Ischemic colitis natural history, complications and prognosis: Difference between revisions

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* The symptoms of ischemic colitis usually develop in the sixth decade of life, and start with symptoms such as abdominal pain, bloody diarrhea, and vomiting.
* The symptoms of ischemic colitis usually develop in the sixth decade of life, and start with symptoms such as abdominal pain, bloody diarrhea, and vomiting.
* Ischemic colitis can progress to different stages depending on the elapsed time:<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><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><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><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 can progress to different stages depending on the elapsed time:<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><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><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><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>
** Reversible ischemic colopathy
**Reversible ischemic colopathy
*** This type is characterized by submucosal haemorrhage at endoscopy, with involvement of superficial mucosa.
***This type is characterized by submucosal haemorrhage at endoscopy, with involvement of superficial mucosa.
*** It is typically self-limiting.
***It is typically self-limiting.
*** Transient: the most common form at These patients present with abdominal pain, per-rectal bleeding and full-thickness involvement of the mucosa.
**Transient: the most common form
*** Chronic segmental or chronic ulcerative These patients present with persistent symptoms or recurrent episodes of pain, per-rectal bleeding, diarrhoea, and segmental colitis on imaging. Resection is often curative.
***These patients present with abdominal pain, per-rectal bleeding and full-thickness involvement of the mucosa.
*** Ischaemic colonic stricture This may be detected acutely, however, more frequently is found at follow-up endoscopy.
**Chronic segmental or chronic ulcerative  
*** Gangrenous colitis This should be suspected when there is increasing abdominal pain, signs of local or generalized peritonitis, fevers or associated ileus.
***These patients present with persistent symptoms or recurrent episodes of pain, per-rectal bleeding, diarrhoea, and segmental colitis on imaging.  
*** Universal fulminant pancolitis This presents acutely with severe symptoms, progressive transmural infarction and necrosis of the entire colon, resultant sepsis and perforation. 75% mortality rate. These patients present with sepsis, severe abdominal pain, peritonitis and per-rectal bleeding.
***Resection is often curative.
**Ischaemic colonic stricture  
***This may be detected acutely, however, more frequently is found at follow-up endoscopy.
**Gangrenous colitis  
***This should be suspected when there is increasing abdominal pain, signs of local or generalized peritonitis, fevers or associated ileus.
**Universal fulminant pancolitis  
***This presents acutely with severe symptoms, progressive transmural infarction and necrosis of the entire colon, resultant sepsis and perforation.  
***75% mortality rate.
***These patients present with sepsis, severe abdominal pain, peritonitis and per-rectal bleeding.


==Complications==
==Complications==

Revision as of 18:26, 8 January 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2]

Overview

Ischemic colitis can span a wide spectrum of severity. Majority of patients are treated supportively and recover fully, while a minority with very severe ischemia may develop sepsis and become critically ill. Most patients make a full recovery. Occasionally, after severe ischemia, patients may develop long-term complications such as a stricture or chronic colitis.

Natural History

  • The symptoms of ischemic colitis usually develop in the sixth decade of life, and start with symptoms such as abdominal pain, bloody diarrhea, and vomiting.
  • Ischemic colitis can progress to different stages depending on the elapsed time:[1][2][3][4][5]
    • Reversible ischemic colopathy
      • This type is characterized by submucosal haemorrhage at endoscopy, with involvement of superficial mucosa.
      • It is typically self-limiting.
    • Transient: the most common form
      • These patients present with abdominal pain, per-rectal bleeding and full-thickness involvement of the mucosa.
    • Chronic segmental or chronic ulcerative
      • These patients present with persistent symptoms or recurrent episodes of pain, per-rectal bleeding, diarrhoea, and segmental colitis on imaging.
      • Resection is often curative.
    • Ischaemic colonic stricture
      • This may be detected acutely, however, more frequently is found at follow-up endoscopy.
    • Gangrenous colitis
      • This should be suspected when there is increasing abdominal pain, signs of local or generalized peritonitis, fevers or associated ileus.
    • Universal fulminant pancolitis
      • This presents acutely with severe symptoms, progressive transmural infarction and necrosis of the entire colon, resultant sepsis and perforation.
      • 75% mortality rate.
      • These patients present with sepsis, severe abdominal pain, peritonitis and per-rectal bleeding.

Complications

The complications of ischemic colitis are as follows:[6][7][8][9]

  • About 20% of patients with acute ischemic colitis may develop a long-term complication known as chronic ischemic colitis.
    • 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.
  • A colonic stricture is a band of scar tissue which forms as a result of the ischemic injury and narrows the 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 although endoscopic dilatation and stenting have also been employed.

Prognosis

The prognosis of ischemic colitis is as follows:[10][11]

  • Majority of 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.
  • Non-gangrenous ischemic colitis, which comprises the majority of cases, is associated with a mortality rate of approximately 6%.
    • Minority of patients who develop gangrene as a result of colonic ischemia have a mortality rate of 50-75% with surgical treatment.
    • Mortality rate is almost 100% without surgical intervention.

References

  1. ↑ Medina C, Vilaseca J, Videla S, Fabra R, Armengol-Miro J, Malagelada J (2004). "Outcome of patients with ischemic colitis: review of fifty-three cases". Dis Colon Rectum. 47 (2): 180–4. PMID 15043287.
  2. ↑ Simi M, Pietroletti R, Navarra L, Leardi S (1995). "Bowel stricture due to ischemic colitis: report of three cases requiring surgery". Hepatogastroenterology. 42 (3): 279–81. PMID 7590579.
  3. ↑ Boley, SJ, Brandt, LJ, Veith, FJ. Ischemic disorders of the intestines. Curr Probl Surg 1978; 15:1.
  4. ↑ Hunter G, Guernsey J (1988). "Mesenteric ischemia". Med Clin North Am. 72 (5): 1091–115. PMID 3045452.
  5. ↑ Cappell M (1998). "Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia". Gastroenterol Clin North Am. 27 (4): 827–60, vi. PMID 9890115.
  6. ↑ Cappell M (1998). "Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia". Gastroenterol Clin North Am. 27 (4): 827–60, vi. PMID 9890115.
  7. ↑ Simi M, Pietroletti R, Navarra L, Leardi S (1995). "Bowel stricture due to ischemic colitis: report of three cases requiring surgery". Hepatogastroenterology. 42 (3): 279–81. PMID 7590579.
  8. ↑ Oz M, Forde K (1990). "Endoscopic alternatives in the management of colonic strictures". Surgery. 108 (3): 513–9. PMID 2396196.
  9. ↑ Profili S, Bifulco V, Meloni G, Demelas L, Niolu P, Manzoni M (1996). "self-expandable uncoated metallic prosthesis". Radiol Med (Torino). 91 (5): 665–7. PMID 8693144.
  10. ↑ Longo W, Ballantyne G, Gusberg R (1992). "Ischemic colitis: patterns and prognosis". Dis Colon Rectum. 35 (8): 726–30. PMID 1643995.
  11. ↑ Parish K, Chapman W, Williams L (1991). "Ischemic colitis. An ever-changing spectrum?". Am Surg. 57 (2): 118–21. PMID 1992867.


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