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Ischaemic colitis: a sequel to femoral artery laceration
Injury,
10,
217-219
Printed in Great Britain
217
lschaemic colitis: a sequel to femoral artery laceration W. G. Humphreys and W. J. H. Graham Craigavon Area Hospital, Northern Ireland Summary
Ischaemic colitis is presented as a sequel to a femoral artery laceration. The course and complications are described and the possible mechanism is discussed.
CASE
REPORT
A 51-year-old man, previously in good health, sustained a stab wound on the anteromedial aspect of the upper third of his left thigh, but had no other major injury. He was admitted to hospital 3 h after the assault. On examination, hypovolaemic shock was evident with a systolic blood pressure of 50 mm/Hg and a tachycardia of 180/min. Following resuscitation the thigh wound was explored under general anaesthesia revealing a laceration of the superficial femoral artery involving three-quarters of its circumference 4 cm distal to the origin of the profunda femoris; the saphenous and femoral veins were intact. The arterial wall, which was free of atheroma, was repaired using a saphenous vein patch taken from the opposite leg. Normal circulation with palpable distal arterial pulsation was achieved 5 h after wounding; anticoagulation was not employed. A 7-day course of broad spectrum antibiotic was given and the wound healed without complication. Seventeen hours after injury, the patient developed vague lower abdominal pain and bloody diarrhoea, though there were no abnormal abdominal physical signs. Sigmoidoscopy demonstrated a normal rectal mucosa with bloodstained fluid in the lumen. A further episode of abdominal pain and bloody diarrhoea associated with minimal tenderness in the left loin and left iliac fossa recurred 10 h later. His temperature was 38.5 “C. A provisional diagnosis of ischaemic colitis was confirmed by barium enema examination showing typica thumb printing of the splenic flexure and descending colon (Figs. 1 and 2). Stool culture was negative for pathogens throughout. Five days after injury, the patient again complained of colicky lower abdominal pain, but no abnormal
physical signs were elicited. A plain abdominal radiograph showed no evidence of intestinal obstruction; the symptoms settled with conservative measures. He was discharged from hospital 10 days after wounding and when seen for review at 1 month and at 4 months, he still complained of slight intermittent, colicky, lower abdominal pain but had no objective evidence of intestinal obstruction. Serial barium enema examinations demonstrated a progressive stricture in the descending colon (Fig. 3). A normal circulation was maintained in his left leg.
DISCUSSION Ischaemic
colitis,
though
uncommon,
is being
recognized increasingly as a clinical entity, usually as a spontaneous event, particularly in association with widespread arteriosclerosis, or cardiogenic shock in patients over the age of 50 years (Ming, 1965). A few cases occur following reconstructive surgery of the aorta, probably secondary to acute ligation of a patent inferior mesenteric artery (Johnston and Nabseth, 1974). Pathological and radiological changes similar to those seen in man may be produced experimentally in animals (Marston et al., 1966; Miiller and Stjernvall. 1971) particularly in the presence of prolonged, impaired arterial perfusion of the intestine (Matthews and Parks, 1976). The course of non-gangrenous ischaemic colitis may be adequately assessed by serial barium enema examination. The place of selective inferior mesenteric arteriography as an investigative procedure is controversial (Westcott, 1972) in view of the prevalence of arterial degenerative changes already present with advancing age. There have been a few reports in the world literature of reversible ischaemic colitis developing after a distal external injury or non-abdominal
218
Injury: the British Journal of Accident
Fig. 1. Early barium enema demonstrating the typical signs of ischaemic colitis with mucosal oedema and thumb printing.
Barium enema demonstrating a tight stricture in the sigmoid and descending colon.
Fig. 3.
Surgery Vol. lo/No.
