Older Patients are Significantly More Likely to Have Colon Ischaemia-associated Conditions That Are Chronic and Complex

Michael Silverman; Olga C. Aroniadis; Paul Feuerstadt; Marc Fenster; Tsipora Huisman; Muhammad Sohail Mansoor; Abdul Qadir Bhutta; Lawrence J. Brandt

Disclosures

Aliment Pharmacol Ther. 2019;49(12):1502-1508. 

In This Article

Abstract and Introduction

Abstract

Background: Colon ischaemia is a common disease which has been associated with various medications and comorbidities.

Aim: To test the hypothesis that there are differences in the frequencies of these associations in older compared with younger patients.

Methods: A retrospective cohort study was performed of patients hospitalized with colon ischaemia at two major medical centres from 2005–2017. Clinical, colonoscopic and pathologic criteria were used to identify patients admitted with colon ischaemia; patients with other types of colitis were excluded. Demographic and medical data were extracted. Two cohorts were created: patients aged 18–64 years and patients > 65 years. These were compared using SAS 14.3.

Results: A total of 788 patients were included, of which 271 (34.4%) were of ages 18–64 years, and 517 (66.6%) were 65 years old or older. In the older cohort, constipation-inducing medications (83.8% vs 64.1%; P = <0.0001), diuretics (38.1% vs 25.1%; P = <0.001) and nonsteroidal anti-inflammatory drugs (58% vs 41.5%; P = <0.0001) were more common than in the younger cohort. Antipsychotic medication use was more common in the younger cohort (10.4% vs 5.4%; P = 0.01). There was a higher percentage of younger patients with a history of hypercoaguable state (1.9% vs 0.2%; P = 0.03) and dialysis dependence (22.9% vs 8.7%; P = <0.01), while a higher percentage of patients in the older cohort had a history of chronic obstructive pulmonary disease (12% vs 6.3%; P = 0.01) or atrial fibrillation (18.9% vs 10.3%; P = <0.01).

Conclusions: Our study shows that older patients are more likely to have colon ischaemia-associated conditions that are chronic and complex, while younger patients are more likely to have acute colon ischaemia-associated conditions.

Introduction

Colon ischaemia is the most common vascular disorder involving the intestine with a reported incidence of 16.3/100 000 people.[1] Additionally, it is likely that there are many more cases of colon ischaemia than are reported, as many cases of colon ischaemia are benign, self-resolving and not prompting patients to seek medical attention.[2] The classic presentation of colon ischaemia, also called ischaemic colitis, includes abdominal cramping, an urgent desire to defecate and passage within 24 hours of bright red blood per rectum, bloody diarrhoea or watery diarrhoea.[3,4] In patients admitted for lower gastrointestinal bleeding, colon ischaemia is found to be the aetiology in 9%-24% of cases based on evidence from subsequent colonoscopy and biopsy.[4] Though most cases of colon ischaemia are self-resolving, the mortality rate of non-gangrenous colon ischaemia is approximately 5%,[5] and the mortality rate of gangrenous colon ischaemia is 50%-75% even with surgical intervention.[6]

Colon ischaemia can result from any disorder that compromises colonic blood flow, whether by means of vessel occlusion, hypoperfusion, vasoconstriction, increased intraluminal colon pressure, alterations in gut microbiome or other mechanisms. It is often difficult to find a specific aetiology of colon ischaemia in any given patient and in most cases, a cause is not identified.[4] There has been a great deal of literature, however, which has identified various associations and risk factors of colon ischaemia. One heavily studied area is the association of colon ischaemia with medications and drugs including antibiotics (most commonly penicillin derivatives, but also macrolides, fluoroquinolones, cephalosporins and tetracycline),[7] chemotherapeutic drugs,[4] constipation-inducing drugs,[8] decongestants (specifically pseudoephedrine),[4] diuretics,[9] hormonal therapies (oral contraceptives and hormone replacement therapy),[10,11] immunomodulating agents,[12,13] antipsychotic drugs,[13] laxatives,[14,15] selective serotonin reuptake inhibitors and selective serotonin and norepinephrine reuptake inhibitors,[16] nonsteroidal anti-inflammatory drugs[13,17] and cocaine.[18]

Disease states and comorbidities that are associated with colon ischaemia is another area of interest in the literature. Patients with diseases and syndromes that place them in a hypercoaguable state are at increased risk for both arterial and venous thrombi with resultant colon ischaemia.[19] Additionally, there are a host of other medical conditions associated with colon ischaemia, several of which have been shown to be strongly associated with colon ischaemia including end-stage kidney disease on dialysis,[20] chronic obstructive pulmonary disease,[21] atrial fibrillation[21] and heart failure with reduced ejection fraction.[8]

One unstudied area, however, is the frequency with which disease states and medications are associated with colon ischaemia in different age groups. Though it is not always possible to identify an aetiology of colon ischaemia with certainty, it would be helpful to have knowledge of what associations are more common with various age groups to more thoroughly investigate cases of colon ischaemia and eliminate risk factors, when possible, to reduce future reoccurrences. We hypothesize that the frequency of different associations of colon ischaemia will vary between older and younger patients who present with colon ischaemia.

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