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Ischemic Bowel Disease

Bowel Ischemia

Ischemic bowel disease is caused by a compromise in the blood supply of the gut. Ischemic colitis is a relatively mild form of the condition, in which the disruption of blood flow is transient, necrosis is limited, and patients often recover in a couple of days with supportive care. Acute mesenteric ischemia can be due to either arterial or venous thrombosis and is a more serious ailment, with a relatively high rate of mortality.


Presentation

Ischemic colitis is the most frequent manifestation of ischemic bowel disease. It is caused by a temporary reduction in the blood flow in small blood vessels. The symptoms are relatively mild, necrosis is restricted and rarely affects the full thickness of the gut; however, about 15% of cases will develop transmural necrosis and, as a result, peritonitis [1]. On the other hand, acute mesenteric ischemia presents with severe pain and is often due to thrombosis or embolism. It may proceed to a compromise in the barrier function of the gut wall, leading to leakage into the peritoneum and systemic inflammation. Both ischemic colitis and mesenteric ischemia may be associated with a range of severity.

Ischemic bowel disease mainly affects the elderly. It may be induced by a variety of conditions, treatments, or medications. Physical exertion may lead to ischemia in the intestines. The ailment can follow vascular surgeries, such as aortic or cardiac bypass, and may be caused by inadequate perfusion during surgery or by ligation of the inferior mesenteric artery [2]. Colonic ischemia is observed relatively frequently in abdominal aortic aneurysm (AAA) repair surgeries [3] and has been reported after placing a stent for AAA [4]. Ischemic colitis can be a consequence of carcinoma or diverticulitis. Deficiencies of coagulation inhibitors (for example protein C) and other hypercoagulation disorders (factor V mutations, the antiphospholipid syndrome) occur in a high proportion of patients with colon ischemia [5]. A large number of medications (for example antihypertensive drugs) may result in or contribute to ischemic colitis. Both arterial and venous thrombosis can be the main pathology responsible for acute mesenteric ischemia.

The initial symptoms of ischemic colitis are abdominal cramps (mainly on the left side), and an urge to defecate, followed by bloody stools - although there is no significant loss of blood. With care including bowel rest and fluid replacement, most patients recover within a couple of days. Surgery may be necessary in the presence of more advanced necrosis or if strictures develop. Severe necrosis will lead to the appearance of signs of peritonitis. Nausea, vomiting and some other findings indicate the development of ileus. Mesenteric ischemia begins with serious abdominal discomfort in the absence of any striking abnormality during a physical exam. Later in the course of the disease, features of peritonitis develop.

