CDR Steven Kriss, MC, USN, Family Practice/Sports Medicine, Naval Hospital Camp Pendleton, California 16 APRIL 2010

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Military Disclaimer 1. “The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department

of Defense or the United States Government.” 2. “I am a military service member. This work was

prepared as part of my official duties. Title 17 U.S.C. 105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.”

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Endurance events

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CC: Abd Pain, Diarrhea, Nausea, Weakness• HPI: 42 yom presented to ED 2 hrs S/P 1st

Marathon• C/O severe, intermittent abd pain, nausea, putrid

red-black loose stools and profound weakness• Brought to ED after multiple episodes of

hematochezia ; could not tol po • Voided after race; brownish-red • Race conditions: Sunny, 65F (20 degrees higher

than training conditions), “hilly” • Trained 3 mos, 3-4x/wk, longest run=23 miles• During race drank 32 oz Gatorade, several small

cups H2O ; ate 2 energy cubes 4

Race Progress8:15-8:30/mile pace x 18 miles (run)Expd abd pain/cramping, light-headedness9:30-10:00/mile pace x last 8.2 miles

(jog/walk)Completed race in 3:57:00

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ROS+Lightheadedness; no HA+Nausea and Diarrhea; no VomitingNo CP or SOBNo Back PainNo Fever or Chills; No Night SweatsNL BM (1) before the race Bronchitis x 3 wks ended 2 days prior to

MarathonWife had VGE 2 wks before race, lasted 7 days

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HistoryPMedHx: Occasional Migraine HAs, Allergic

RhinitisPSurgHx: L. MMT/Partial Meniscectomy (1988),

R. UCL tear/repair (1995)FamHx: Migraine HAs, Allergic Rhinitis, AFib,

MVP, HTN, Hernias, Psoriatic ArthritisSoc Hx: 1 Beer/day, No Tobacco, No

SupplementsMeds: Flonase, Occas Excedrin; took 1 before

raceNKDA

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Questions and Answers (Q&A)

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Physical ExamVS: T=98.9F, HR=90, BP=130/90, RR=20,

O2Sats=99%Gen: A/O x 3, pale, lying in fetal pos, occas writhingHEENT: MM dry, otherwise NLLungs: CTABCardiac: RRRAbd: Mild-Mod TTP 4 Quads, BS hyperactive, no

rebound , no McBurney’s pt TTP, Murphy’s sign neg, no bruits, no masses, no CVA TTP. Rectal: declined

MS: NLNeuro: CN II-XII intact

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Differential Diagnosis (Q&A)

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Tests and ResultsECG: NSR (rate=75), No ST-T changesChem: (Abn) Glucose=120, CK=2672CBC: (Abn) WBC=13.2UA: (Abn) SG=1.031, bili=small,

ketones=large, blood=trace, protein=30, leukest=small, bacteria=many

Imaging: None

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Differential Diagnosis (DDx)AppendicitisAbdominal Aortic Aneurysm (AAA)Mesenteric IschemiaAbdominal Migraine (Migraine Variant)Viral Gastroenteritis (VGE)DiverticulitisIschemic Colitis (Infectious/Inflammatory)Myocardial Infarction (MI)

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Working DDxMesenteric IschemiaDiverticulitisVGEAbdominal MigraineIschemic Colitis

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Treatment 100 % Oxygen (NC) 2L NS boluses (IV)Rest/Relative bowel restAnalgesics declined by pt

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Outcome4 hrs in ED pt was feeling somewhat betterProduced light-colored urine and flatusHematochezia resolved lightheadedness energyNo dry mouth or thirstIntermittent abd pain (moderate); abd exam

benignVS (before DC): T=98.1F, HR=60, BP=115/70,

RR=12,O2Sats=100% (RA)

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Discharge Diagnoses 1. Heat Exhaustion 2. Dehydration 3. Exercise-induced Ischemic Colitis

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Literature ReviewSearches were conducted using: 1. Ovid 2. Pub Med 3. Up to Date/E-Medicine

* 4 good quality articles

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Articles 1. Lucas W, Schroy PC. Reversible ischemic colitis in a high endurance athlete. Am J Gastroenterol. 1998; 93: 2231-2234.

