Ischemic colitis (IC) is caused by brief episodes of compromised blood flow to the colon. It is usually self-limiting. The condition can affect any part of the colon, sometimes involving more than one segment in the same individual [1]. IC is responsible for over 50% of reported cases of gastrointestinal ischemia, making it the most frequently encountered ischemic condition of the gastrointestinal tract [2]. There are numerous risk factors for developing IC, ranging from preexisting medical conditions affecting the cardiovascular system to obstructive lesions in the abdomen, drug use, and surgery [3] [4].

IC is commonly seen in individuals in and beyond the sixth decade of life. Patients often have preexisting vascular diseases such as atherosclerosis. In rare cases, otherwise healthy individuals with no predisposing factors and young people may develop spontaneous IC [5].

Presentation varies considerably. Furthermore, most symptoms are non-specific, making the diagnosis challenging. The typical presentation includes sudden onset of abdominal pain or discomfort, bloody stool, diarrhea, as well as an urge to defecate. In right-sided IC, abdominal pain is more likely to be experienced than bleeding per rectum. Patients are often apyrexic. Peritonitis may be present if there is gangrene. This is associated with septic shock and metabolic derangement. The true prevalence of the condition is likely higher than what is recorded in the literature, as many cases are self-limiting. In addition, due to the vague nature of IC symptomatology, some cases are incorrectly diagnosed.

IC can either be gangrenous or non-gangrenous, and these two types can be distinguished clinically. The majority of cases are non-gangrenous [6]. A small proportion of cases, of the gangrenous type, progress to chronic IC [6] [7]. Patients who tend to develop chronic disease are those with a longer period of initial IC, prolonged leukocytosis, or advanced age [5]. Another complication of IC is fulminant pancolitis, reported in less than 1 in 100 cases [6].

• Plethora

  RISK FACTORS A plethora of conditions may predispose to IC: Mesenteric artery emboli, thrombosis, or trauma may lead to occlusive vascular disease and impaired colonic perfusion[ 5 ]. [wjgnet.com]

• Pseudotumor

  These findings parallel the “thumbprints” or “pseudotumors” found on barium studies[ 5 ]. The purple submucosal hemorrhages usually dissipate within 48 h or are followed by ulceration. [wjgnet.com]

• Rectal Bleeding

  Clinical vigilance for ischemic colitis is recommended for patients receiving lubiprostone who are presenting with abdominal pain and rectal bleeding. [ncbi.nlm.nih.gov]

  Ischemic Colitis Colonoscopic findings in a 78 year-old woman who presented with painless rectal bleeding. [endoatlas.com]

• Cardiomegaly

  Note the cardiomegaly and blood diversion in the upper lobe, which is suggestive of cardiac decompensation. Right: Plain radiograph shows several dilated loops of the jejunum. Note also the stricture of the proximal transverse colon. [emedicine.com]

• Venous Insufficiency

  However, chronic venous insufficiency due to obstruction of macrovascular mesenteric vein rarely causes ischemia of the bowel. This report describes the first case of ischemic colitis caused by obstruction of the mesenteric and splenic veins. [ncbi.nlm.nih.gov]

As the symptoms of ischemic colitis are ambiguous, further tests and imaging are necessary to reach the diagnosis. Laboratory tests include the following:

• Basic tests such as a complete blood count and liver function tests.
• Markers for ischemia. These include lactate dehydrogenase, serum amylase, and creatine kinase.
• Stool cultures for E. coli (O157:H7 strain), shigella, and salmonella. Viral and parasitic organisms may also be tested for.

The following imaging methods are used:

• Abdominal radiograph- X-ray signs that may be observed are ileus, free air in the abdomen, as well as a thumbprint pattern due to damage to the intestinal wall [8].
• Computerized tomography (CT)- Early IC may go undetected by CT scanning; however, the method is still useful as it excludes other pathologies as the cause of symptoms. Air in the abdomen, or in the hepatic portal vein, is indicative of tissue infarction [9]. Other visible signs are bowel wall thickening and stranding.
• Colonoscopy- This is now the imaging technique of choice in IC, as direct visualization of the colon is made possible. This method has largely replaced barium enemas. A biopsy may be taken, although its usefulness is limited. The colon mucosa may display erythema, bleeding, petechiae, or edema.
• Ultrasonography.

Angiography and magnetic resonance imaging are not routine. Peritonitic patients require immediate fluid resuscitation and surgical intervention.

