Acute ischemic colitis in elderly: medical or surgical urgency?

Background

Ischemic colitis is frequent disease in the elderly population. Early medical or surgical treatment is the key factor for a favourable prognosis. Many clinical, biohumoral and pathologic factors had been considered to indicate better treatment. "Severity" of the disease seems a prognostic factor for surgery. Aim of this study is to identified objective factors predictive of the better type and time of treatment.

Materials and methods

Seventy-two elderly patients (m:39, f:33; median age 74.8 years) affected by ischemic colitis were observed in the Surgery Unit of the University of L'Aquila from 1986 to 2008. The clinical records of the patients were reviewed retrospectively in order to asses clinical, biohumoral, endoscopic and x-ray findings predictive of the most suitable treatment. Clinical follow-up was implemented to evaluate the long-term prognosis after mean period of 6 years post treatment.

Fifty-eight percent of the ischaemic lesions involved the left colon, 23.6% the right colon, 9.7% the sigmoid colon and 8.3% involved transverse colon. Cardiovascular disease was associated in 79% of patients. Fifty-tree patients (73.6%) were treated by medical therapy only (broad spectrum antibiotics, fasting, parenteral nutrition and heparin prophylaxis) for a mean period of 7 days, with positive outcome. Nineteen patients (26.3%) underwent surgery: left (42.1%) and right hemicolectomy (15.7%), Hartmann resection (26.3%), subtotal resection (10.5%), sigmoid resection (5.4%). Urgent surgery was performed in 6 patients within 12–36 hours from admission; 13 patients underwent surgery after failure of previous medical treatment.

Results

Absence of bowel sounds (χ² = 61.9, p < 0.001), ileus (χ² = 17.8, p < 0.001), and air fluid levels in plain abdominal x-rays (χ² = 18.6, p < 0.001) were significant risk factors for surgery. The postoperative morbidity rate was 52.5% (10 cases) and included pneumonia (5 cases), abdominal sepsis (2 cases), wound sepsis (2 cases) and pulmonary embolism (1 case). The postoperative mortality rate was 36.8% (7 cases), due to sepsis and multi-organ failure in all cases. At follow-up we observed favourable outcome in the remaining 65 patients, without findings of recurrent acute or chronic ischemic colitis.

Conclusion

In conclusion, our results seem to suggest that medical therapy is the mainstay of treatment for acute ischemic colitis in elderly patient with good results. Surgery, with high rate of postoperative morbidity and mortality is indicated only in cases of peritonitis. Segmental resection of colon with ischemic lesions is the gold standard.