Reversible Vascular Occlusion of the Colon

JAMES E. DAVIS, M.D.

From the Department of Surgery, Watts Hospital, Durham, North Carolina

IT is now recognized that occlusion ofthe vessels of the intestines does not in-variably result in gangrene of the affectedsegment. The bowel may survive such oc-clusion with resultant scarring and stenosis,or with complete repair and no permanentchange. These stages of ischemic colitishave been classified as gangrenous, stric-turing, and transient forms.9 Transient orreversible occlusion occurs more frequentlythan is generally recognized, can be diag-nosed accurately, and, in most instances,can be managed safely without operation.The degree and extent of injury resulting

from sudden withdrawal of blood to a loopof intestine depends on a number of fac-tors. Size and location of the occluded ves-sels, duration of the occlusion, efficiency ofcollateral circulation, and presence of bac-teria within the lumen may all be impor-tant.10 If the length of bowel involved isgreater than marginal and intramural ves-sels can supply, necrosis, sloughing, anddeath from peritonitis will ensue.12 Ifenough blood is supplied to prevent deathof the intestine, but insufficient for the re-pair of the damaged mucosa, a combina-tion of necrosis and bacterial invasion takesplace. This results in a variable pathologicprocess which may include muscular atro-phy or hypertrophy, fibrosis, giant-cell sys-tems, and stenosis.6 13, 14, 18, 19 If only asmall segment of bowel is involved, or ifthe obstructed vessel is adequately by-passed by collaterals, transient ischemia is

followed by vasodilatation and completehealing, and no permanent lesion.' Whentransient occlusion occurs, there is a char-acteristic clinical and radiological course.We have recently encountered six patientswith this lesion, five in a community hos-pital and one in a state psychiatric insti-tution.

Clinical FeaturesClinical features are summarized in the

Table. Reversible occlusions occur in pa-tients in middle and advanced age groups,and there seems to be no sex preference.Typically, a patient who has been in goodhealth and without significant colonic dis-ease has a sudden onset of generalized ab-dominal pain, usually crampy, and rectalbleeding. Neither pain nor bleeding tendsto be severe. On physical examination thepatient is not acutely ill, and has mild tomoderate abdominal tenderness. A poly-morphonuclear leukocytosis sometimes oc-curs. Characteristically, the clinical condi-tion remains good, hematocrit remains sta-ble or drops slightly and the abdominaldiscomfort disappears. No specific therapyis usually required. Within 1 to 6 weeks,the patient is normal. Recurrences are rare.

Radiological FindingsAs demonstrated by barium x-rays, the

pathologic process is always segmental,and may occur in any part of the colon ex-cept the rectum.9 Four types of abnormali-ties have been described. The most con-stant and significant is the "thumb print-ing" or pseudotumor formation (Fig. 1).

789

Presented at the Annual Meeting of the South-em Surgical Association, December 8-10, 1969,Hot Springs, Virginia.

DAVIS Annals of SurgerYMay 1970

TABLE 1.

Case Age Presenting Associated AdmissionNo. Sex Symptoms Disease Hemoglobin

1 75 Bleeding, abdominal Rheumatoid arthritis, 14.4 Gm.F discomfort for 48 hr. generalized arterio-

sclerosis, previousmyocardial infarction

2 85 Upper abdominal Disorientation, general- 13.1 Gm.F pain, nausea, vomit- ized arteriosclerosis,

ing for one week myocardial infarc-tion, cardial decom-pensation

3 39 Lower abdominal pain, None 16.7 Gm.M bleeding for 12 hr.

4 59 Lower abdominal pain, None 14.9 Gm.F bleeding for 9 hr.

5 55 Generalized abdominal Peptic ulcer 13.7 Gm.F pain, vomiting,

bleeding for 12 hr.

6 45 Generalized abdominal Mentally deficient 14.5 Gm.M pain, bleeding for

one week

This is a polypoid change giving a scal-loped margin to the bowel wall with trans-lucent rounded filing defects extendinginto the lumen in the filled phase of thebarium enema, and showing as soft tissuemasses in double contrast films.15 Otherchanges frequently seen are sacculation,tubular narrowing, and ragged, saw-toothirregularity of the mucosa (Fig. 2). Thomasrecently showed that the narrowing seen

in this condition is marked by a gradualwidening or "funnelling" at either end ofthe ischemic stricture at its junction withunaffected colon. This is unlike the fun-neling seen in carcinoma or Crohn's dis-ease where the change from affected tonormal colon is more abrupt. In procto-colitis, the change from the abnormal seg-ment to the normal is imperceptible."7

Simultaneously with improvement in thepatients clinical condition, radiological

signs gradually disappear. Complete dis-appearance of radiological signs, and espe-

cially "thumb printing" is essential in mak-ing the diagnosis of reversible vascularocclusion. Any extension of the original ra-

diological findings, correlated with a de-cline in clinical status, suggests a non-

reversible occlusion. Persistence of radio-logical defects beyond one or two weeksexcludes a diagnosis of vascular occlusionand suggests a more ominous lesion.

