376 - 380 Three cases of ischaemic colitis

E.S. was a woman of 77 years, who was admitted to hospital on 3 May 1965. She had been on Aldomet tablets for hypertension for one year, but was active and fit. For 10 days before admission, she had complained of abdominal pain and had gradually weakened. A few hours before her admission the abdominal pain had increased in severity and her general condition had deteriorated rapidly. During this 10-day period, she had only opened her bowels on one day, when she passed several loose motions but no blood or mucus. On examination she was found to be extremely ill. She was in peripheral circulatory failure, her blood pressure was 90/60 mm Hg, and her pulse was 90 per minute. She was dehydrated. She had marked abdominal distension with moderate rigidity and tenderness in the lower abdomen. Bowel sounds were absent. On rectal examination, she was tender in the pouch of Douglas. The faecal smear was normal. Her heart was found to be enlarged with left ventricular hypertrophy. Her peripheral pulses were all present. Some immediate investigations were carried out. Haemoglobin was 102 %, total white cell count 13,200 per cu mm (95 % polymorphs), sedimentation rate 44 mm/hour, an ECG showed bundle branch block and left ventricular strain, and a chest radiograph showed an enlarged heart. Following resuscitation, she was taken to the theatre. On the way to the theatre a plain radiograph of the abdomen was taken in the supine position (Fig. 1), and it showed a distended loop of bowel, which was later found to be the transverse colon. This colonic loop had lost its haustrations; this could only be confused with 'toxic dilatation' of the colon in ulcerative colitis. However, the dilatation is so localized that this x-ray picture is almost diagnostic of gangrenous colitis. At operation the transverse colon was found to be gangrenous. The hepatic and splenic flexures were involved to a lesser extent and the ascending and descending colons were oedematous. The involved colon was resected; the proximal ascending colon and the sigmoid colon were brought out as terminal colostomies. At operation an attempt was made to feel pulsations in the mesenteric vessels but, as the patient's blood pressure was low and her general condition poor, time could not be allowed for a detailed examination. The postoperative course was stormy and she died on the ninth postoperative day. During this period she developed renal failure. For the first five postoperative days she passed less than 50 ml of urine each day, the blood urea level rose to 250 mg%, serum potassium to 6 m-equiv/litre, and she became acidotic. The concentration of urea in the urine was less than five times the concentration of urea in the blood. She was treated by limiting the fluid and protein intake, administering carbohydrate intravenously, and using an ion exchange resin. At the time of her death kidney function was