• Escherichia Coli O157:H7

  All patients with clinical suspicion of IC should have stool cultures for Salmonella, Shigella, Campylobacter and Escherichia coli O157:H7[ 35 ]. The latter organism has been implicated in causing colonic ischemia. [wjgnet.com]

  Stool studies should be performed for Salmonella, Shigella, Campylobacter, and Escherichia coli (O157:H7) as well as Clostridium difficile. [ncbi.nlm.nih.gov]

[…] colitis itself and for the bad prognosis of surgical treatment. [ncbi.nlm.nih.gov]

Aim of this study is to identified objective factors predictive of the better type and time of treatment. [bmcgeriatr.biomedcentral.com]

[…] ischemic colitis might be achieved by means of a prompt recognition of the initial picture and through a better control of the many associated diseases, that represent the main risk factor for the development of ischemic colitis itself and for the bad prognosis [ncbi.nlm.nih.gov]

Clinical follow-up was implemented to evaluate the long-term prognosis after mean period of 6 years post treatment. [bmcgeriatr.biomedcentral.com]

Comment: The differential diagnosis includes: drug reaction, infectious etiologies and, less likely, inflammatory bowel disease. Clinical correlation is required. [librepathology.org]

PURPOSE: This paper aims at evaluating CT findings of occlusive and nonocclusive ischemic colitis (IC), in correlation with the etiology and the different phases of the disease. [ncbi.nlm.nih.gov]

Other types often can be traced to such etiologic factors as bacteria and viruses, drugs such as antibiotics, and radiation from x-rays or radioactive materials. [medical-dictionary.thefreedictionary.com]

[…] many laboratory tests and radiographic images may suggest the diagnosis, colonic endoscopic with histological analysis of biopsies is the gold standard for identification of colonic ischemia. aim : The aim of this study was to resume in 5 points: the epidemiology [ncbi.nlm.nih.gov]

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]

Epidemiology The incidence of ischaemic colitis has risen from 6.1 cases/100 000 person-years in 1976-80 to 22.9/100 000 in 2005-09 [ 5 ]. Many mild cases may go unreported. [patient.info]

“First of all, we wanted to get an estimate of the incidence of this condition, and the unique resources of the Rochester Epidemiology Project allowed us to do this. [healio.com]

Conclusions: The epidemiology of migraine headaches and depression, and the association of migraine headaches with menses increase the likelihood of young female patients taking combinations of 5‐hydroxytryptamine‐l (5HT1) receptor agonists with OCPs [shmabstracts.com]

Gastrointestinal disease: pathophysiology, diagnosis, management. 5th ed. Philadelphia, Pa: Saunders, 1993 ; 1940-1945. Google Scholar 5 Brandt LJ, Boley SJ, Goldberg L, et al. Colitis in the elderly. Am J Gastroenterol 1981 ; 76: 239-245. [doi.org]

For the first time we have demonstrated its pathophysiological significance in a real clinical scenario, linking the anatomical variation to the clinical complication. [ncbi.nlm.nih.gov]

Objectives Anatomy Review Ischemic Colitis - Introduction - Pathophysiology - Underlying Causes - Phases of IC - Clinical Picture - Investigations - Management 3. [slideshare.net]

Transverse Colon Colonic Supply of the Inferior Mesenteric Artery Branches of the IMA include: Left Colic Artery Sigmoid Artery Superior Rectal Artery Respectively, these branches supply the: Splenic Flexure and Descending Colon Sigmoid Colon Upper Rectum Pathophysiology [fastbleep.com]

Ischemic colitis prevention It is difficult to prevent ischemic colitis as there are many factors that can contribute to its onset. [belmarrahealth.com]

Since the cause of ischemic colitis isn't always clear, there's no certain way to prevent the disorder. [mayoclinic.org]

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2. Greenwald DA, Brandt LJ. Colonic ischemia. J Clin Gastroenterol. 1998;27(2):122-128.
3. Steele SR. Ischemic colitis complicating major vascular surgery. Surg Clin North Am. 2007;87(5):1099-1114,ix.
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8. Sreenarasimhaiah J. Diagnosis and management of intestinal ischaemic disorders. BMJ. 2003;326(7403):1372-1376.
9. Elder K, Lashner B A, Al Solaiman F. Clinical approach to colonic ischemia. Cleve Clin J Med. 2009;76(7):401-409.