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| | __NOTOC__ |
| | {{Ischemic colitis}} |
| | '''For the main page on colitis, please click [[Colitis|here]]'''<br> |
| | '''For more information on allergic colitis, please click [[Allergic colitis|here]]'''<br> |
| | '''For more information on infectious colitis, please click [[Infectious colitis|here]]'''<br> |
| | '''For more information on chemical colitis, please click [[Chemical colitis|here]]'''<br> |
| | '''For more information on drug-induced colitis, please click [[Drug-induced colitis|here]]'''<br> |
| | '''For more information on radiation colitis, please click [[Radiation colitis|here]]'''<br> |
| | '''For patient information on this topic, click [[Ischemic colitis (patient information)|here]]''' |
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| {{Infobox_Disease | | | {{Infobox_Disease | |
| Name = Ischemic colitis | | | Name = Ischemic colitis | |
| Image = Colonic blood supply.png| | | Image = Colonic blood supply.png|thumb|right|150px| |
| Caption = Colonic blood supply. Pink - supply from [[superior mesenteric artery]] (SMA) and its branches: middle colic, right colic, ileocolic arteries. Blue - supply from [[inferior mesenteric artery]] (IMA) and its branches: left colic, sigmoid, superior rectal artery. 7 is for so-called Cannon-Böhm point (the border between the areas of SMA and IMA supplies), which lies at the splenic flexure| | | Caption = Colonic blood supply. Pink - supply from [[superior mesenteric artery]] (SMA) and its branches: middle colic, right colic, ileocolic arteries. Blue - supply from [[inferior mesenteric artery]] (IMA) and its branches: left colic, sigmoid, superior rectal artery. 7 is for so-called Cannon-Böhm point (the border between the areas of SMA and IMA supplies), which lies at the splenic flexure| |
| DiseasesDB = 34162 |
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| ICD10 = {{ICD10|K|55|9|k|55}} |
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| ICD9 = {{ICD9|557.9}} |
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| OMIM = |
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| MedlinePlus = 000258 |
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| eMedicineSubj = radio |
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| eMedicineTopic = 180 |
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| }} | | }} |
| {{SI}}
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| {{CMG}}
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| '''Associate Editor-In-Chief:''' {{CZ}}
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| {{Editor Join}}
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| :''This article concerns ischemia of the large bowel. See [[mesenteric ischemia]] for ischemia of small bowel''
| | {{CMG}}; {{AE}} {{HQ}} |
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| ==Overview==
| | '''''Synonyms and keywords:''''' [[Ischemic colitis|Colon ischemia]]; [[Ischemic colitis|colonic ischemia]]; [[Ischemic colitis|colitis ischemic]]; [[Ischemic colitis|ischaemic colitis]]; |
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| '''Ischemic colitis''' (Ischaemic Colitis - British English) is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply. Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel [[ischemia]]<ref name="pmid15043513">{{cite journal | author = Higgins P, Davis K, Laine L | title = Systematic review: the epidemiology of ischaemic colitis. | journal = Aliment Pharmacol Ther | volume = 19 | issue = 7 | pages = 729-38 | year = 2004 | id = PMID 15043513}}</ref><ref name="pmid10784596">{{cite journal |author=Brandt LJ, Boley SJ |title=AGA technical review on intestinal ischemia. American Gastrointestinal Association |journal=Gastroenterology |volume=118 |issue=5 |pages=954-68 |year=2000 |pmid=10784596}}</ref><ref name="pmid10784595">{{cite journal |author=American Gastroenterological Association |title=American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia |journal=Gastroenterology |volume=118 |issue=5 |pages=951-3 |year=2000 |pmid=10784595}} http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3069&nbr=2295</ref>. Causes of the reduced blood flow can include changes in the systemic circulation (e.g. [[hypotension|low blood pressure]]) or local factors such as [[vasoconstriction|constriction of blood vessels]] or a [[blood clot]]. In most cases, no specific cause can be identified.<ref>Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., 2002 Saunders, p. 2332.</ref>
| | ==[[Ischemic colitis overview|Overview]]== |