Pathology

Boley and associates 1',2 have shown thatin an occlusion which proves to be re-

versible occlusion does not occur in pri-mary vessels supplying the affected loop ofbowel, nor in the arcades, but in t-he ar-

teries or veins which lie distal to the ar-

cades. In experimental studies in dogs,various types of arterial, venous, and com-

790

Volume 171Number 5

REVERSIBLE VASCULAR OCCLUSION OF THE COLON

Review of Six Cases

AdmissionWBC

Neutrophils) Site of Lesion Treatment Course

13,)00 Transverse None Recovered. BE one(90%70) month later.

Normal

22,750 Hepatic flexure Supportive Recovered. BE(92%o) three months

later. Normal

24,400 Distal transverse, None Recovered. Asymp-(90%) descending, tomatic for one

proximal yearsigmoid

10,500 Transverse None Recovered. BE one(82%) month later.

Normal

8,150 Descending None Recovered.(65%) Asymptomatic

for six months

9,350 Ascending Negative laparotomy Recovered. BE one(63%) 3 weeks after x-ray week after opera-

demonstration tion. Normal

bined occlusions of the distal vessels re-

produce clinical and radiological featuressimilar to those in humans. As in patients,experimental changes also proved to be re-

versible.

The sequence of events following a tran-sient occlusion appears to be established.Initially there is mucosal hemorrhage as-

sociated with intraluminal bleeding andthe appearance of pseudotumors on barium

-- uIg': -m- _,

...

FIG. 1. a (left) "Thumb-Printing" of the superior border of transverse colon. b (right)"Thumb-Printing" and pseudotumor formation in descending and sigmoid colon.

791

Annals of SurgeryMay 1970

FIG. 2a. Sactilation oftransverse colon.

FiG. 2b. "Saw-Tooth"irregularities of trans-verse colon.

enema x-rays. Gradual subsidence of hem-orrhage and pericolic inflammation if thenassociated with diminishing evidence of"thumb printing." Disappearance of theindentations radiologically coincides withthe development of ulcers in the area ofsubmucosal hemorrhage. Finally, healingoccurs with or without narrowing of thecolon.-Wolf and MarshakL9 have shown experi-

mentally that various layers of the intes-

tines differ in sensitivity to interferencewith blood supply. The mucosa is most de-pendent upon intact vascularity and theearliest and most profound changes occur

in this layer. Regenerative capacity of mu-

cosa explains rapid healing, and if thedeeper layers of the bowel are not in-volved, no permanent changes result. Evensevere ischemic changes can be repairedwithin hours or days.3' Clinical correlationof such a rapid and progressive change has

792 DAVIS

REVERSIBLE VASCULAR OCCLUSION OF THE COLON

been reported by Littman et al.7 in a pa-

tient with vascular occlusion of the lowersigmoid colon. By repeated sigmoidoscopicand biopsy examinations this sequence ofevents was observed.

Discussion

The importance of recognizing reversiblevascular occlusion of the colon lies in theavoidance of unnecessary operations. Whileimproved radiological and surgical technicsfacilitate and stimulate an aggressive op-

erative approach to major vascular acci-dents, recognition of this syndrome shouldlead to surgical conservatism. The mesen-

teric vessels involved lie distal to the ar-

cades, are not demonstrated by arteriog-raphy 1, 4 7, 16, 17 and are not amenable to

operative therapy. The lesion produced islimited, reversible, and results in no per-

manent changes.Such infarction of small vessels of the

bowel has been compared with infarctionof coronary vessels. The age of the patientsinvolved, the histological pictures pro-

duced,9 and the reversibility are similar.The processes differ in that the infarctedmyocardium is sterile, while infarction ofthe bowel mucosa is followed by bacterialinvasion. This apparently accounts for theleukocytosis in some cases. The intriguingsuggestion has been made that intestinalinfarction occurs as commonly as myocar-

FIG. 2c. Narrowing of hepatic flexuresuggesting neoplasm.

dial infarction, but because of the presence

of bacteria the bowel lesions are inter-preted as specific infections."1 It is antici-pated that ultimately a vascular factor willbe recognized in the pathogenesis of manyintestinal diseases.

Progression of the vascular occlusion can-

not be predicted on the initial physical,radiographic, or sigmoidoscopic evaluation.These patients must be followed carefully.If signs or symptoms persist or increase,surgical intervention may be indicated. Inpersistent radiographic defects, the differ-

FIG. 3a. (Case 6) Ob-structive lesion of hepaticflexure, presumed to becarcinoma.

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six months to four and one half years. Twopatients died of unrelated causes. Failureto recoginize this syndrome resulted mn oneunnecessary operation (Table 1, Case 6).In this instance, an obstructive lesion ofthe hepatic flexure was found and pre-sumed to be carcinoma (Fig. 3). The pa-

tient was admitted to a state mental insti-tution. Three weeks after demonstration ofthe lesion, a negative laparotomy was per-formed without repeated x-ray studies.Barium enema x-ray one week after op-eration confirmed the operative findings ofa normal colon. Similar circumstances wereencountered in Case 2 (Table 1). This pa-tient was also originally thought to have acarcinoma of the colon, but cardiac decom-pensation contraindicated operation. Afterimprovement of the cardiac status, 3 monthslater barium enema x-rays were normal.

