Clinical presentation, prognostic factors and epidemiology of ischemic bowel disease in the very old

Abstract: Background: Acute ischemic bowel disease (AIBD) is a potentially death-threatening vascular emergency predominantly affecting the elderly (>65 years). The prognosis is dismal and early diagnosis and treatment is of vital importance for the outcome. Clinical presentation is unspecific. The five studies were retrospective. The patients were retrieved from Malmö University Hospital. The aim with this thesis was to illustrate a geriatric perspective in AIBD by comparing clinical presentation and roentgenological findings in older and in younger patients, and to describe changes in the incidence in relation to demographic data and autopsy frequency. Results: One-hundred and thirty-five patients were identified with AIBD in Malmö 1987-1996. In 75 operations, 42 patients had bowel-resection. The prognosis was poor for the very old, whereas the less old have a much more favourable prognosis (p<0.001). The elderly had higher incidence of unresectable gangrene despite the same time course to operation as the younger (p<0.001). Delay in surgical intervention was associated to increasing mortality (p= 0.038), but no age differences were noted. AIBD in the old was associated with a significantly different clinical presentation (confusion, hematemesis, vomiting and dehydration) and a higher mortality compared with younger patients (p=0.003). Digitalis treatment seems to be associated with increased mortality in ischemic bowel disease. Prodromal signs were prognostically unfavorable. Eighty-nine patients were examined by abdominal plain film. Plain film findings differed with age. Bowel dilatation, which was associated to mortality, was more frequent in the elderly with AIBD (p<0.05), whereas gasless abdomen was more common in younger patients (p=0.001). Between 2004-2008, 36 patients were examined with multi detector computed tomography with intravenous contrast (MDCTiv). Two out of three were correctly diagnosed by MDCTiv at first evaluation. At re-evaluation, SMA occlusion was found in all cases with MDCTiv, and intestinal findings were present in half. In-hospital mortality rate was 42% for patients who underwent MDCTiv, which was significantly lower compared to 90% for the 10 patients examined with plain MDCT (p=0.007), and 71% for patients not examined with MDCTiv or plain MDCT (p=0.031). Between 2000–2006, the overall incidence rate of AIBD decreased from 8.6 to 5.4/100 000 person years compared to 1970 –1982, and the autopsy rate from 87% to 25% over time. The in-hospital mortality rate was 63% in the latter time period. For those being investigated with MDCTiv and undergoing vascular intervention the in-hospital mortality was 34% (9/25) and 20% (2/20), respectively. General and vascular surgeons collaborated in 25 out of 61 patients that underwent an intervention, of which 21 (84%) (p<0.001) survived. Conclusions: Advanced age is a strong risk factor in surgery for AIBD, with higher incidence of unresectable gangrene despite the same time course from admission to operation as younger age groups. AIBD in the old is associated with a different clinical presentation and higher mortality compared to younger patients. Elderly with AIBD presented more frequent with colon dilatation with G/F-levels and small bowel dilatation in plain film, whereas younger patients presented with a gasless abdomen. Examination with MDCTiv in patients with acute SMA occlusion was associated with survival benefit. The overall mortality rate in patients with acute SMA occlusion remains high. A close collaboration between radiologists, general and vascular surgeons seems to be most important to lower the mortality in patients with acute SMA occlusion.