Weight Loss
  • Systemic signs such as fever, night sweats and weight loss may be present in advanced stages . Mesenteric lymphoma may involve the small bowel by direct extension or mass effect.[aischannel.com]
  • WEIGHT LOSS CHRONIC mesenteric ischemia sometimes leads you to lose weight because, although you may feel hungry, you eat less or less frequently to avoid the pain.[vascular.org]
  • These blood clots in the small intestine and bowels can lead to: Weight loss Pain with eating Fear of food Left untreated over time, blockages can decrease blood flow so much that the tissues in your intestines die.[upmc.com]
  • IBS doesn’t cause gastrointestinal bleeding and doesn’t result in systemic symptoms such as weight loss. It’s not a risk factor for colon cancer.[hcpro.com]
  • Symptoms common to this group of diseases may include: Diarrhea Vomiting Abdominal Cramping Rectal Bleeding Weight loss Additionally, these illnesses may be accompanied by other problems, such as arthritis , liver disease ( primary sclerosing cholangitis[disability-benefits-help.org]
Coronary Artery Disease
  • Control Diabetes People with uncontrolled diabetes are prone to developing blockages in the arteries, which can lead to coronary artery disease and heart attack—risk factors for mesenteric ischemia.[nyulangone.org]
  • Coronary artery disease 3. Cardiac valvular disease 4. History of dysrhythmias **Atrial fibrillation 5. Post-myocardial infarction mural thrombi 6. History of thromboembolic disease 7. Aortic surgery 8. Aortography 9. Coronary angiography 10.[brainscape.com]
  • artery disease or heart attack)[my.clevelandclinic.org]
Lymphadenopathy
  • Images were evaluated for bowel wall changes, mesenteric changes, fluid collection, retroperitoneal lymphadenopathy, peritoneal enhancement, and hepatomegaly as well as for changes in other abdominal organs.[ncbi.nlm.nih.gov]
Abdominal Pain
  • CONCLUSION: The most common CT finding in patients with SLE and acute abdominal pain is ischemic bowel disease.[ncbi.nlm.nih.gov]
  • CONCLUSION: It is mandatory to have an index suggestive of ischemic bowel disease in chronic dialysis patients with unexplained abdominal pain or discomfort.[ncbi.nlm.nih.gov]
  • The majority of patients presented with the triad of abdominal pain, diarrhea and vomiting. In 13 patients the diarrhea was associated with the passage of bright red blood per rectum.[ncbi.nlm.nih.gov]
  • The post-procedural period was complicated by severe abdominal pain. Abdominal computed tomography revealed hepatic portal venous gas. Multiple kidney and splenic ischemic areas were also identified.[ncbi.nlm.nih.gov]
  • We suggest that ischemic bowel disease should be considered while dealing with cases presenting as acute abdomen or with chronic abdominal pain.[ncbi.nlm.nih.gov]
Diarrhea
  • The majority of patients presented with the triad of abdominal pain, diarrhea and vomiting. In 13 patients the diarrhea was associated with the passage of bright red blood per rectum.[ncbi.nlm.nih.gov]
  • Of the patients with diarrhea, 13 of 33 (40%) had colon gas/fluid levels with/without colon dilatation compared to 2 of 29 (7%) without (P 0.003).[ncbi.nlm.nih.gov]
  • […] cholesterol or peripheral artery disease) Bowel obstruction (something is stuck in the intestines) Scar tissue from surgery Tumor in the intestines Hernia The symptoms of ischemic bowel disease can include: Abdominal pain Blood in your bowel movements Diarrhea[mainlinehealth.org]
  • ,Chronic ischemia may masquerade asinflammatory bowel disease, with episodes ofbloody diarrhea interspersed with periods of healing. 53.[slideshare.net]
  • Her daughter says her mother also had episodes of nausea, vomiting, diarrhea, and abdominal cramps. Assessment hints Ms. Lister, who has a history of atrial fibrillation and peripheral vascular disease, has been recovering from a recent splenectomy.[americannursetoday.com]
Constipation
  • He declined to eat and reported constipation.[theexpertinstitute.com]
  • Frequent constipation, hardening of the arteries, and low blood pressure are all conditions that may occur more often in old age and simultaneously increase your risk of ischemic colitis. High cholesterol can also be a factor.[doctorshealthpress.com]
  • Constipation is a more rare symptom compared todiarrhea and manifestation of this symptom depends on the allocation of ischemia.[lecturio.com]
  • Anorexia 53-54% 3. vomiting 41-77% 4. diarrhea 36%, constipation 13-34% 5. hematemesis 9-42% More insidious onset of symptoms Mesenteric venous thrombosis risk factors? 9 1. Hypercoagulable state (up to 75% have a hypercoagulable disorder) 2.[brainscape.com]
  • IBS IBS is a benign condition in which bowel peristalsis is abnormal, resulting in cramps and abdominal pain accompanied by alternating diarrhea and constipation. Some patients experience only diarrhea or only constipation as the primary symptom.[hcpro.com]
Abdominal Distension
  • RESULTS: Abdominal pain, abdominal distension and bloody stool were major initial presentations. The mean age of the patients was 62.4 years at the time of diagnosis of ischemia.[ncbi.nlm.nih.gov]
  • Symptoms• Cramping and abdominal pain• Bloody stools• Frequent urge to defecate• Diarrhea• Nausea or vomiting• Abdominal distension 44. Ischemia bowel• acute or chronic.• arterial or venous• occlusive or nonocclusive. 45.[slideshare.net]
  • distension, back pain and shock are late features indicating compromise of bowel viability Investigations WCC 15 in 75% metabolic acidosis in 50% plain AXR normal in early stages.[aic.cuhk.edu.hk]
  • Nausea , Vomiting , Blood in the stool , Abdominal distension, Urgency to defecate, Fever . In case of thrombosis or embolism, the following symptoms develop: At first , the person has a lot of pain, similar to a colic.[hickeysolution.com]
Abdominal Cramps
  • The initial symptoms of ischemic colitis are abdominal cramps (mainly on the left side), and an urge to defecate, followed by bloody stools - although there is no significant loss of blood.[symptoma.com]
  • Her daughter says her mother also had episodes of nausea, vomiting, diarrhea, and abdominal cramps. Assessment hints Ms. Lister, who has a history of atrial fibrillation and peripheral vascular disease, has been recovering from a recent splenectomy.[americannursetoday.com]
  • Symptoms common to this group of diseases may include: Diarrhea Vomiting Abdominal Cramping Rectal Bleeding Weight loss Additionally, these illnesses may be accompanied by other problems, such as arthritis , liver disease ( primary sclerosing cholangitis[disability-benefits-help.org]
Grunting
  • Physical examination was significant for lethargy, dry mucous membranes, and grunting without increased work of breathing or adventitious lung sounds. His abdomen had normoactive bowel sounds, mild distention, generalized tenderness, and rigidity.[pediatrics.aappublications.org]

