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].

• Fever

  The common symptoms are watery diarrhea, abdominal cramps, and fever. [medical-dictionary.thefreedictionary.com]

  He later developed multiple episodes of hematochezia and fever. Within the preceding 2 weeks, his medication regimen of divalproex sodium, aripiprazole, and trihexyphenidyl, had been changed to olanzapine, benztropine, and bupropion. [ncbi.nlm.nih.gov]

  You may need surgery if you have abdominal tenderness and fever that are severe and persistent, despite initial conservative medical care. [streetdirectory.com]

  History of gallstones or alcohol abuse Large bowel obstruction - Constipation Diverticular Disease - Fever common in diverticulitis with pain depending on where the diverticula are and diarrhoea Gastroenteritis - Epigastric pain is less profound than [fastbleep.com]

• Severe Pain

  Bloody diarrhea and severe belly pain are the most common symptoms. Other symptoms include vomiting, fever, and fainting. Diarrhea can lead to severe dehydration. This is the rapid loss of the fluids your body needs to function. [saintlukeskc.org]

  When only the right side of the colon is affected, it's common to experience severe pain but no bleeding. [everydayhealth.com]

  Patients at risk for acute mesenteric ischemia, as defined in the technical review, who have abdominal pain severe enough to call to the attention of a physician, whose pain persists for more than 2 or 3 hours, and whose clinical picture does not suggest [web.archive.org]

• 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]

• Chronic Diarrhea

  We report on a 71-year-old woman who presented with chronic diarrhea and intermittent hematochezia, who was first misdiagnosed as mucinous adenocarcinoma of the colon, but finally diagnosed as a rare entity of chronic ischemic colitis, phlebosclerotic [ncbi.nlm.nih.gov]

  Without these diagnostic steps, it could take weeks, months, or even years to discover the reason for the chronic diarrhea. [ccfa.org]

  Related articles: Diabetic Diarrhea Causes of Chronic Colitis Causes of Chronic Diarrhea Left Side Abdominal Pain References: Chronic ischemic colitis (merck.com) [healthhype.com]

  Colitis can be caused by infections, loss of blood supply, or chronic diseases. [medicinenet.com]

• Abdominal Bloating

  A paralytic phase can follow if ischemia continues; in this phase, the abdominal pain becomes more widespread, the belly becomes more tender to the touch, and bowel motility decreases, resulting in abdominal bloating, no further bloody stools, and absent [en.wikipedia.org]

• Abdominal Distension

  Physical examination revealed abdominal distension with abdominal tympanic sounds and tenderness. Emergency laboratory tests were notable for increased acute phase reagents. [ncbi.nlm.nih.gov]

  However, the patient may also experience: Nausea Vomiting Tenesmus Fever Hypotension Tachycardia Abdominal distension Tenderness Differential Diagnosis Ulcerative Colitis - Patients complain of PR bleeding, chronic diarrhoea and lower abdominal pain Crohn's [fastbleep.com]

  Anorexia, nausea, vomiting, or abdominal distension Peritoneal signs ( 15 %) physical examination usually reveals only mild abdominal tenderness. 25. [slideshare.net]

  Case Report A sixty year old man presented with seven days history of post-prandial bilious vomiting, right flank and upper quadrant cramping pain, abdominal distension and diarrhoea for four days followed by absent bowel motions for three days. [ispub.com]

• Hypertension

  RESULTS: IRs of pIC in hypertensive and non-hypertensive subjects were 18.6 (95% CI 17.6-19.8) and 4.0 (95% CI 3.4-4.7), respectively. The non-hypertensive cohort consisted of younger patients who may have been less prone to developing IC. [ncbi.nlm.nih.gov]

  RESULTS: Hypertension (51 percent) was the main risk factor associated with ischemic colitis. Clinical presentation did not differ between groups, except for peritonitis which was present only in the severe group. [doi.org]

• Flushing

  A flush aortogram showed only the origin of the superior mesenteric artery, but the celiac artery and the inferior artery origins were not identified. [emedicine.com]

• Skin Ulcer

  Skin disorders that tend to be seen more with ulcerative colitis than Crohn disease include, red knot-like swellings (erythema nodosum) and pus-filled skin ulcers on the shins and ankles (pyoderma gangrenosum). [mountsinai.org]