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| Ischemic colitis is usually suspected on the basis of the clinical setting, [[physical examination]], and laboratory test results; the diagnosis can be confirmed via [[endoscopy]]. Ischemic colitis can span a wide spectrum of severity; most patients are treated supportively and recover fully, while a minority with very severe ischemia may develop [[sepsis]] and become critically ill.<ref>{{cite journal | author = Medina C, Vilaseca J, Videla S, Fabra R, Armengol-Miro J, Malagelada J | title = Outcome of patients with ischemic colitis: review of fifty-three cases. | journal = Dis Colon Rectum | volume = 47 | issue = 2 | pages = 180-4 | year = 2004 | id = PMID 15043287}}</ref>
| | ==[[Ischemic colitis pathophysiology|Pathophysiology]]== |
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| Patients with mild to moderate ischemic colitis are usually treated with IV fluids, [[analgesia]], and bowel rest (that is, no food or water by mouth) until the symptoms resolve. Those with severe ischemia who develop complications such as sepsis, intestinal [[gangrene]], or [[bowel perforation]] may require more aggressive interventions such as [[surgery]] and [[intensive care]]. Most patients make a full recovery; occasionally, after severe ischemia, patients may develop long-term complications such as a [[stricture]]<ref>{{cite journal | author = Simi M, Pietroletti R, Navarra L, Leardi S | title = Bowel stricture due to ischemic colitis: report of three cases requiring surgery. | journal = Hepatogastroenterology | volume = 42 | issue = 3 | pages = 279-81 | year = 1995 | id = PMID 7590579}}</ref> or chronic colitis.<ref>{{cite journal | author = Cappell M | title = Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia. | journal = Gastroenterol Clin North Am | volume = 27 | issue = 4 | pages = 827-60, vi | year = 1998 | id = PMID 9890115}}</ref>
| | ==[[Ischemic colitis causes|Causes]]== |
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| ==Causes and epidemiology== | | ==[[Ischemic colitis differential diagnosis|Differentiating Ischemic colitis from other Diseases]]== |
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| The exact incidence of ischemic colitis is difficult to estimate, as many patients with mild ischemia may not seek medical attention. Ischemic colitis is responsible for about 1 in 2000 hospital admissions, and is seen on about 1 in 100 endoscopies.<ref name="textp2332">Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., 2002 Saunders, p. 2332.</ref> Men and women are affected equally; ischemic colitis is a disease of the elderly, with more than 90% of cases occurring in people over the age of 60.<ref name="textp2332"/>
| | ==[[Ischemic colitis epidemiology and demographics|Epidemiology and Demographics]]== |
| | | ==[[Ischemic colitis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| Ischemic colitis is often classified according to the underlying cause. ''Non-occlusive'' ischemia develops because of low blood pressure or constriction of the vessels feeding the colon; ''occlusive'' ischemia indicates that a [[blood clot]] or other blockage has cut off blood flow to the colon. | |
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| ===Non-occlusive ischemia===
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| In hemodynamic instable patients (i.e. shock) the mesenteric perfusion may be compromised. This condition is commonly asymptomatic, and usually only apparent through a systemic inflammatory response.
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| ===Occlusive ischemia===
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| Mostly the result of a [[thromboembolism]]. Commonly the embolism is caused by [[atrial fibrillation]], valvular disease, [[myocardial infarction]], or [[cardiomyopathy
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| ==Pathophysiology==
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| ===Colonic blood supply===
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| The colon receives blood from both the [[superior mesenteric artery|superior]] and [[inferior mesenteric artery|inferior mesenteric arteries]]. The blood supply from these two major arteries overlap, with abundant collateral circulation. However, there are weak points, or "watershed" areas, at the borders of the territory supplied by each of these arteries. These watershed areas are most vulnerable to ischemia when blood flow decreases, as they have the fewest vascular collaterals.
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| The [[rectum]] receives blood from both the inferior mesenteric artery and the [[internal iliac artery]]; the rectum is rarely involved by colonic ischemia due to this dual blood supply.