Workup

Laboratory tests show signs of ischemia, such as elevated lactic acid levels and acidosis, but these may develop too late for diagnosis.

Among the imaging techniques, plain abdominal radiography is not sensitive enough to detect ischemic colitis but may indicate towards mucosal edema (thumbprinting), and intramural gas, as well as intraperitoneal gas if there is a perforation. It is also useful for ruling out other conditions. Barium enema also detects thumbprinting in the large majority of patients with ischemic colitis [6], but the technique is not widely used anymore. The techniques of choice are colonoscopy and computed tomography (CT). In the early stages, colonic edema with pale mucous membranes, and capillary hemorrhages are found by colonoscopy. In later stages, a single linear ulcer may be detected [7]. In severe cases, the membranes look blue, gray or black. CT will show, among other features, symmetrical thickening of the wall, uneven narrowing of the lumen, and edema. A segmental distribution of anomalies is also characteristic of ischemic colitis [8], and is one of the features that tend to occur less in inflammatory bowel disease; thus it may be used to distinguish the two conditions. Ultrasound is not widely used but may indicate luminal thickening, edema, hemorrhage, and intramural gas [9].

Timely identification is crucial in the case of acute mesenteric ischemia because of the high mortality rates. Angiography is useful, but the clinical assessment is of primary importance.

ST Elevation
  • A 64-year-old man with acute ST-elevation myocardial infarction complicated by cardiogenic shock was treated with percutaneous angioplasty and intra-aortic balloon percutaneous counterpulsation.[ncbi.nlm.nih.gov]
Colitis
  • Ischemic colitis can be a consequence of carcinoma or diverticulitis.[symptoma.com]
  • What Is the Difference between Ischemic Colitis and Ulcerative Colitis? Ischemic colitis vs. ulcerative colitis. What is the difference? While both affect the bowel regions, the two different types of colitis do have some major differences.[doctorshealthpress.com]
  • How to Diagnose Ischemic Colitis Your doctor will utilize several different tests to properly diagnose ischemic colitis.[belmarrahealth.com]
  • Abstract A 50-year-old woman developed ischemic colitis temporally related to ingestion of a large dose of ergotamine tartrate. The patient did not have cardiovascular, metabolic, or inflammatory conditions predisposing to bowel ischemia.[ncbi.nlm.nih.gov]
  • Colonoscopy showed signs referring to acute ischemic colitis. Computed tomography detection of hepatic portal venous gas has permitted the non-invasive diagnosis of bowel necrosis.[ncbi.nlm.nih.gov]
Liver Biopsy
  • Biopsy Assessment in Liver Disease 604 Acute Hepatitis Management and Prevention 611 Chronic Hepatitis B 616 Chronic Hepatitis C 621 Viral Hepatitis in Children 625 Fulminant Hepatic Failure 629 Adult Liver Transplantation Selection and Pretransplant[books.google.com]

