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Updated: Dec 15 2021

Ischemic Colitis

  • Snapshot
    • A 69-year-old female presents to the emergency room for bright red blood per rectum for the past 2 hours. She noticed some blood in her stool shortly after experiencing some abdominal pain. The pain is reported as dull, achy, 5/10, and concentrated at the left lower quadrant. Her past medical history is significant for hypertension and a past myocardial infarction (MI).
  • Introduction
    • Clinical definition
      • medical condition characterized by inadequate blood supply to the large intestine leading to inflammation and injury of the colon
  • Epidemiology
    • Demographics
      • more common in the elderly population
      • most common form of bowel ischemia
    • Risk factors
      • aortoiliac surgery/instrumentation
      • myocardial infarction
      • hemodialysis
      • hypercoagulable states (e.g., hereditary thrombophilia)
    • Pathogenesis
      • ischemic colitis is the result of blood flow reduction to the colon and is particularly prominent at the “watershed” areas of the colon where collateral blood flow is limited
        • the splenic flexure and rectosigmoid junction are particularly at risk for ischemia
      • nonocclusive colonic ischemia
        • accounts for the mass majority of cases (95%)
        • typically transient hypoperfusion
        • examples include shock or systemic hypotension
      • occlusive colonic ischemia
        • can be embolic (e.g., spontaneous or iatrogenic) or thrombotic secondary to atherosclerotic disease
      • mesenteric vein thrombosis
        • extremely rare and usually involves the small intestine
  • Presentation
    • Symptoms
      • mild cramping abdominal pain commonly involving the left side
        • less severe compared to mesenteric ischemia
      • hematochezia
        • usually follows after abdominal pain
      • diarrhea
      • vomiting
    • Physical exam
      • fever
      • abdominal tenderness
      • weight loss
  • imaging
    • Abdominal radiograph
      • usually normal but may be useful in excluding other causes of abdominal pain
      • may also identify complications of mesenteric ischemia (e.g., necrosis)
    • Computed tomography (CT) angiography without oral contrast
      • best initial test
      • may see bowel wall thickening in a segmental pattern (thumbprinting), bowel dilation, mesenteric stranding, or intestinal pneumatosis
    • Endoscopic evaluation
      • can be done via colonoscopy for flexible sigmoidoscopy
      • allows for biopsy of suspicious areas
      • positive findings include edematous, friable mucosa, erythema, and interspersed pale areas
  • Studies
    • Diagnostic testing
      • diagnostic approach
        • diagnosis is often based on clinical presentation and confirmed via endoscopy
      • studies
        • laboratory studies
          • leukocytosis
          • elevated lactate
          • metabolic acidosis
  • Differential
    • Mesenteric ischemia
      • differentiating factors
        • commonly presents with severe abdominal pain and does not accompany hematochezia
    • Colonic malignancy
      • differentiating factors
        • will appear differently on endoscopy and abdominal CT
  • Treatment
    • Management approach
      • treatment is dependent on its etiology, severity, and the clinical setting
    • Mild colonic ischemia
      • supportive care
        • bowel rest and observation
        • nasogastric tube if ileus is present
        • monitor for persistent fever, leukocytosis, peritonitis, or other signs of clinical deterioration
      • most patients will recover within days
    • Moderate colonic ischemia
      • antibiotics
      • antithrombotic therapy
        • indicated for patients with mesenteric venous thrombosis or thromboembolism
    • Severe colonic ischemia
      • signs of peritonitis, pneumatosis on imaging, or gangrene on colonoscopy
      • exploratory laparotomy
        • inidicated in patients with signs of bowel ischemia
        • resected of necrotic bowel if applicable
  • Complications
    • Bowel necrosis
    • Perforation
    • Sepsis
    • Death
    • Stricture/obstruction
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