion: This study demonstrates that statin use is a risk factor for ischemic colitis. The pathway of causality is unclear. Statins have been shown to enhance barro receptor sensitivity and therefore could lead to hypotension. The medications could induce hypercoaguability.
Increased Risk of Non-Occlusive Ischemic Colitis With Statin Use: A Case Control Study
Goldberg, Neil
American Journal of Gastroenterology: October 2018 - Volume 113 - Issue - p S1527
- Purpose: To retrospectively evaluate the utility of biphasic multi-detector computed tomography (MDCT) with arterial and portal venous phases for the detection of suspected acute mesenteric ischemia (AMI) in emergency department (ED) patients compared to limited surgical confirmation.
Conclusion: Emergent biphasic MDCT demonstrated low but non-trivial yield (11.1%) for the depiction of suspected acute mesenteric ischemia but was particularly low for occlusive venous AMI (0.9%). The relationship between serum lactate elevation and positive MDCT findings of AMI in our study conforms to prior work and cautiously suggests value in routine serum lactate assessment preceding imaging for patient prioritization.
Utility of biphasic multi-detector computed tomography in suspected acute mesenteric ischemia in the emergency department
Gopee-Ramanan P et al.
Emergency Radiology (2019) 26:523–529 - “Our single center retrospective assessment of biphasic MDCT for AMI demonstrates a low but non-trivial yield for imaging diagnosis of ischemia (11.1%) in the setting of clinically suspected AMI, lower than found by Ofer et al. The PPV of biphasic MDCT and sub-stratified PPVs of arterial and venous-occlusive is- chemia in our study are comparable to those in the aforementioned published literature. There were no false-positive diagnoses in our retrospective review.”
Utility of biphasic multi-detector computed tomography in suspected acute mesenteric ischemia in the emergency department
Gopee-Ramanan P et al.
Emergency Radiology (2019) 26:523–529 - "Additionally, within limitations of our study design, the relationship between serum lactate elevation and positive MDCT findings of AMI warrants further tai- lored investigation as there may be potential impact to triage of patients to reduce time to disposition, whether surgical or otherwise. Further prospective assessment has potential to improve overall imaging contribution to the assessment of AMI in the ED setting.”
Utility of biphasic multi-detector computed tomography in suspected acute mesenteric ischemia in the emergency department
Gopee-Ramanan P et al.
Emergency Radiology (2019) 26:523–529
- Ischemic Enteritis: Time Course
Arterial deficiency
- Early – reflex spastic ileus (bowel contracted, gasless)
- Intermediate – reflex hypotonic ileus (paper thin wall, dilated gas-filled bowel)
- Late – paralytic ileus (no enhancement, still dilated and gas/fluid filled, pneumatosis)
- Reperfusion – submucosal edema, mural thickening, heterogeneous enhancement, hemorrhage
Venous deficiency
- Homogenous mural thickening (< 1.5 cm), followed by submucosal edema and mucosal hemorrhage - Ischemic Bowel: Extraintestinal Findings
Arterial compromise
- Emboli or thrombi in SMA, IMA, or branches
Venous insufficiency
- Venous thrombus in SMV, IMV or branches
- Engorgement of mesenteric veins w/ collaterals
Non-occlusive
- Small caliber SMA and branches
Reperfusion injury
- Mesenteric fat stranding- often pronounced and localized
Late phase
-Portomesenteric venous gas
- Ischemic Colitis: Facts
- Compromise of mesenteric blood supply leading to colonic injury
- Elderly, cardiac patients
- More commonly hypoperfusion (not embolic)
- Diagnostic clue:
- Pneumatosis
- Mesenteric venous gas
- Symmetric bowel wall thickening
- Thumbprinting on CT - Misty Mesentery:Facts
- Pancreatitis
- Fibrosing (retractile) mesenteritis
- GI tract (appendicitis, diverticulitis, etc.)
- Peritonitis (bacterial, TB, etc.)