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| ===Development of ischemia===
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| Under ordinary conditions, the colon receives between 10% and 35% of the total cardiac output.<ref name="uptodate">UpToDate, ''Colonic ischemia'', accessed 2 September 2006.</ref> If blood flow to the colon drops by more than about 50%, ischemia will develop. The arteries feeding the colon are very sensitive to vasoconstrictors; presumably this is an evolutionary adaptation to shunt blood away from the bowel and to the [[heart]] and [[brain]] in times of stress.<ref>{{cite journal | author = Rosenblum J, Boyle C, Schwartz L | title = The mesenteric circulation. Anatomy and physiology. | journal = Surg Clin North Am | volume = 77 | issue = 2 | pages = 289-306 | year = 1997 | id = PMID 9146713}}</ref> As a result, during periods of [[hypotension|low blood pressure]], the arteries feeding the colon clamp down vigorously; a similar process can result from vasoconstricting drugs such as [[ergotamine]], [[cocaine]], or [[vasopressor]]s. This vasoconstriction can result in non-occlusive ischemic colitis.
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| ===Pathologic findings===
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| A range of pathologic findings are seen in ischemic colitis, corresponding to the spectrum of clinical severity. In its mildest form, mucosal and submucosal [[hemorrhage]] and [[edema]] are seen, possibly with mild [[necrosis]] or [[ulceration]].<ref name="textp2332"/> With more severe ischemia, a pathologic picture resembling [[inflammatory bowel disease]] (i.e. chronic ulcerations, crypt [[abscess]]es and psuedopolyps) may be seen.<Ref>Brandt LJ, Boley SJ, Goldberg L, et al: Colitis in the elderly. Am J Gastroenterol 76:239, 1981.</ref> In the most severe cases, transmural infarction with resulting perforation may be seen; after recovery, the muscularis propria may be replaced by fibrous tissue, resulting in a stricture.<ref name="textp2332"/> Following restoration of normal blood flow, [[reperfusion injury]] may also contribute to the damage to the colon.<ref>{{cite journal | author = Granger D, Rutili G, McCord J | title = Superoxide radicals in feline intestinal ischemia. | journal = Gastroenterology | volume = 81 | issue = 1 | pages = 22-9 | year = 1981 | id = PMID 6263743}}</ref>
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| ==Diagnosis== | | ==Diagnosis== |
| | | [[Ischemic colitis history and symptoms|History and Symptoms]] | [[Ischemic colitis physical examination|Physical Examination]] | [[Ischemic colitis laboratory findings|Laboratory Findings]] | [[Ischemic colitis abdominal x ray|Abdominal X Ray]] | [[Ischemic colitis CT|CT]] | [[Ischemic colitis endoscopy|Endoscopy]] |
| Ischemic colitis must be differentiated from the many other causes of [[abdominal pain]] and [[lower gastrointestinal bleeding|rectal bleeding]] (for example, [[infection]], [[inflammatory bowel disease]], [[diverticulosis]], or [[colon cancer]]). It is also important to differentiate ischemic colitis, which often resolves on its own, from the more immediately life-threatening condition of acute mesenteric ischemia of the [[small bowel]].
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| ===Signs and symptoms===
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| Three progressive phases of ischemic colitis have been described:<ref>Boley, SJ, Brandt, LJ, Veith, FJ. Ischemic disorders of the intestines. Curr Probl Surg 1978; 15:1.</ref><ref>{{cite journal | author = Hunter G, Guernsey J | title = Mesenteric ischemia. | journal = Med Clin North Am | volume = 72 | issue = 5 | pages = 1091-115 | year = 1988 | id = PMID 3045452}}</ref>
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| *A ''hyperactive'' phase occurs first, in which the primary symptoms are severe abdominal pain and the passage of bloody stools. Many patients get better and do not progress beyond this phase.
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| *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 bowel sounds on exam.