Treatment

  • Anything that can produce such disturbing symptoms must require a relatively disturbing treatment, right? Actually, most of the treatment options for ischemic colitis are fairly mundane.[doctorshealthpress.com]
  • It has a high mortality rate of 59 to 93% and patient survival is highly dependent on a timely diagnosis and treatment.[websurg.com]
  • CT is useful for detecting the primary cause of gastrointestinal symptoms, planning treatment, and monitoring for infarction or perforation.[ncbi.nlm.nih.gov]
  • Remember that symptoms can be controlled, but the ischemic bowel disease treatment cannot give a good prognosis.[ic.steadyhealth.com]
  • Ischemic colitis treatment The severity of the ischemic colitis decides which treatment will used. Symptoms can subside within days, but your doctor may still prescribe medications as a precaution to prevent infection.[belmarrahealth.com]

Prognosis

  • Colonic ischemia is the commonest of these disorders and has a favorable prognosis in most cases. In contrast, acute mesenteric ischemia, most commonly caused by a superior mesenteric artery embolus, is a disease with a poor prognosis.[ncbi.nlm.nih.gov]
  • Thus, the serum phosphate concentration was not a sensitive indicator of ischemic bowel disease, but elevations did predict extensive injury and poor prognosis.[ncbi.nlm.nih.gov]
  • The prognosis was grave; 6 patients died within 3 months of onset. CONCLUSIONS: Intestinal angiocentric T-cell lymphoma represents a distinct etiology of bowel ischemia.[ncbi.nlm.nih.gov]
  • Prognosis? 4. When do symptoms develop? 1. Usually can elicit a history of chronic mesenteric ischemia 2. Usual site of blockage is the -origin of the SMA or -celiac axis 3. Less favorable prognosis 4.[brainscape.com]
  • Remember that symptoms can be controlled, but the ischemic bowel disease treatment cannot give a good prognosis.[ic.steadyhealth.com]

Etiology

  • Acute Vasoocclusive Etiologies Acute vasoocclusive etiologies of ischemic bowel injury arise from sudden occlusion of mesenteric vasculature which can affect arteries or veins.[pathwaymedicine.org]
  • CONCLUSIONS: Intestinal angiocentric T-cell lymphoma represents a distinct etiology of bowel ischemia. The condition should be taken into consideration, particularly in young adults with ischemic bowel disease.[ncbi.nlm.nih.gov]
  • Abstract In this review the author's opinion regarding the etiology of most cases of perinatal and neonatal bowel ischemia has been stated.[ncbi.nlm.nih.gov]
  • Comment: The differential diagnosis includes: drug reaction, infectious etiologies and, less likely, inflammatory bowel disease. Clinical correlation is required.[librepathology.org]
  • See also acute abdomen Prognosis References: [1] [5] [6] [4] Acute mesenteric ischemia Etiology Acute arterial embolism ; ( 50% of cases ): generally resulting from atrial fibrillation , myocardial infarction , valvular heart disease, or endocarditis[amboss.com]

Epidemiology

  • Definition / general Ischemic changes may be mucosal, mural (due to hypoperfusion) or transmural (major vessels involved) Chronic ischemia may produce similar changes as acute ischemia, may be segmental and patchy Epidemiology Usually age 50 years but[pathologyoutlines.com]
  • It offers up-to-date information on epidemiology, genetics, immunology, aetiology, and pathogenesis of the disease.[libreriacortinamilano.it]
  • "Epidemiology, clinical features, high-risk factors, and outcome of acute large bowel ischemia". Clin Gastroenterol Hepatol. vol. 7. 2009. pp. 1075-80.[clinicaladvisor.com]
  • […] flow to the small intestine (arterial or venous) that can result in bowel infarction Chronic mesenteric ischemia : constant or episodic hypoperfusion of the small intestine, usually due to atherosclerosis References: [1] [2] [3] [4] Ischemic colitis Epidemiology[amboss.com]
  • Epidemiology of Ischemic Colitis The cases of ischemic colon mid-children are very rare; the risk of incidence of the condition increases with age, especially after 49 years.[lecturio.com]
Sex distribution
Age distribution