2. Cohen DC, Skipworth JR. Marathon-induced ischemic colitis: why running is not always good for you. Am J Emerg Med. 2009; 27: 255.e5-255.e7.

3. Sanchez LD, Corwell B, Berkoff D, Pedrosa I. Ischemic colitis in marathon runners: A case-based review. J Emerg Med. 2006; 30: 321-326.

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Articles (cont) 4. Moses FM. Exercise-associated intestinal

ischemia. Curr Sports Med Rep. 2005; 4: 91-95.

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Article 1 - Case30 yof elite runner ran highly competitive marathonDeveloped crampy abd pain during race;

hematochezia On OCP-sAdmitted to HospSigmoidoscopy demonstrated patchy erythema,

friability, exudate in rectum, severe hemorrhagic segmental colitis in the sigmoid colon.

Histology demonstrated hemorrhagic necrosis of the mucosa with stromal hemorrhage, crypt effacement and mucopurulent exudate

Pt recd IV Fluids, bowel rest, Abx - DC and did well

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Sigmoidoscopy

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Histology

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Article 2 - Case31 yom amateur runner collapsed after completing

London marathon. Shortly after, he presented to ED.After 16 mi began having cramps and hematocheziaCT (contrast-enhanced) revealed thickened and

enhancing cecum and ascending colon, representing ischemic colitis

Admitted to Hosp, given O2, IV Fluids, analgesicsPeritoneal signs developed after 48 hrsPt underwent laparotomy, R.

hemicolectomy/ileostomyOperative and histologic findings confirmed ischemic

colitis of cecum and proximal colonDC well after 10 d; ileostomy reversed later

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Computed Tomography (CT)

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Figure 27. Diffuse ischemic colitis.

Horton K M et al. Radiographics 2000;20:399-418

©2000 by Radiological Society of North America

Article 3 - ReviewIn 2002 there were 200 marathons in the U.S.30,000 runners in some races ; 43 % over age 40More pts presenting to ED-s/clinics30-80% of long-distance runners report GI

complaints16% have had bloody diarrhea after a race or run7 previous pts reported in literature with ischemic

colitis (2 men; 5 women; 2 gender not specified)OCP-s used in 2/5 womenNSAIDS used in 3/7 cases

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Article 3 (cont) Proposed mechanisms of ischemic colitis:

Mesenteric blood flow (reduced 80% in exercise)

Mechanical trauma from moving/vibrationDehydration ; hypovolemiaHyperthermiaOCP-sNSAIDSTegaserod (Zelnorm), a 5-HT4 receptor antagonist

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Article 3 (cont)CT useful to detect colon abnormalities that

support clinical diagnosis of ischemic colitisUsed to R/O appendicitis, diverticulitis,

mesenteric thrombosis, AAAFindings in ischemic colitis: colon wall

thickening, enhancement of mucosa, edema, loss of

haustra

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Article 4To R/O mesenteric infarction in pts with pain out of

proportion and peritoneal signs mesenteric angiography is the procedure of choice

Abdominal pain and diarrhea are the initial symptoms of ischemia which usually limit further damage by inhibiting

activity. This threshold may be exceeded during extreme

athletic competition and endurance eventsIschemic colitis is usually mild but may require

volume and transfusion support, rarely progressing to resection or stricture

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Pt Follow UpPt cont to have intermittent abd pains and

hematochezia x 12 hrsDiet: yogurt, banana and Gatorade Next day, felt NL except for occas abd painVS NLReturned to work as an FP Sports Medicine

Fellow

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Key Teaching Points 1. a. For Acute Abdominal Pain presenting to the ED

or FP Clinic, life-threatening diagnoses must be R/O. 1. b. Along with H & P, Abdominal CT is extremely

helpful in ruling out serious diagnoses in this setting. 2. a. Exercise (Marathon)-induced Ischemic Colitis is a

condition more likely to present to the ED or FP Clinic during or after extreme endurance sporting events.

2. b. Treatment is IV Fluids, O2, analgesics, rest and F/U.

3. a. Most cases do well, however, serious cases of exercise-induced ischemic colitis have been documented, requiring rapid diagnosis, surgical intervention and even colectomy.

3. b. Educate athletes and coaches alike and be vigilant.

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Thank You

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