What Is an Ischemic Ulcer?

No matter what cause the intestinal ischemia, its clinical manifestations are similar. Although the symptoms and signs are not specific, they still have their characteristics and have certain value for diagnosis. The most common manifestation is sudden spastic pain in the left lower abdomen, accompanied by obvious infestation. In the next 24 hours, the blood in the stool is bright red or dark red. The blood and feces are mixed, and the amount of bleeding is small. Blood transfusions are rarely needed, otherwise Consider other diagnoses. by

Ischemic bowel disease

Ischemic bowel disease (ischemicboweldisease) is a disease caused by intestinal wall ischemia, hypoxia, and eventually infarction. This disease is more common in elderly patients with arteriosclerosis and cardiac insufficiency. Most of the lesions occurred segmentally with the spleen curvature of the colon as the center. Most of the direct causes of colonic ischemia are mesenteric arteries and veins, especially vascular occlusion and stenosis caused by atherosclerosis or thrombosis in the superior mesenteric artery. Heart failure and shock cause blood pressure to drop, and intestinal local blood supply insufficiency can also be the cause of the disease.

Western Medicine Name: Ischemic bowel disease
English name: ischemicboweldisease
Affiliated Department: Internal Medicine-Gastroenterology
Disease site: Intestine

The main symptoms: Bleeding
Main cause: Atherosclerosis
Multiple groups: Middle-aged and elderly
Contagious: Non-contagious
Whether to enter health insurance: Yes

Clinical manifestations of ischemic bowel disease

Ischemic bowel disease Intestinal dysfunction due to intestinal ischemia can cause nausea, vomiting, belching, bloating, diarrhea and other symptoms. Of the 19 patients, 19 had abdominal pain during ischemic bowel disease, 17 had blood in the stool, and 4 had nausea and vomiting due to intestinal dysfunction. The symptoms were accompanied by abdominal distension, diarrhea, and constipation in 5 cases, 4 cases, and 2 cases. example. In the early stage of the lesion, bleeding and edema appeared in the intestinal mucosa and submucosa, and the mucosa was dark red. With the progress of the disease course and the exacerbation of the lesion, the surface layer of the mucosa is necrotic and the ulcer forms. In severe cases, intestinal wall full-thickness necrosis (transmural infarction) may even cause intestinal wall rupture, peritonitis, and shock to death. Those with a small infarct size may not penetrate the intestinal wall and localized fibrosis. Intestinal stenosis can be caused by scar formation after the lesion has healed.

Colonoscopy of ischemic bowel disease

It has diagnostic significance, especially emergency endoscopy in the blood phase of the stool, which is the key to early diagnosis. And can be sure

Ischemic bowel disease The scope and stage of the lesion, and the ability to obtain histological examinations at the same time, are helpful for the differential diagnosis of other inflammatory bowel diseases and colon cancer. According to the duration and severity of ischemia of colonic lesions, ICs are generally classified into two types, non-gangrene and gangrene. Among them, non-gangrene is divided into transient and chronic. Transient lesions are transient transient ischemia. The lesions involve the mucosa and submucosa, which are manifested as mucosal hyperemia, edema, ecchymosis, submucosal hemorrhage, and mucosa showed Dark red, vascular network disappears, there may be some mucosal necrosis, followed by shedding of mucous membranes, ulcer formation, annular, vertical, serpentine and scattered ulcer erosion. The ulcer has a clear boundary in the subacute phase, which can be 3 to 4 cm long and 1 to 2 cm wide. The peripheral mucosa is edema and hyperemia, which requires dynamic observation. Among the 19 patients with IC: 14 non-gangrene ICs, of which 11 were transient and 3 were chronic; 4 were gangrene ICs: severe ischemia or mesenteric artery thrombosis, and intestinal mucosal lesions were full-wall necrosis, Deep longitudinal ulcers were formed (one case was perforated without microscopic examination).

