P48 Shock Colon

Introduction Non-occlusive mesenteric ischaemia (NOMI) is rare in children. There are individual case reports of ischaemic colitis, with various underlying causes for the acute deterioration. The likely mechanism is hypoperfusion/reperfusion injury. The outcome tends to be poor. Potentially; because the initial hit to the whole system is so significant, or possibly because of the toxicity of the colonic insult. Promptness of colonic resection does not seem to improve survival. In our institutions we recognised a series of critically ill patients with a similar pattern of colonic injury. The patients had a comparable clinical picture and outcome. Therefore, we hypothesised; a similar underlying pathophysiology might be responsible. By collaborating, the expectation was that we would identify key learning points. Aim We aimed to identify patterns in presentation and correlate these with, surgical and pathology findings. By studying our cohort and reviewing the existing literature, we hoped to identify a possible means of improving survival. Subject and Methods We reviewed clinical notes, histology, radiology and laboratory results of 4 consecutive cases of idiopathic colonic gangrene associated with acute cardiovascular collapse. Patients presented over a 2-year period to our 2 institutions (both providing tertiary paediatric surgery). We reviewed the literature on young adults and children with ischaemic colitis and non-occlusive mesenteric ischaemia. Results Four critically ill children (aged 1–14 years), requiring resection of ischaemic colon following sudden cardiovascular collapse, presented to our institutions over a 2-year period. Three had a preceding history of recent illness; the other had been well prior to out of hospital cardiac arrest. The 3 who were unwell experienced: headache (1), cough (1) and polyuria and polydipsia (1) for up to 2 weeks prior to hospital attendance. None had abdominal or gastrointestinal (GI) symptoms in their initial symptoms, although all but 1 developed GI upset during their rapid deterioration phase. Three had cardiac arrest before colectomy. All developed abdominal distension after resuscitation. All had significant derangement of blood sugar on monitoring. All 4 received inotropic support before surgery. All 4 had total colonic ischaemia diagnosed during surgical intervention and on histology report. There was no other underlying disease on histology (bowel was ganglionic). No infective organism was isolated (specifically all were negative for clostridium difficile). All 4 died due to multi organ failure. Summary and Conclusion From this case series we could not identify any specific condition that predisposed these 4 children to develop non occlusive mesenteric ischaemia and colonic injury. Therefore we could not clearly identify means of prevention. All 4 had a sudden deterioration over less than 24 hrs, and all received inotropes before developing abdominal distension. In addition, 3 out of 4 had cardiac arrest and return of circulation before colectomy. These would support the hypothesis of hypoperfusion/reperfusion injury. Even though all 4 patients had colonic resection as part of the resuscitation the outcomes were very poor leading to multi organ failure or cerebral ischaemia and death.