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Am J Gastroenterol ; Each section of the document will present key recommendations or summary statements followed by a comprehensive summary of supporting evidence.
A search of MEDLINE to present and EMBASE to present with language restriction to English was conducted using the search terms ischemic colitis, ischaemic colitis, colon ischemia, colonic ischemia, colon ischaemia, colonic ischaemia, colon gangrene, colonic gangrene, colon infarction, colonic infarction, rectal ischemia, rectal ischaemia, ischemic proctitis, ischaemic proctitis, cecal ischemia, cecal Risk management and evidence, ischemic colon stricture, ischaemic colon stricture, ischemic colonic stricture, ischaemic colonic stricture, ischemic megacolon, ischaemic megacolon, colon cast, and colonic cast.
The references obtained were reviewed and the best studies were included as evidence for guideline statements or in the absence of quality evidence, expert opinion was offered. Of note, Risk management and evidence this clinical guideline there are several sections focusing on factors associated with prognosis in CI.
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Recommendations and summary statements Colon Ischemia Recommendations and Best Practice Summary Statements Recommendation and Best Practice Statements Clinical Presentation The diagnosis of CI is usually established in the presence of symptoms including sudden cramping, mild, abdominal pain; an urgent desire to defecate; and passage within 24 h of bright red or maroon blood or bloody diarrhea.
Strong recommendation, very low level of evidence 7, 9, 17 A diagnosis of non-isolated right colon ischemia non-IRCI should be considered when patients present with hematochezia. Strong recommendation, very low level of evidence 7, 9, 17 Imaging of CI CT with intravenous and oral contrast should be the first imaging modality of choice for patients with suspected CI to assess the distribution and phase of colitis.
Strong recommendation, moderate level of evidence, The diagnosis of CI can be suggested based on CT findings e. Strong recommendation, moderate level of evidenceCT or MRI findings of colonic pneumatosis and porto-mesenteric venous gas can be used to predict the presence of transmural colonic infarction.
Strong recommendation, moderate level of evidence In a patient in whom the presentation of CI may be a heralding sign of AMI e. Conditional recommendation, low level of evidence Colonoscopy in the Diagnosis of CI Early colonoscopy within 48 h of presentation should be performed in suspected CI to confirm the diagnosis.
Strong recommendation, low level of evidence 17 When performing colonoscopy on a patient with suspected CI, the colon should be insufflated minimally. Conditional recommendation, very low level of evidence 69, In patients with severe CI, CT should be used to evaluate the distribution of disease.
Limited colonoscopy is appropriate to confirm the nature of the CT abnormality. Colonoscopy should be halted at the distalmost extent of the disease. Strong recommendation, low level of evidence Biopsies of the colonic mucosa should be obtained except in cases of gangrene.
Strong recommendation, very low level of evidence Colonoscopy should not be performed in patients who have signs of acute peritonitis or evidence of irreversible ischemic damage i. Strong recommendation, very low level of evidence Severity and Treatment of CI Most cases of CI resolve spontaneously and do not require specific therapy.
Strong recommendation, low quality of evidence, Surgical intervention should be considered in the presence of CI accompanied by hypotension, tachycardia, and abdominal pain without rectal bleeding; for IRCI and pan-colonic CI; and in the presence of gangrene. Strong recommendation, moderate level of evidence 17,Antimicrobial therapy should be considered for patients with moderate or severe disease.
The end result of this process is that colonocytes become acidotic, dysfunctional, lose their integrity and, ultimately, die. Moreover, ischemia may be followed by reperfusion injury and, for relatively brief periods of ischemia, this combined injury may produce more damage than just reduction of blood flow without reperfusion.
The degree to which colonic blood flow must diminish before ischemia results varies with the acuteness of the event, the degree of preexisting vascular collateralization, and the length of time the low flow state persists.
CI may manifest with reversible or irreversible damage. Reversible damage includes colopathy, i. In reversible disease, such resorption occurs rather promptly, usually within 3 days. Ulcerations may persist for several months before resolving, although during this time, the patient usually is asymptomatic.
Irreversible manifestations of CI include gangrene, fulminant colitis, stricture formation, and, rarely, chronic ischemic colitis.
Recurrent sepsis due to bacterial translocation is another rare manifestation of irreversibly damaged bowel. This system, which is commonly used in the United States, assigns the hospital discharge code Therefore, either medical records must be reviewed carefully or clear stipulations must be applied to databases to reliably identify patients with CI 3.
A national insurance claims-based survey of patients hospitalized with CI revealed an annual incidence rate of In the population-based, record-review study of patients hospitalized in the Kaiser San Diego Medical Care Program, the estimated annual incidence was Because of multiple admissions of some patients, the hospitalization rate was A recently published population-based study yielded an incidence of An insurance claims-based study reported an incidence of only 7.
There seems to be much less female predominance among young Japanese patients Particular predisposing illnesses have been reported with recurrent disease, such as hypercoagulable states Therefore, in any large survey, recurrence will be related to the relative proportions of patients with spontaneous, idiopathic disease and those with illnesses likely to foster recurrence.
Pathophysiology CI can result from alterations in the systemic circulation or from anatomic or functional changes in the mesenteric vasculature; the proximate cause is thought to be local hypoperfusion and reperfusion injury.
In most cases, no specific cause for ischemia is identified, and such episodes are attributed to localized nonocclusive ischemia, likely a result of small-vessel disease.1 | Drivers of risk management Adapting risk management to organisational motives Main findings, implications and overview of project Risk management’s official argument is clear: it is good business.
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iii PANDEMIC INFLUENZA RISK MANAGEMENT Contents Acknowledgements iv Abbreviations v Executive summary 1 New in the guidance 1 1. Introduction 3.
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