Radiological examination of ischemic bowel disease

Of the 19 cases of abdominal plain film, localized spasm was seen early in 16 cases, followed by gas accumulation in the intestinal cavity, segmental dilatation, and disappearance of the colonic pocket of the diseased intestinal segment, but no specificity; 7 cases of Kerkring folds similar to the small intestine Characteristic X-ray

Ischemic bowel disease One of the signs, 1 case with free gas, was considered to be perforation of severe ischemic bowel disease. Barium enema, especially double contrast imaging of the colon, is of great significance in the diagnosis of this disease. The characteristic polypoid filling defect can be seen in 17 cases in the acute stage, which is called "acupressure sign" or "pseudo tumor sign". Intestinal spasm The acute angle sign of spleen flexion is also common in the early stage. In one case, the appearance of barium in the intestinal wall has specificity, indicating that the necrosis reaches the muscular layer. One patient had no perforation. CT examination of 13 of the 19 cases in the middle and late stages of the lesion can clearly show the intestinal wall thickening, stenosis, dilated gas accumulation, gas in the portal vein and free gas in the abdominal cavity, and changes in mesenteric artery embolism, which are of great significance for diagnosis. .

Cause analysis of ischemic bowel disease

Vascular pathology The pathological changes of the blood vessels themselves are the main pathological basis for intestinal ischemia. (1) Atherosclerosis (15 cases): narrowing of the lumen of blood vessels and poor blood flow caused a decrease in blood supply to the corresponding site. (2) Embolism (8 cases): Hypertensive heart disease, rheumatic heart disease, infective endocarditis, myocardial infarction, atrial fibrillation, trauma fracture, long-term bed rest, etc., because of the diameter of the main mesenteric artery It is large and has an oblique angle with the abdominal aorta, so it is easy to receive emboli from the heart and cause embolism. Acute intestine

Related books 50% of the infarct. (3) Systemic vascular disease (one case of nodular polyarteritis): it is also one of the local manifestations. Such as nodular polyarteritis, systemic lupus erythematosus and other immune system diseases, intestinal arterioles are involved, resulting in poor intestinal blood supply and ischemic changes.

Hematological lesions in patients with true erythrocytosis, thrombocytosis, long-term oral contraceptives, severe infection with ICD, chemotherapy, and radiation therapy, the blood is in a hypercoagulable state, and it is easy to form thrombus or emboli to block the intestinal blood vessels. 19 patients One patient received radiation therapy for gynecological tumors. Colon perforation and intestinal gangrene occurred after 1.5 years due to ischemic colitis. Partial intestinal resection and end-to-end anastomosis were performed. Intestinal fistula was caused by perforation again 9 days after surgery. 56 Days later died.

Insufficient blood flow can cause intestinal ischemia due to decreased visceral blood flow, leading to ischemic enteritis, such as reduced cardiac output due to coronary heart disease, heart valve disease or arrhythmia, and peripheral blood vessels during hypotension shock Insufficient perfusion, especially the use of digitalis drugs, alpha adrenergic agonists or beta receptor agonists in the treatment of the above diseases can be used as exogenous stimuli to further reduce intestinal blood flow and induce or exacerbate deficiency The occurrence of bloody bowel disease occurred in 6 of 19 patients.

Other diseases such as superior mesenteric artery compression, intestinal vascular malformations, intestinal and abdominal malignant tumors, intestinal obstruction, and acute pancreatitis can also cause the occurrence of ischemic bowel disease. Acute pancreatitis is a common clinical disease, and its complication rate is about 20%. Vascular complications are not uncommon. Two out of 19 patients are affected by acute pancreatitis and ischemic bowel caused by intestinal arteries and veins. disease. The main symptoms of the patient are abdominal pain, blood in the stool, accompanied by nausea, vomiting, and poor appetite, as well as abdominal distension, diarrhea, pale or dark tongue, and pulses that are heavy or slow or knots, and generation. Due to the frailness of old age, the deficiency of gas in the air, and the "due to stasis caused by deficiency" in the long-term, causes the intestinal choroid to stagnate, causing the blood to fail to pass through the menstrual flow, and the blood in the blood to the stool outside the veins; Abdominal bloating; Cardiac cardio is unfavorable, so nausea, vomiting, and poor appetite; pale or dark purple tongue, heavy or slow pulse or nodule, and generation are also manifestations of stasis caused by deficiency.