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| *Finally, a ''shock'' phase can develop as fluids start to leak through the damaged colon lining. This can result in [[Shock (medical)|shock]] and [[metabolic acidosis]] with [[dehydration]], [[hypotension|low blood pressure]], [[tachycardia|rapid heart rate]], and confusion. Patients who progress to this phase are often critically ill and require [[intensive care]].
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| Symptoms of ischemic colitis vary depending on the severity of the ischemia. The most common early signs of ischemic colitis include [[abdominal pain]] (often left-sided), with mild to moderate amounts of [[lower gastrointestinal bleeding|rectal bleeding]].<ref name="Greenwald">{{cite journal | author = Greenwald D, Brandt L, Reinus J | title = Ischemic bowel disease in the elderly. | journal = Gastroenterol Clin North Am | volume = 30 | issue = 2 | pages = 445-73 | year = 2001 | id = PMID 11432300}}</ref>. The sensitivity of findings among 73 patients were<ref name="pmid17071206">{{cite journal |author=Huguier M, Barrier A, Boelle PY, Houry S, Lacaine F |title=Ischemic colitis |journal=Am. J. Surg. |volume=192 |issue=5 |pages=679-84 |year=2006 |pmid=17071206 | doi=10.1016/j.amjsurg.2005.09.018}}</ref>:
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| * [[abdominal pain]] (78%)
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| * [[gastrointestinal bleeding|lower digestive bleeding]] (62%)
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| * [[diarrhea]] (38%)
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| * [[Fever]] higher than 38°C (34%) (38°C equals approximately 100.4°F)
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| Physical examination<ref name="pmid17071206">.</ref>
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| * [[abdominal pain]] (77%)
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| * [[abdominal tenderness]] (21%)
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| ===Diagnostic tests===
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| There are no specific blood tests for ischemic colitis. The sensitivity of tests among 73 patients were<ref name="pmid17071206">.</ref>:
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| * The white blood cell count was more than 15,000/mm3 in 20 patients (27%)
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| * The serum bicarbonate level was less than 24 mmol/L in 26 patients (36%)
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| Plain [[X-ray]]s are often normal or show non-specific findings.<ref>{{cite journal | author = Smerud M, Johnson C, Stephens D | title = Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases. | journal = AJR Am J Roentgenol | volume = 154 | issue = 1 | pages = 99-103 | year = 1990 | id = PMID 2104734}}</ref>. In a series of 73 patients, plain abdominal radiography (56%) showing colic distension in 53% or a pneumoperitoneum in 3%<ref name="pmid17071206">.</ref>.
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| [[CT scan]]s are often used in the evaluation of abdominal pain and rectal bleeding, and may suggest the diagnosis of ischemic colitis, pick up complications, or suggest an alternate diagnosis.<ref>{{cite journal | author = Alpern M, Glazer G, Francis I | title = Ischemic or infarcted bowel: CT findings. | journal = Radiology | volume = 166 | issue = 1 Pt 1 | pages = 149-52 | year = 1988 | id = PMID 3336673}}</ref><ref>{{cite journal | author = Balthazar E, Yen B, Gordon R | title = Ischemic colitis: CT evaluation of 54 cases. | journal = Radiology | volume = 211 | issue = 2 | pages = 381-8 | year = 1999 | id = PMID 10228517}}</ref><ref>{{cite journal | author = Taourel P, Deneuville M, Pradel J, Régent D, Bruel J | title = Acute mesenteric ischemia: diagnosis with contrast-enhanced CT. | journal = Radiology | volume = 199 | issue = 3 | pages = 632-6 | year = 1996 | id = PMID 8637978}}</ref> | |
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| '''Patient #1'''
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| <gallery>
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| Image:Shock-bowel-001.jpg
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| Image:Shock-bowel-002.jpg
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| Image:Shock-bowel-003.jpg
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| Image:Shock-bowel-004.jpg
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| </gallery>
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| '''Patient #2'''
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| <gallery>
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| Image:Shock.jpg
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| Image:Shock2.jpg
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| Image:Shock3.jpg
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| </gallery>
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| [[Endoscopy|Endoscopic]] evaluation, via [[colonoscopy]] or flexible [[sigmoidoscopy]], is the procedure of choice if the diagnosis remains unclear. Ischemic colitis has a distinctive endoscopic appearance; endoscopy can also facilitate alternate diagnoses such as [[infection]] or [[inflammatory bowel disease]]. [[biopsy|Biopsies]] can be taken via endoscopy to provide more information.