Pathophysiology

  • It offers a complete overview of anatomy, physiology, pharmacology, and pathophysiology, and offers practical coverage of equipment and anesthesia management.[books.google.com]
  • Pathophysiology• Arterial sources v.s. venous sources:proximately 9:1.[slideshare.net]
  • The pathophysiology of the ischemic event usually will determine the management approach used.[link.springer.com]
  • Pathophysiology Intestinal blood flow of the superior mesenteric artery ( SMA ) and/or inferior mesenteric artery ( IMA ) is suddenly compromised (see “Etiology” for causes) intestinal hypoxia intestinal wall damage mucosal inflammation possibly bleeding[amboss.com]

Prevention

  • Ischemic colitis prevention It is difficult to prevent ischemic colitis as there are many factors that can contribute to its onset.[belmarrahealth.com]
  • Gastrointestinal Bleeding 584 Transcatheter Management of Upper and Lower Gastrointestinal Tract Bleeding 590 Diverticular Disease of the Colon 597 Laboratory Evaluation and Liver Biopsy Assessment in Liver Disease 604 Acute Hepatitis Management and Prevention[books.google.com]
  • Since the cause of ischemic colitis isn't always clear, there's no certain way to prevent the disorder.[mayoclinic.org]
  • Prevention, diet and feeding for intestinal ischemia It is possible to reduce the risk of intestinal ischaemia with some changes in lifestyle that help prevent atherosclerosis: Choose a diet rich in fruits, vegetables, nuts and seeds.[hickeysolution.com]

References

Article

  1. Cappell MS. Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia. Gastroenterol Clin North Am. 1998 Dec;27(4):827-860.
  2. Brewster DC, Franklin DP, Cambria RP, et al. Intestinal ischemia complicating abdominal aortic surgery. Surgery. 1991 Apr;109(4):447-454.
  3. Piotrowski JJ, Ripepi AJ, Yuhas JP, Alexander JJ, Brandt CP. Colonic ischemia: the Achilles heel of ruptured aortic aneurysm repair. Am Surg. 1996 Jul;62(7):557-60; discussion 560-561.
  4. Jaeger HJ, Mathias KD, Gissler HM, Neumann G, Walther LD. Rectum and sigmoid colon necrosis due to cholesterol embolization after implantation of an aortic stent-graft. J Vasc Interv Radiol. 1999 Jun;10(6):751-755.
  5. Koutroubakis IE, Sfiridaki A, Theodoropoulou A, Kouroumalis EA. Role of acquired and hereditary thrombotic risk factors in colon ischemia of ambulatory patients. Gastroenterology. 2001 Sep;121(3):561-565.
  6. Iida M, Matsui T, Fuchigami T, Iwashita A, Yao T, Fujishima M. Ischemic colitis: serial changes in double-contrast barium enema examination. Radiology. 1986 May;159(2):337-341.
  7. Zuckerman GR, Prakash C, Merriman RB, Sawhney MS, DeSchryver-Kecskemeti K, Clouse RE. The colon single-stripe sign and its relationship to ischemic colitis. Am J Gastroenterol. 2003 Sep;98(9):2018-2022.
  8. Balthazar EJ, Yen BC, Gordon RB. Ischemic colitis: CT evaluation of 54 cases. Radiology. 1999 May;211(2):381-388.
  9. Ripollés T, Simó L, Martínez-Pérez MJ, Pastor MR, Igual A, López A. Sonographic findings in ischemic colitis in 58 patients. AJR Am J Roentgenol. 2005 Mar;184(3):777-785.

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Last updated: 2018-06-22 00:33