Ischemic colitis after enema administration: Incidence, timing, and clinical features

Table 1 Incidence of enema-related ischemic colitis and its major adverse events

	Glycerin	Kalimate	Duphalac	Total
Total number of enemas	8320 (50.3)	7819 (47.3)	406 (2.5)	16545
Number of IC	19 (0.23)	0 (0.0)	0 (0.0)	19 (0.11)
Major adverse event	10 (52.6)	N/A	N/A	10
Surgical resection	9 (47.4)	N/A	N/A	9
In-hospital mortality	4 (21.1)	N/A	N/A	4

Data are n (%). IC: Ischemic colitis; N/A: Not applicable.

Table 2 Demographic and clinical characteristics of the study patients receiving glycerin enema

Number	IC group (n = 19)	Control (n = 76)	P value
Age	70.2 ± 11.7	70.2 ± 11.5	0.996
Sex, male	8 (42.1%)	32 (42.1%)	1.000
Initial vital sign
Systolic blood pressure (mmHg, mean ± SD)	138.5 ± 34.4	135.8 ± 27.3	0.716
Diastolic blood pressure (mmHg, mean ± SD)	83.6 ± 22.1	81.7 ± 16.0	0.678
Pulse rate	85.8 ± 22.9	84.0 ± 19.4	0.727
Respiratory rate	20.6 ± 2.1	19.9 ± 2.3	0.146
Initial symptom			0.847
Abdominal pain	11 (57.9)	47 (61.8)
Constipation	3 (15.8)	7 (9.2)
Vomiting	2 (10.5)	9 (11.8)
Miscellaneous symptom	3 (15.8)	13 (17.1)
Constipation score1 (mean ± SD)	1.1 ± 1.2	0.5 ± 0.8	0.022
Condition
History of chronic constipation	8 (42.1)	17 (22.4)
Recurrent usage of enema agent	3 (15.8)	7 (9.2)
Last defection more than 5 d	4 (21.1)	10 (13.2)
Failure: Unsuccessful attempts for evacuation before admitting ED	6 (31.6)	3 (4.0)
ACCI score
mean ± SD	5.8 ± 3.1	4.9 ± 2.3	0.245
Condition
Myocardial infarction	2	2
Congestive heart failure	3	1
Peripheral vascular disease	1	2
Cerebral vascular disease	3	7
Dementia	2	2
Chronic pulmonary disease	0	1
Connective tissue disease	0	1
Peptic ulcer	2	4
Mild liver disease	1	1
Hemiplegia	0	1
Diabetes	6	15
Moderate or severe renal disease	3	5
Diabetes with end-organ damage	1	3
Solid tumor	5	25
Leukemia	2	1
Lymphoma	0	2
Moderate or severe liver disease	1	2
Metastatic solid tumor	3	11
AIDS	0	0
Drug proposed to predispose to IC
Total No. of patients (moderate + low)	13	57	0.560
No. of patients taking drugs with moderate evidence	7	39	0.259
Constipation-inducing drugs	7	39
No. of patients taking drugs with low evidence	6	18	0.479
Antibiotics	4	12
Chemotherapeutic drugs	2	2
Decongestants	0	1
Diuretics	1	3
Laxative	3	7
Psychotropic drugs	0	6
Initial Laboratory test
CRP (mg/dL)	5.9 ± 1.0	1.4 ± 2.8	0.429
WBC (× 103/μL)	13.4 ± 7.5	8.4 ± 3.4	0.004
Plain abdominal radiograph
Abnormal findings	5 (26.3)	9 (11.8)	0.146
New symptom after enema
Hematochezia	11 (57.9)	0
Abdominal pain	5 (26.3)	0	N/A
Sudden drop in blood pressure	3 (15.8)	0
Asymptomatic	0 (0.0)	76 (100.0)
Diagnostic tools			N/A
Non contrast-enhanced AP-CT	1 (5.3)	NA
Contrast-enhanced AP-CT	18 (94.7)	NA
Colonoscopy	14 (73.7)	NA
Treatment			N/A
Supported care	10 (52.6)	NA
Surgical resection	9 (47.4)	NA

Data are presented as mean ± SD or n (%). P values were calculated by the Mann-Whitney U test, t test, χ² test, or Fisher’s exact test, as appropriate.

¹Calculated using a modified simple criteria based on the Wexner constipation scoring system[19]. IC: Ischemic colitis; ED: Emergency department; ACCI: Age-adjusted Charlson comorbidity index; SD: Standard deviation; CRP: C-reactive protein; WBC: White blood cell; AP-CT: Abdominopelvic computed tomography; NA: Not available; N/A: Not applicable.

Table 3 Conditional regression analysis for the prediction of glycerin enema-related ischemic colitis

	Univariate analysis		Multivariate analysis
	Odds ratio (95%CI)	P value	Odds ratio (95%CI)	P value
Constipation score1	1.9 (1.1-3.3)	0.015	2.0 (1.1-3.5)	0.017
ACCI score	1.2 (0.9-1.4)	0.144
Leukocytosis	4.4 (1.4-13.5)	0.009	4.5 (1.4-14.7)	0.012
CRP	2.2 (0.8-6.1)	0.151
Abnormal abdominal radiograph	2.5 (0.8-8.6)	0.132
Drug proposed to predispose to IC	1.9 (0.6-5.7)	0.260

¹Calculated using modified simple criteria based on the Wexner constipation scoring system[19]. CI: Confidence interval. ACCI: Age-adjusted Charlson comorbidity index; CRP: C-reactive protein; IC: Ischemic colitis.

Table 4 Radiologic features on computed tomography in patients with ischemic colitis after glycerin enema administration (n = 19)

	CE-CT (n = 18)	NCE-CT (n = 1)
Segmental wall thickening	n = 18	n = 1
Location (Rectum/sigmoid/descending/transverse/ascending colon)	16/17/10/7/2	1/1/0/0/0
Wall thickening thickness (mm), mean ± SD	9.57 ± 2.39	5.6
Wall thickening pattern (circumferential/eccentric)	18/0	1/0
Skip area	3	0
Decreased wall enhancement	n = 10	N/A
Involving layer (no/inner layer/transmural)	8/3/7
Target sign	15
Skip area	7
Pericolic stranding or fluid	9	1
Peritoneal free fluid or mesenteric edema	2	0
Pneumatosis coli	1	0
Portal or drain venous gas	1	0
Pneumoperitoneum	1	0
Vascular occlusion	0	N/A

Data are presented as n or mean ± standard deviation. SD: Standard deviation; CE-CT: Contrast-enhanced abdominopelvic computed tomography; NCE-CT: Non-contrast enhanced abdominopelvic computed tomography; N/A: Not applicable.