3
2. Barium enema radiograph of spleuic flexure showing marked ischaemic colitis.
Fig.
trauma (Renton, 1967; Rickert et al., 1974). In the case described, an otherwise healthy man without evidence of cardiovascular disease and with apparently normal peripheral arteries developed typical ischaemic colitis of the left colon following an episode of hypovolaemic shock. The close temporal relationship between the injury and the onset of intestinal symptoms and signs suggests hypotension as an important predisposing factor in this patient and adds further support to the theory that ischaemic colitis may be produced by prolonged hypotension leading to poor tissue perfusion. Ischaemic colitis is an unusual complication of peripheral arterial injury (Rickert et al., 1974) and should be considered in any patient presenting with abdominal symptoms after a prolonged hypotensive or hypovolaemic episode. The value of an early barium enema examination is emphasized. With the development of a stricture this patient falls into the second group of Marston’s classification (1966) and the present clinical state agrees with the findings of Parks and his COworkers (1972) that the lumen of these strictures is usually adequate to avoid intestinal obstruction. As the patient remains well, no surgical intervention is intended.
Humphreys
and Graham:
lschaemic
Colitis
Acknowledgements The authors wish to thank Dr M. McCurdy for permission to reproduce the barium enema radiographs, Mr T. G. Parks for helpful criticism of the text and Miss A. Graham for typing the manuscript. REFERENCES
Johnston R. C. and Nabseth D. C. (1974) Visceral infarction following aortic surgery. Ann. Surg. 180, 312. Marston A., Pheils M. T. and Thomas M. L. (1966) Ischaemic colitis. Gut 7, 1. Matthews J. and Parks T. G. (1976) Ischaemic colitis in the experimental animal, Parts I and II. Gut 17, 671, 677. Requests
for reprints
219
Ming, Si-chun (1965) Haemorrhagic necrosis of the gastro-intestinal tract and its relation to cardiovascular status. Circulation 32, 332. Mijller C. and Stjernvall L. (1971) Ischaemic colitis. Acta Chir. &and. 137, 75. Parks T. G., Johnston G. W. and Kennedy T. L. (1972) Spontaneous ischaemic proctocolitis. Stand. J. Gastroenterol. 7, 241. Renton C. J. C. (1967) Massive intestinal infarction following multiple injury. Br. J. Surg. 54, 399. Rickert R. R., Johnston R. C. and Wignarajan K. R. (1974) Ischaemic colitis in a young adult patient. Dis. Colon Rectum 17, 112. Westcott J. K. (1972) Angiographic demonstration of arterial occlusion in ischaemic colitis. Gastroenterology 63, 486.
should be addressed to: Mr W. G. Humphreys, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA.
10,
217-219
Printed in Great Britain
217
lschaemic colitis: a sequel to femoral artery laceration W. G. Humphreys and W. J. H. Graham Craigavon Area Hospital, Northern Ireland Summary
Ischaemic colitis is presented as a sequel to a femoral artery laceration. The course and complications are described and the possible mechanism is discussed.
CASE
REPORT
A 51-year-old man, previously in good health, sustained a stab wound on the anteromedial aspect of the upper third of his left thigh, but had no other major injury. He was admitted to hospital 3 h after the assault. On examination, hypovolaemic shock was evident with a systolic blood pressure of 50 mm/Hg and a tachycardia of 180/min. Following resuscitation the thigh wound was explored under general anaesthesia revealing a laceration of the superficial femoral artery involving three-quarters of its circumference 4 cm distal to the origin of the profunda femoris; the saphenous and femoral veins were intact. The arterial wall, which was free of atheroma, was repaired using a saphenous vein patch taken from the opposite leg. Normal circulation with palpable distal arterial pulsation was achieved 5 h after wounding; anticoagulation was not employed. A 7-day course of broad spectrum antibiotic was given and the wound healed without complication. Seventeen hours after injury, the patient developed vague lower abdominal pain and bloody diarrhoea, though there were no abnormal abdominal physical signs. Sigmoidoscopy demonstrated a normal rectal mucosa with bloodstained fluid in the lumen. A further episode of abdominal pain and bloody diarrhoea associated with minimal tenderness in the left loin and left iliac fossa recurred 10 h later. His temperature was 38.5 “C. A provisional diagnosis of ischaemic colitis was confirmed by barium enema examination showing typica thumb printing of the splenic flexure and descending colon (Figs. 1 and 2). Stool culture was negative for pathogens throughout. Five days after injury, the patient again complained of colicky lower abdominal pain, but no abnormal
physical signs were elicited. A plain abdominal radiograph showed no evidence of intestinal obstruction; the symptoms settled with conservative measures. He was discharged from hospital 10 days after wounding and when seen for review at 1 month and at 4 months, he still complained of slight intermittent, colicky, lower abdominal pain but had no objective evidence of intestinal obstruction. Serial barium enema examinations demonstrated a progressive stricture in the descending colon (Fig. 3). A normal circulation was maintained in his left leg.