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| === Histopathology of Ischemic Colitis===
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| <youtube v=LCwMQU7ylYg/>
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| ==Treatment== | | ==Treatment== |
| | [[Ischemic colitis medical therapy|Medical Therapy]] | [[Ischemic colitis surgery|Surgery]] | [[Ischemic colitis primary prevention|Primary Prevention]] | [[Ischemic colitis secondary prevention|Secondary Prevention]] | [[Ischemic colitis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Ischemic colitis future or investigational therapies|Future or Investigational Therapies]] |
| | ==Case Studies== |
| | [[Ischemic colitis case study one|Case #1]] |
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| Except in the most severe cases, ischemic colitis is treated with supportive care. [[Intravenous therapy|IV fluids]] are given to treat [[dehydration]], and the patient is placed on bowel rest (meaning nothing to eat or drink) until the symptoms resolve. If possible, cardiac function and oxygenation should be optimized to improve oxygen delivery to the ischemic bowel. A [[nasogastric tube]] may be inserted if an [[ileus]] is present.
| | ==Related Chapters== |
| | ''This article concerns ischemia of the large bowel. See [[mesenteric ischemia]] for ischemia of small bowel'' |
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| [[Antibiotic]]s are sometimes given in moderate to severe cases; the data supporting this practice date to the 1950s,<ref>PATH, EJ, McCLURE, JN Jr. Intestinal obstruction; the protective action of sulfasuxidine and sulfathalidine to the ileum following vascular damage. Ann Surg 1950; 131:159.</ref> although there is more recent animal data suggesting that antibiotics may increase survival and prevent [[bacteria]] from crossing the damaged lining of the colon into the bloodstream.<ref>{{cite journal | author = Plonka A, Schentag J, Messinger S, Adelman M, Francis K, Williams J | title = Effects of enteral and intravenous antimicrobial treatment on survival following intestinal ischemia in rats. | journal = J Surg Res | volume = 46 | issue = 3 | pages = 216-20 | year = 1989 | id = PMID 2921861}}</ref><ref>{{cite journal | author = Bennion R, Wilson S, Williams R | title = Early portal anaerobic bacteremia in mesenteric ischemia. | journal = Arch Surg | volume = 119 | issue = 2 | pages = 151-5 | year = 1984 | id = PMID 6696611}}</ref><ref>{{cite journal | author = Redan J, Rush B, Lysz T, Smith S, Machiedo G | title = Organ distribution of gut-derived bacteria caused by bowel manipulation or ischemia. | journal = Am J Surg | volume = 159 | issue = 1 | pages = 85-9; discussion 89-90 | year = 1990 | id = PMID 2403765}}</ref> The use of [[prophylactic]] antibiotics in ischemic colitis has not been prospectively evaluated in [[human]]s, but many authorities recommend their use based on the animal data.<ref>Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., 2002 Saunders, p. 2334.</ref>
| | {{Gastroenterology}} |
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| Patients being treated supportively are carefully monitored. If they develop worsening symptoms and signs such as [[leukocytosis|high white blood cell count]], [[fever]], worsened abdominal pain, or increased bleeding, then they may require [[surgery|surgical intervention]]; this usually consists of [[laparotomy]] and [[bowel resection]].
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| ==Prognosis==
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| Most patients with ischemic colitis recovery fully, although the prognosis depends on the severity of the ischemia. Patients with pre-existing [[peripheral vascular disease]] or ischemia of the ascending (right) colon may be at increased risk for complications or death.
