ischemic colitis; ischemic bowel; colonic ischemia
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Etiology
- arterial
- hypoperfusion
- decreased cardiac output
- cardiac arrhythmias
- sepsis with shock
- vasocontriction due to vasopressors
- diversion of blood supply
- long-distance running
- may be aggravated by high altitude
- dehydration[3]
- thrombosis of the inferior mesenteric artery
- embolic
- arterial emboli
- cholesterol emboli
- hypoperfusion
- drug-induced
- post-operative
- vasculitis: systemic lupus erythematosus
- hypercoagulable state
- risk factors[3][4]
Epidemiology
- much more common than acute or chronic mesenteric ischemia
- occurs in older patients with atherosclerosis
- 90% of patients > 60 years of age
- occurs in others (see etiology)
- more common in women[3]
Pathology
- most commonly affected sites
- right colon (25%)
- transverse colon (10%)
- left colon (33%)
- sigmoid colon (25%)
- may involve watershed areas between arterial supply, such as splenic flexure & rectosigmoid[3]
- involvement of the ascending colon (right side)
- suggests concurrent mesenteric ischemia (right colon supplied by superior mesenteric artery)
- associated with worse outcomes[2]
Clinical manifestations
- left lower quadrant pain is generally mild
- self-limited bloody diarrhea, urgent defecation, tenesmus
- rectal blooding (BRBPR) or maroon color
- bleeding insufficient to require transfusion
- mild abdominal tenderness over involved segment of colon
- hypoactive bowel sounds (case description)[1]
- abdominal distension (case description)[1]
- nausea may occur[3]
- patients do not appear very ill
- hypovolemia & peritonitis herald intestinal gangrene, intestinal perforation or transmural necrosis
Laboratory
- complete blood count (CBC)
- leukocytosis may be observed (case description)[1]
- basic metbolic panel
- INR
- stool studies for Clostridium difficile (GRS9)[3]*
- presumably Clostridium difficile enterotoxin A+B in stool or Clostridium difficile toxin genes in stool with fast turnaround, but test specifics omitted in (GRS9)[3]
* priority over colonoscopy due to concern for toxic megacolon (GRS9)[3]
Diagnostic procedures
- colonoscopy within 48 hours[3]
- segmental involvement
- sharply demarcated pale mucosa with petechial bleeding
- hemorrhagic nodules
- linear & circumferential ulceration
- gangrene
- findings overlap with those of inflammatory bowel disease
Radiology
- abdominal CT
- segmental thickening of watershed areas between arterial supply, such as splenic flexure or rectosigmoid[3]
- CT angiography is diagnostic imaging modality of choice[1]
- angiography after revascularization plan established with CT angiography[1]
- barium enema (no longer diagnostic procedure of choice)
- thumbprinting representing submucosal hemorrahages
- segmental wall thickening may be noted, especially at splenic flexure (GRS9)[3]
Complications
Differential diagnosis
- diverticulitis
- diverticular bleeding (without diverticulitis) is painless[1]
Management
- evidence base for management is weak
- supportive
- intravenous fluids
- antibiotics to cover anaerobes & gram negative bacteria
- bowel rest (NPO)
- most cases resolve spontaneously[1]
- identify & correct contributing factors if feasible
- immediate exploratory laparotomy if signs of
- prognosis
- overall mortality (12%), 20-22% with right-sided & pancolitis[2]
- 37% mortality associated with surgery
- risk factors for failure of medical management[3][5]
- clopidogrel use
- lack of rectal bleeding
- intraperitoneal fluid identified on abdominal CT
- low serum bicarbonate on hospital admission (metabilic acidosis)
More general terms
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021.
- ↑ 2.0 2.1 2.2 Brandt LJ et al. Anatomic patterns, patient characteristics, and clinical outcomes in ischemic colitis: A study of 313 cases supported by histology. Am J Gastroenterol 2010 Oct; 105:2245 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20531399
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - ↑ 4.0 4.1 Cubiella Fernandez J, Nunez Calvo L, Gonzalez Vazquez E et al Risk factors associated with the development of ischemic colitis. World J Gastroenterol. 2010 Sep 28;16(36):4564-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20857527
- ↑ 5.0 5.1 Paterno F, McGillicuddy EA, Schuster KM, Longo WE. Ischemic colitis: risk factors for eventual surgery. Am J Surg. 2010 Nov;200(5):646-50. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21056146
- ↑ Tadros M, Majumder S, Birk JW. A review of ischemic colitis: is our clinical recognition and management adequate? Expert Rev Gastroenterol Hepatol. 2013 Sep;7(7):605-13. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24070152
- ↑ Trotter JM, Hunt L, Peter MB. Ischaemic colitis. BMJ. 2016 Dec 22;355:i6600. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28007701 Free Article
- ↑ Oglat A, Quigley EM. Colonic ischemia: usual and unusual presentations and their management. Curr Opin Gastroenterol. 2017;33:34-40. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27798439