Diagnosis of ischemic bowel disease

Because the symptoms of ischemic bowel disease are not specific, early diagnosis based on clinical manifestations is difficult.

If there is a basic lesion of ischemic enteritis, if there is persistent or sudden abdominal pain, the possibility of ischemic enteritis should be considered when there is no special examination, such as positive occult blood in the gastrointestinal secretion or bloody stool, elevated peripheral white blood cells, etc. It is helpful, such as severe abdominal pain, acute abdomen or shock signs, you need to be alert for the possibility of bowel perforation. Emergency endoscopy is of definite significance, especially in the bloody stage of the stool, and is the key to early diagnosis. It can determine the scope and stage of the lesion, and obtain histological examination, which is helpful for the differential diagnosis with other inflammatory bowel diseases and colon cancer. Notes for endoscopy:

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(1) If there is persistent abdominal pain, blood in the stool and peritoneal irritation, gangrene should be considered, and microscopic examination is contraindicated;

(2) Disabling blind-sliding, hook-pulling, relieving, etc., aggravating bleeding and even perforation;

(3) Colonoscopy: This test is feasible for patients with ischemic colitis. Segmental lesions and ulcers of the intestinal mucosa can be seen under the microscope. At 24 hours after onset, the intestinal cavity is filled with bloody fluid, local mucosal hyperemia, and the mucosa is prone to bleeding. After 48 hours, the area became white and edema, with red blood spots in between, with submucosal stasis or scattered superficial ulcers. Due to inadequate blood supply caused by pathological changes in certain blood vessels, there is a clear boundary between the ischemic lesion and the non-lesion. The rectum provides dual blood supply, so it rarely involves rectal mucosal lesions.

(4) Submucosal hemorrhage is usually quickly absorbed or replaced by ulcers, so endoscopy is very important within 72 hours after onset. Serum, CT, angiography, color Doppler, and endoscopy can be performed if necessary for patients suspected of the disease. Color Doppler is a non-invasive and relatively sensitive test. Some scholars performed color Doppler examination on 24 cases of ischemic bowel disease. By measuring the thickness of intestinal wall and intestinal arterial blood flow, they found that the sensitivity of the diagnosis of ischemic bowel disease was 82% and the specificity was 92%. The positive predictive value is 81%, so color Doppler ultrasound is of great significance for the early diagnosis and prognosis monitoring of ischemic bowel disease. The determination of special gas in the intestinal cavity also helps the diagnosis of this disease. The disease is mainly distinguished from ulcerative colitis, colonic disease, and colon cancer.

Barium test: In gangrene ischemic colitis, there is a curved notch at the edge of the colon called a "shiatsu sign" or "pseudotumors".

In some patients with severe symptoms, obvious mucosal edema, swelling, congestion, bleeding, and intestinal stenosis are seen under the colonoscopy. The colonoscopy cannot pass and may be misdiagnosed as colon cancer. Therefore, pay attention to differential diagnosis.

In the chronic phase, the colon mucosa is pale, atrophied, and the blood vessels are unclear in texture. Chronic intestinal cavity stenosis can occur, making colonoscopy impossible. Colonoscopy must be performed carefully to avoid perforation.

Colonoscopy biopsy histology: non-specific changes, submucosal bleeding and edema, disappearance of mucus on the surface of epithelial cells, infiltration of lamina propria, and formation of mucosal crypt abscesses, destruction of glandular structures, and macrophages There are hemosiderins. Chronic mucosal atrophy is accompanied by fibrous and granulation tissue hyperplasia and regeneration of epithelialization.

