Article, Gastroenterology

Marathon-induced ischemic colitis: why running is not always good for you

Case Report

Marathon-induced ischemic colitis: why running is not always good for you

Abstract

We present the case of a 31 year-old man who presented to the emergency department of University College Hospital London after collapsing upon finishing the London mara- thon. Contrast-enhanced multidetector computed tomogra- phy scanning revealed ischemic colitis of the cecum and Ascending colon, which progressed to the development of clinical peritonism after 48 hours. This patient subsequently underwent a laparotomy and right hemicolectomy, with ileostomy formation, on the third day after admission. Operative and Histologic findings confirmed ischemic colitis of the cecum and proximal colon. The postoperative recovery was uneventful, and he was discharged home well. Possible mechanisms of ischemia in marathon runners and those undergoing intense exercise include a combination of splanchnic vasoconstriction, dehydration, and hyperther- mia, combined with mechanical forces. Most patients presenting with marathon-running-induced ischemic colitis respond to conservative treatment and the need for operative intervention is extremely rare.

RB was a 31-year-old man, with no medical history of note. He was an amateur sportsman, who engaged in occasional exercise but was about to run his first marathon. He underwent 6 weeks of distance running training (although never completing a distance of more than 14 miles) before running the London marathon.

After 16 miles, RB began to experience abdominal cramps, mainly localized in the right iliac fossa. Fresh red Rectal bleeding, requiring frequent toilet stops en route toward the finish line, soon developed. Upon completion of the marathon, RB complained of worse abdominal pain, together with dizziness, and subsequently collapsed. He was brought to the emergency department (ED) by the London Ambulance Service. In the ED, he was tachycardic with a heart rate of 110 beats per minute, but his other vital signs were within normal limits. abdominal palpation revealed tenderness and guard- ing in the right iliac fossa with active bowel sounds. Rectal examination was normal. Both hemoglobin and White blood cell counts were normal, and blood gas analysis showed lactate 2.7 mmol/L and base excess -1.9mmol/L. Oxygen was administered, intravenous cannulae inserted, and fluid resuscitation initiated. En route to the radiology department

for a contrast-enhanced Multidetector computed tomography (ceMDCT) scan of his abdomen and pelvis, he passed a further 400 mL of fresh blood per rectum. The subsequent ceMDCTscan revealed a thickened and enhancing cecum and proximal colon, prominent arteries of the cecum and ascending colon, and free fluid in the right paracolic gutter (Fig. 1), consistent with a diagnosis of ischemic colitis.

RB improved with resuscitation and was admitted to the surgical ward, where fluid balance and pain control optimization were combined with repeated assessments of his clinical status. However, 36 hours after admission, RB appeared to be deteriorating with increased abdominal pain, worsening inflammatory markers, and signs of generalized peritonism on Abdominal examination. After a multidisci- plinary meeting involving gastroenterologists and colorectal surgeons, a consensus opinion was reached that laparotomy with resection of the ischemic bowel had become necessary. RB underwent a laparotomy on the third day after admission. At operation, the cecum and proximal colon were edematous, hemorrhagic, and covered in inflammatory exudates. A right hemicolectomy was performed without primary anastomosis due to the ischemic etiology. A Brooke ileostomy and mucous fistula were fashioned. Histology of the resected specimen revealed infarction and ulceration of

Fig. 1 A ceMDCT scan of this 31-year-old man’s abdomen and pelvis revealed a thickened and enhancing cecum and proximal colon, prominent arteries of the cecum and ascending colon, and free fluid in the right paracolic gutter, consistent with a diagnosis of ischemic colitis.

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255.e6 Case Report

the mucosa and submucosa (Figs. 2 and 3). RB’s post- operative recovery was uncomplicated, and he was dis- charged home well 10 days after admission. His ileostomy was subsequently reversed without complication.

During or after a marathon, up to 60% of runners report gastrointestinal (GI) symptoms, including bloating, epigas- tric pain, abdominal cramps, diarrhea, and fecal incon- tinence, with lower GI symptoms occurring more frequently than upper [1]. Gastrointestinal symptoms are most common in runners, but other athletes including cyclists and rugby players are also affected [2,3].

Endoscopic evaluation reveals that occult bleeding can be found in up to 85% of endurance athletes, most commonly from the lower GI tract [4,5].

The primary mechanism for these GI disturbances appears to be increased sympathetic tone in the splanchnic vasculature [6], leading to a reduction in splanchnic blood flow of up to 80% at maximal exercise intensity [7]. Thus, critical levels of ischemia can occur during intense and prolonged exercise. This may be further exacerbated by hyperthermia, dehydration, hypoxia, and alterations in blood viscosity and aggregability [8]. Training can reduce dramatic vascular shifts away from the GI tract and, therefore, the extent of GI disturbance [9]; consequently, RB may have been more susceptible to these phenomena as his premara- thon training was relatively light.

Alterations in flow dynamics should primarily affect those areas most sensitive to low flow states-the watershed area near the splenic flexure and the hypogastric supply at the rectosigmoid junction. However, for unknown reasons, exercise-induced ischemic colitis and shock-induced ischemic colitis appear to primarily affect the cecum and ascending colon [10,11]. Mechanical trauma has been postulated as a further potential cause of GI effects seen in intense exercise. Mechanical vibration

[2] and acceleration/deceleration forces contributing to Fluid shifts and liquefaction of stool contents have been

Fig. 2 A low-power view showing patchy mucosal infarction, with an area of residual large bowel mucosa. The underlying submucosa is edematous and inflamed.

Fig. 3 Focal mucosal infarction.

implicated [12,13]. Other possible contributory factors include nonsteroidal anti-inflammatory drugs, commonly taken before, during, and after intense exercise, which can exacerbate existing bowel disease [14], and the oral contraceptive pill, which has been implicated in the development of ischemic colitis in women [15].

Most patients with exercise-induced ischemic colitis respond to fluid resuscitation, bowel rest, and analgesia [6,16-21]. However, occasionally operative intervention, in the form of resection of ischemic bowel, is required. Literature and PubMed review reveals that we report only the third case of marathon-running-induced ischemic colitis requiring surgery (others requiring a right hemicolectomy and a subtotal colectomy), and the first documented case of a first- time marathon runner requiring surgery for exercise-induced ischemic colitis [22,23]. The increasing popularity for healthy lifestyles, keeping fit, and marathon running among amateur sportsmen means that emergency physicians and surgeons are more likely to see such patients in the future.

Daniel C. Cohen MBChB, BSc, MRCS Alison Winstanley MBBS, BSc, MRCPath Alec Engledow MBBS, BSc, FRCS

Alastair C. Windsor MBBS, MD, FRCS, FRCS (Ed)

Department of Colorectal Surgery University College Hospital NHS Trust

NW1 2BU London, UK

James R. Skipworth MBBS, BSc, MRCS Department of Colorectal Surgery University College Hospital NHS Trust

NW1 2BU London, UK Department of Surgery

4th floor Medical School Building 74 Huntley Street, University College

WCIE 6AU, London, UK

E-mail address: [email protected] doi:10.1016/j.ajem.2008.06.033

Case Report

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