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| Non-gangrenous ischemic colitis, which comprises the vast majority of cases, is associated with a mortality rate of approximately 6%.<Ref>{{cite journal | author = Longo W, Ballantyne G, Gusberg R | title = Ischemic colitis: patterns and prognosis. | journal = Dis Colon Rectum | volume = 35 | issue = 8 | pages = 726-30 | year = 1992 | id = PMID 1643995}}</ref> However, the minority of patients who develop [[gangrene]] as a result of colonic ischemia have a mortality rate of 50-75% with surgical treatment; the mortality rate is almost 100% without surgical intervention.<Ref>{{cite journal | author = Parish K, Chapman W, Williams L | title = Ischemic colitis. An ever-changing spectrum? | journal = Am Surg | volume = 57 | issue = 2 | pages = 118-21 | year = 1991 | id = PMID 1992867}}</ref>
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| ==Long-term complications==
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| About 20% of patients with acute ischemic colitis may develop a long-term complication known as ''chronic ischemic colitis''.<ref>{{cite journal | author = Cappell M | title = Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia. | journal = Gastroenterol Clin North Am | volume = 27 | issue = 4 | pages = 827-60, vi | year = 1998 | id = PMID 9890115}}</ref> Symptoms can include recurrent infections, bloody diarrhea, weight loss, and chronic abdominal pain. Chronic ischemic colitis is often treated with surgical removal of the chronically diseased portion of the bowel.
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| A ''[[stricture|colonic stricture]]'' is a band of scar tissue which forms as a result of the ischemic injury and narrows the [[lumen (anatomy)|lumen]] of the colon. Strictures are often treated observantly; they may heal spontaneously over 12-24 months. If a [[bowel obstruction]] develops as a result of the stricture, surgical resection is the usual treatment,<ref>{{cite journal | author = Simi M, Pietroletti R, Navarra L, Leardi S | title = Bowel stricture due to ischemic colitis: report of three cases requiring surgery. | journal = Hepatogastroenterology | volume = 42 | issue = 3 | pages = 279-81 | year = 1995 | id = PMID 7590579}}</ref> although endoscopic dilatation and [[stent]]ing have also been employed.<ref>{{cite journal | author = Oz M, Forde K | title = Endoscopic alternatives in the management of colonic strictures. | journal = Surgery | volume = 108 | issue = 3 | pages = 513-9 | year = 1990 | id = PMID 2396196}}</ref><ref>{{cite journal | author = Profili S, Bifulco V, Meloni G, Demelas L, Niolu P, Manzoni M | title = [A case of ischemic stenosis of the colon-sigmoid treated with [[Self-expandable metallic stent|self-expandable uncoated metallic prosthesis]]] | journal = Radiol Med (Torino) | volume = 91 | issue = 5 | pages = 665-7 | year = 1996 | id = PMID 8693144}}</ref>
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| ==References==
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| {{Reflist|2}}
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| ==Further reading==
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| <div class="references-small">
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| * {{cite journal | author = | title = Ischemic colitis: a brief review. | journal = Curr Surg | volume = 58 | issue = 2 | pages = 192-194 | year = 2001 | id = PMID 11275243}}
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| * {{cite journal | author = Sreenarasimhaiah J | title = Diagnosis and management of ischemic colitis. | journal = Curr Gastroenterol Rep | volume = 7 | issue = 5 | pages = 421-6 | year = 2005 | id = PMID 16168242}}
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| * {{cite journal | author = Green B, Tendler D | title = Ischemic colitis: a clinical review. | journal = South Med J | volume = 98 | issue = 2 | pages = 217-22 | year = 2005 | id = PMID 15759953}}
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| </div>
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| ==External links==
| | [[Category:Disease]] |
| * [http://www.endoskopischer-atlas.de/k84.htm Endoscopy images of ischemic colitis (German site)]
| | [[Category:Gastroenterology]] |
| | | [[Category:Cardiology]] |
| {{Gastroenterology}}
| | [[Category:Emergency medicine]] |
| {{SIB}}
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| [[Category:Gastroenterology|Ischemic colitis]] | | [[Category:Gastroenterology|Ischemic colitis]] |