B-ultrasound: It can be found that the intestinal wall is thickened. Doppler changes in blood flow can help diagnosis, but more experience is needed. ^[1]

Ischemic bowel disease treatment

Overview of ischemic bowel disease

For the treatment of intestinal dysfunction caused by ischemic bowel disease, the primary disease should be mainly treated. Such as actively correcting shock, fasting, intravenous high nutrition, so that the intestine is fully rested, and given broad-spectrum antibiotics. When the heart function is normal, remove drugs that cause mesenteric blood vessels to contract, such as digitalis and vasopressin. Severe intestinal dysfunction is not only not conducive to the recovery of ischemic lesions, but also can aggravate ischemia, and even cause complications such as water and electrolyte disorders, protein-deficient colon disease, and colon perforation. Therefore, active symptomatic treatment should be given. For example, patients with colonic bloating should be given decompression of intestinal exhaust gas and nasal feeding tube decompression; those with nausea and vomiting should be given antiemetic drugs and gastrointestinal motility drugs; those with diarrhea should be given intestinal mucosal protective agents such as Smecta, bismuth hypocarbonate. Antispasmodics such as atropine, anisodamine, etc. and opioids such as phenepiperidine, loperamide, etc. can reduce bowel movements, allowing salt and water to increase reabsorption due to increased contact with the intestine, thereby reducing stool Frequency and relieve abdominal pain, but because some drugs may induce intestinal paralysis and bowel perforation, it should be carefully selected in actual work. Glucocorticoids are not helpful for the recovery of ischemic lesions, and may cause intestinal perforation, so it is not recommended. Most of the non-gangrene patients can be improved within 1 week after the above treatment. If they continue to have diarrhea, bleeding or obvious obstruction symptoms, they usually need surgery.

General method of ischemic bowel disease

General treatment includes gastrointestinal decompression, intravenous fluid replacement to maintain water and electrolyte balance, blood transfusion and the use of broad-spectrum antibiotics for acute mesenteric ischemia. Once diagnosed, papaverine should be diluted with physiological saline to 1.0 mg / ml, and 30 to 60 mg / h. The infusion pump is intubated through the superior mesenteric artery. For non-occlusive mesenteric ischemia, papaverine infusion is continued for 24 hours. Whether papaverine is discontinued depends on the relief of vasospasm, usually 24 hours, but it can be extended to 120 hours. Glucocorticoids are not helpful for the recovery of ischemic lesions, and may cause intestinal perforation. The use of glucocorticoids such as suspected intestinal gangrene and intestinal perforation should be performed by laparotomy. Some cases can be treated with mesenteric artery vascular replacement.

Traditional Chinese Medicine for Ischemic Bowel Disease

The disease should belong to the category of "blood syndrome" in traditional Chinese medicine. It is caused by stasis due to deficiency, blood stasis, blood not flowing through the veins, and overflowing out of the veins. In Chinese medicine's characteristic theory of blood syndrome, Miao Xiyong's "Three Essential Methods of Treating Blood Spitting" and Tang Rongchuan's "Four Methods of Treating Blood" pay particular attention to the methods of blood circulation and blood stasis elimination. In the Ming Dynasty, Miao Xiyong's "Xian Zhai Zhuang Medicine Guang Notes · Hematemesis" emphasized the important role of blood circulation, nourishing the liver, and lowering qi in the treatment of hematemesis, and proposed "the blood should not be stopped but the liver should not be cut", There are three ways to treat vomiting blood, which should be "lower gas and lower fire". From a historical perspective, this is a new development in the treatment of bleeding disorders, and it has the nature of supplementing and remedying evils. The three pairs of treatment methods: blood circulation-hemostasis, liver nourishing-cutting liver, reducing qi-reducing fire should be treated dialectically according to the condition. In the Qing Dynasty, Tang Rongchuan proposed four methods of treating blood, including hemostasis, dissipating blood stasis, restless blood, and tonifying deficiency. Therefore, hemostasis is not the first priority when treating blood syndromes. Therefore, the method of removing blood stasis is indeed an outline for the treatment of intestinal dysfunction of ischemic bowel disease, which is worthy of clinical reference.

Ischemic bowel disease