Lawrence J. Brandt, MD, MACG, AGAF, FASGE,1 Paul Feuerstadt, MD, FACG,2 George F. Longstreth, MD, FACG, AGAF3 and Scott J. Boley, MD, FACS4
1Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; 2Gastroenterology Center of Connecticut, Yale University School of Medicine, Hamden, Connecticut, USA; 3Department of Gastroenterology, Kaiser Permanent Medical Care Program, San Diego, California, USA; 4 Division of Pediatric Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.
Am J Gastroenterol 2015; 110:18–44; doi: 10.1038/ajg.2014.395; published online 23 December 2014
Received 24 February 2014; accepted 7 November 2014
Correspondence: Lawrence J. Brandt, MD, MACG, AGAF, FASGE, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York 10467, USA. E-mail: firstname.lastname@example.org
This clinical guideline was designed to address colon ischemia (CI) including its definition, epidemiology, risk factors, presentations, methods of diagnosis, and therapeutic interventions. Each section of the document will present key recommendations or summary statements followed by a comprehensive summary of supporting evidence. An overall summary of all recommendations is listed in Table 1.
A search of MEDLINE (1946 to present) and EMBASE (1980 to present) with language restriction to English was conducted using the search terms ischemic colitis, ischaemic colitis, colon ischemia, colonic ischemia, colon ischaemia, colonic ischaemia, colon gangrene, colonic gangrene, colon infarction, colonic infarction, rectal ischemia, rectal ischaemia, ischemic proctitis, ischaemic proctitis, cecal ischemia, cecal ischaemia, ischemic colon stricture, ischaemic colon stricture, ischemic colonic stricture, ischaemic colonic stricture, ischemic megacolon, ischaemic megacolon, colon cast, and colonic cast. The references obtained were reviewed and the best studies were included as evidence for guideline statements or in the absence of quality evidence, expert opinion was offered.
The GRADE system (Grading of Recommendations Assessment, Development, and Evaluation) was used to evaluate the quality of evidence and strength of recommendations (1,2). The level of evidence ranged from “high” (implying that further research was unlikely to change the authors’ confidence in the estimate of the effect) to “moderate” (further research would be likely to have an impact on the authors’ confidence in the estimate of effect) to “low” (further research would be expected to have an important impact on the authors’ confidence in the estimate of the effect and would be likely to change the estimate) to “very low” (any estimate of effect is very uncertain). The strength of a recommendation was graded as “strong” when the desirable effects of an intervention clearly outweighed the undesirable effects and as “conditional” when there was uncertainty about the tradeoffs between the desirable and undesirable effects of an intervention. Of note, in this clinical guideline there are several sections focusing on factors associated with prognosis in CI. Because the GRADE system currently is not designed to rate the quality of the literature for these topics, we have preceded each of these sections with “summary statements” that detail the most important concepts regarding each area, but without a GRADE rating.