• Arthritis

  There are few reports of segmental ischemic colitis associated with the use of NSAIDs and gold therapy in rheumatoid arthritis. [ispub.com]

  Hemolytic anemia associated with ulcerative colitis ; Hemolytic anemia, with ulcerative colitis ; Mild chronic ulcerative colitis ; Moderate chronic ulcerative colitis ; Severe chronic ulcerative colitis ; Ulcerative colitis ; Ulcerative colitis with arthritis [icd10data.com]

  Ischaemic colitis and immune complexes during gold therapy for rheumatoid arthritis. Ann Rheum Dis 1984;43:495–7. PubMed Google Scholar 21. Carratu R, Parisi P, Agozzino A. [link.springer.com]

  Ischaemic colitis and immune complexes during gold therapy for rheumatoid arthritis. Ann Rheum Dis. 1984; 43 (3):495–497. [ PMC free article ] [ PubMed ] 21. Carratù R, Parisi P, Agozzino A. [ncbi.nlm.nih.gov]

  Patient Sex Age (yr) Pre-existing disease Number of CT/MR Diagnostic proof Status of discharge 1 F 54 Multiple myeloma relapsed treated with Lenalinomide 1/2 E L 2 F 89 Ischemic heart disease, hypertension, rheumatoid arthritis 1/1 E L 3 F 80 Hypertension [wjgnet.com]

• Osteoporosis

  Osteoporosis is more common with Crohn disease than with ulcerative colitis. Click the icon to see an image of osteoporosis. [mountsinai.org]

  Oral corticosteroids like prednisone are useful for reducing inflammation, but they also carry some significant side effects -- like high blood pressure, osteoporosis, and diabetes -- that may outweigh their benefits. [ccfa.org]

  The malnourished state often leads to other metabolic and endocrine problems, such as osteoporosis and easy bruising. Ischaemic colitis This is caused by a compromise of the blood circulation supplying the colon. [patient.info]

• Fracture

  Tubillovillous 12/29/15 Colonoscopy/Endoscopy - Ascending Colon Mass- Hemicolectomy Scheduled 1/17/2016 Right Hemicolectomy Cancelled 1/25/2016 CT No evidence of other disease 2/12/2016 EMR-ascending colon mass 80% removed 5/29/2016 Compressed lumbar spinal fracture [coloncancersupport.colonclub.com]

• Kidney Failure

  It has also been postulated that some people develop the problem due to low blood pressure in these areas of the intestine, such as kidney failure patients during dialysis. How is it diagnosed? A diagnosis is made by colonoscopy with colon biopsy. [patientblog.clotconnect.org]

  failure, colon cancer history and diagnosis of atrial fibrillation ( Table 1 ). [scielo.br]

• Renal Insufficiency

  Right-sided IC and chronic renal insufficiency did not affect severity. Special attention should be given to patients with the following risk factors for a severe course: atrial fibrillation, elevated white blood cell count, and anemia. [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.

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

The condition resolves completely with conservative treatment, in most cases, but late diagnosis or severe ischemia can be associated with high rates of complications and death. [japanlinkcenter.org]

[…] 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]

Treatment and prognosis Mesenteric arterial or venous occlusion can be treated with anticoagulation or thrombolysis, either systemically or locally. [radiopaedia.org]

Our aim was to review the clinical characteristics of patients diagnosed of ischemic colitis and analyze predictive factors of poor prognosis. [doi.org]

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

The structured IC scoring system appears to be applicable for drug-related as well as other etiological causes of IC. [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]

[…] 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]

“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]

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]

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]

Urgent treatment with laxatives and fecal disimpaction is indicated to prevent perforation and peritonitis. [ncbi.nlm.nih.gov]

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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.
4. Champagne BJ, Lee EC, Valerian B, Mulhotra N, Mehta M. Incidence of colonic ischemia after repair of ruptured abdominal aortic aneurysm with endograft. J Am Coll Surg. 2007;204(4):597-602.
5. Gandhi SK, Hanson MM, Vernava AM, Kaminski DL, Longo WE. Ischemic colitis. Dis Colon Rectum. 1996;39(1):88–100.
6. Baixauli J, Kiran RP, Delaney CP. Investigation and management of ischemic colitis. Cleve Clin J Med. 2003;70(11):920-934.
7. Brandt LJ, Boley SJ. Colonic ischemia. Surg Clin North Am. 1992;72(1):203-229.
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.