Summary1. Six patients as examples of reversible

vascular occlusion of the colon are re-ported. This condition is contrasted withmore advanced forms of ischemic colitis,stenotic and gangrenous types.

2. Recognition of this condition shouldlead one to surgical conservatism, and op-erative intervention is seldom required.

3. Clinical features of abdominal pain,rectal bleeding, and paucity of signs onphysical examination are combined withthe radiological demonstration of "thumbprints" or pseudotumors and less frequentlysacculation, tubular narrowing, and "saw-tooth" irregularity of the mucosa.

4. With subsidence of signs and symp-toms colonic x-ray findings rapidly returnto normal.

5. Progression of vascular occlusion ofthe colon cannot be predicted on initialphysical and radiographic examination. Ifsymptoms and signs persist, operative ther-apy may be indicated.

References1. Boley, S. J., Schwartz, S., Lash, J. and Stem-

hill, V.: Reversible Vascular Occlusion of theColon. Surg. Gynec. Obstet., 116:53, 1963.

2. Boley, S. J., Schwartz, S., Krieger, H., Schultz,L., Siew, F. and Allen, A. C.: Further Ob-servations on Reversible Vascular Occlusionof the Colon. Amer. J. Gastroent., 44:260,1965.

3. Cameron, G. R. and Khanna, S. D.: Regenera-tion of the Intestinal Villi After Extensive

Volume 171 REVERSIBLE VASCULAR OCCLUSION OF THE COLON 795Number 5

Mucosal Infarction. J. Path. Bact., 77:505,1959.

4. Dunbar, J. D.: Reversible Cecal Infarction.Amer. J. Surg., 112:447, 1966.

5. Glotzer, D. J., Villegas, A. H., Anakayama, S.and Shaw, R. S.: Healing of the Intestine inExperimental Bowel Infarction. Ann. Surg.,155:183, 1962.

6. Klein, E.: Embolism and Thrombosis of theSuperior Mesenteric Artery. Surg. Gynec.Obstet., 33:385, 1921.

7. Littman, L., Boley, S. J. and Schwartz, S.:Sigmoidoscopic Diagnosis of Reversible Vas-cular Occlusion of the Colon. Dis. ColonRectum, 6:142, 1963.

8. Marshak, R. H., Maklansky, D. and Calem,S. H.: Segmental Infraction of the Colon.Amer. J. Dig. Dis., 10:86, 1965.

9. Marston, A., Pheils, M. T., Thomas, M. L.and Morson, B. C.: Ischaemic Colitis. GUT,7:1, 1966.

10. Marston, A.: Patterns of Intestinal Ischaemia.Ann. Roy. Coll. Surg. Eng., 35:151, 1964.

11. Marston, A.: Mesenteric Arterial Disease: ThePresent Position. GUT, 8:203, 1967.

12. Niederstein, K.: Die Zirkulationstorungen im

Mesenterialgebiet. Disch. Z. Chir., 85:710,1906.

13. Pope, C. H. and O'Neal, R. M.: IncompleteInfarction of Ileum Simulating RegionalEnteritis. J. Amer. Med. Ass., 161:963, 1956.

14. Reeves, J. D. and Wang, C. C.: The Stagesof Mesenteric Artery Disease. Southern Med.J., 54:541, 1961.

15. Schwartz, S., Boley, S. J., Robinson, K.,Krieger, H., Schultz, L. and Allen, A. C.:Roentgenologic Features of Vascular Disor-ders of the Intestines. Radiol. Clin. N.Amer., 2:71, 1964.

16. Schwartz, S., Boley, S. J., Lash, J. and Stern-hill, V.: Roentgenologic Aspects of Reversi-ble Vascular Occlusion of the Colon and ItsRelationship to Ulcerative Colitis. Radiology,80:625, 1963.

17. Thomas, M. L.: Further Observations on Is-chaemic Colitis. Proc. Roy. Roc. Med., 61:341, 1968.

18. Wang, C. C. and Reeves, J. D.: MesentericVascular Disease. Amer. J. Roentgen., 83:895, 1960.

19. Wolf, B. S. and Marshak, R. H.: SegmentalInfarction of the Small Bowel. Radiology,66:701, 1956.

DIscussIoNDR. JAMES E. DAVIS (Closing): The inevitable

question arises: Does this same process occur inthe small bowel as well as in the colon?

The obvious answer is: Yes, it does, but moreinfrequently. This is apparently so because of thedifference in blood supply and collaterals of thesmall bowel, plus a difference, of course, in thebacterial population of the two segments of bowel.

One would like to know a great deal moreabout the underlying causes and etiology, and thisis not clear. Certainly, in this age group athero-sclerosis and resultant vascular narrowing mustplay an important role, and all forms of vasculitis,diabetes, the rheumatoid diseases, Berger's dis-ease, and lupus erythematous all have been im-plicated as underlying causes of such a reversibleocclusion.