DISCUSSION Ischaemic
colitis,
though
uncommon,
is being
recognized increasingly as a clinical entity, usually as a spontaneous event, particularly in association with widespread arteriosclerosis, or cardiogenic shock in patients over the age of 50 years (Ming, 1965). A few cases occur following reconstructive surgery of the aorta, probably secondary to acute ligation of a patent inferior mesenteric artery (Johnston and Nabseth, 1974). Pathological and radiological changes similar to those seen in man may be produced experimentally in animals (Marston et al., 1966; Miiller and Stjernvall. 1971) particularly in the presence of prolonged, impaired arterial perfusion of the intestine (Matthews and Parks, 1976). The course of non-gangrenous ischaemic colitis may be adequately assessed by serial barium enema examination. The place of selective inferior mesenteric arteriography as an investigative procedure is controversial (Westcott, 1972) in view of the prevalence of arterial degenerative changes already present with advancing age. There have been a few reports in the world literature of reversible ischaemic colitis developing after a distal external injury or non-abdominal
218
Injury: the British Journal of Accident
Fig. 1. Early barium enema demonstrating the typical signs of ischaemic colitis with mucosal oedema and thumb printing.
Barium enema demonstrating a tight stricture in the sigmoid and descending colon.
Fig. 3.
Surgery Vol. lo/No.
3
2. Barium enema radiograph of spleuic flexure showing marked ischaemic colitis.
Fig.
trauma (Renton, 1967; Rickert et al., 1974). In the case described, an otherwise healthy man without evidence of cardiovascular disease and with apparently normal peripheral arteries developed typical ischaemic colitis of the left colon following an episode of hypovolaemic shock. The close temporal relationship between the injury and the onset of intestinal symptoms and signs suggests hypotension as an important predisposing factor in this patient and adds further support to the theory that ischaemic colitis may be produced by prolonged hypotension leading to poor tissue perfusion. Ischaemic colitis is an unusual complication of peripheral arterial injury (Rickert et al., 1974) and should be considered in any patient presenting with abdominal symptoms after a prolonged hypotensive or hypovolaemic episode. The value of an early barium enema examination is emphasized. With the development of a stricture this patient falls into the second group of Marston’s classification (1966) and the present clinical state agrees with the findings of Parks and his COworkers (1972) that the lumen of these strictures is usually adequate to avoid intestinal obstruction. As the patient remains well, no surgical intervention is intended.
Humphreys
and Graham:
lschaemic
Colitis
Acknowledgements The authors wish to thank Dr M. McCurdy for permission to reproduce the barium enema radiographs, Mr T. G. Parks for helpful criticism of the text and Miss A. Graham for typing the manuscript. REFERENCES
Johnston R. C. and Nabseth D. C. (1974) Visceral infarction following aortic surgery. Ann. Surg. 180, 312. Marston A., Pheils M. T. and Thomas M. L. (1966) Ischaemic colitis. Gut 7, 1. Matthews J. and Parks T. G. (1976) Ischaemic colitis in the experimental animal, Parts I and II. Gut 17, 671, 677. Requests
for reprints
219
Ming, Si-chun (1965) Haemorrhagic necrosis of the gastro-intestinal tract and its relation to cardiovascular status. Circulation 32, 332. Mijller C. and Stjernvall L. (1971) Ischaemic colitis. Acta Chir. &and. 137, 75. Parks T. G., Johnston G. W. and Kennedy T. L. (1972) Spontaneous ischaemic proctocolitis. Stand. J. Gastroenterol. 7, 241. Renton C. J. C. (1967) Massive intestinal infarction following multiple injury. Br. J. Surg. 54, 399. Rickert R. R., Johnston R. C. and Wignarajan K. R. (1974) Ischaemic colitis in a young adult patient. Dis. Colon Rectum 17, 112. Westcott J. K. (1972) Angiographic demonstration of arterial occlusion in ischaemic colitis. Gastroenterology 63, 486.
should be addressed to: Mr W. G. Humphreys, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA.