Diseases of the Colon & Rectum

, Volume 39, Issue 1, pp 88–100 | Cite as

Ischemic colitis

  • Sanjiv K. Gandhi
  • Morin M. Hanson
  • Anthony M. Vernava
  • Donald L. Kaminski
  • Walter E. Longo
Current Status


Ischemic colitis represents the most common form of gastrointestinal ischemia. The presumed etiologies are numerous; however, it typically develops “spontaneously,” in the absence of major vasculature occlusion, and in the presence of viable intestine elsewhere. It is most usefully classified into gangrenous and nongangrenous forms, the latter of which may be subdivided into transient and chronic types. Ischemic colitis may develop in people who are otherwise healthy, although a variety of clinical settings, such as shock, predispose to its occurrence. It usually presents as an acute abdominal illness with bloody diarrhea. Diagnosis is confirmed by colonoscopy. Therapy and outcome are dependent on the severity of disease. Nongangrenous colonic ischemia usually requires only medical management and is associated with a good prognosis. The chronic subtype may lead to the sequelae of persistent segmental colitis or colonic strictures, occasionally requiring surgery. Urgent operative intervention and a high morbidity and mortality are the hallmarks of gangrenous colonic ischemia. Special considerations must be given to those patients in whom ischemic colitis develops in the context of colon carcinoma or obstructing colon lesions, after abdominal aortic surgery, and following cardiopulmonary bypass. This review will discuss the clinical spectrum of ischemic colitis.

Key words

Ischemia Colitis Colon Large intestine 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Boley SJ, Schwartz S, Lash J, Sternhill V. Reversible vascular occlusion of the colon. Surg Gynecol Obstet 1963;116:53–60.PubMedGoogle Scholar
  2. 2.
    Martson A, Pheils MT, Thomas L, Morson BC. Ischemic colitis. Gut 1966;7:1–15.PubMedGoogle Scholar
  3. 3.
    Stamos MJ. Colonic ischemia. In: Mazier WP, Luchtefeld MA, Levien DH, Senagore AJ, eds. Surgery of the colon, rectum, and anus. WB Saunders, 1995:705–13.Google Scholar
  4. 4.
    Michels NA, Siddarth P, Kornblith PL, Parke WW. The variant blood supply to the descending colon, rectosigmoid, and rectum based on 400 dissections. Its importance in regional resections: a review of the literature. Dis Colon Rectum 1965;8:251–78.Google Scholar
  5. 5.
    Sonneland J, Anson B, Beaton L. Surgical anatomy of the arterial supply of the colon from the superior mesenteric artery based upon a study of 600 specimens. Surg Gynecol Obstet 1958;106:385–98.PubMedGoogle Scholar
  6. 6.
    Steward JA, Rankin FW. Blood supply of the large intestine: its surgical considerations. Arch Surg 1933;26:843–91.Google Scholar
  7. 7.
    Griffiths JD. Surgical anatomy of the blood supply of the distal colon. Ann R Coll Surg Engl 1956;19:241–56.PubMedGoogle Scholar
  8. 8.
    Fisher DF, Fry WJ. Collateral mesenteric circulation. Surg Gynecol Obstet 1959;108:641–50.PubMedGoogle Scholar
  9. 9.
    Harnsberger JR, Longo WE, Vernava AM. Vascular anatomy. Semin Colon Rectal Surg 1994;5:2–13.Google Scholar
  10. 10.
    Drummond H. Some points relating to the surgical anatomy of the arterial supply of the large intestine. J R Soc Med 1913;7:185–93.Google Scholar
  11. 11.
    Kornblith PL, Boley SJ, Whitehouse BS. Anatomy of the splanchnic circulation. Surg Clin North Am 1992;72:1–30.Google Scholar
  12. 12.
    Renton CJ. Massive intestinal infarction following multiple injury. Br J Surg 1967;54:399–402.PubMedGoogle Scholar
  13. 13.
    Young TB. Post-traumatic delayed rupture of the colon without identifiable cause. Injury 1985;16:327–30.PubMedGoogle Scholar
  14. 14.
    Trinh TD, Jones B, Fishman EK. Amyloidosis of the colon presenting as ischemic colitis: a case report and review of the literature. Gastrointest Radiol 1991;16:133–6.PubMedGoogle Scholar
  15. 15.
    Ho MS, Teh LB, Goh HS. Ischaemic colitis in systemic lupus erythematosus—report of a case and review of the literature. Ann Acad Med Singapore 1987;16:501–3.PubMedGoogle Scholar
  16. 16.
    Reissman P, Weiss EG, Teoh TA, Lucas FV, Wexner SD. Gangrenous ischemic colitis of the rectum: a rare complication of systemic lupus erythematosus. Am J Gastroenterol 1994;89:2234–6.PubMedGoogle Scholar
  17. 17.
    Kaminski DL, Herrmann VM. Ischemic colitis. In: Cameron J, ed. Current surgical therapy. 2nd ed. Toronto: BC Decker 1986:110–4.Google Scholar
  18. 18.
    Gurbuz AK, Gurbuz B, Sales L, Rosenshein NB, Donowitz M, Giardiello FM. Premarin-induced ischemic colitis. J Clin Gastroenterol 1994;19:108–11.PubMedGoogle Scholar
  19. 19.
    Miyata T, Tamechika Y, Torisu M. Ischemic colitis in a 33 year old woman on danazol treatment for endometriosis. Am J Gastroenterol 1988;83:1420–3.PubMedGoogle Scholar
  20. 20.
    Wright A, Benfield GF, Felix-Davies D. Ischaemic colitis and immune complexes during gold therapy for rheumatoid arthritis. Ann Rheum Dis 1984;43:495–7.PubMedGoogle Scholar
  21. 21.
    Carratu R, Parisi P, Agozzino A. Segmental ischemic colitis associated with nonsteroidal anti-inflammatory drugs. J Clin Gastroenterol 1993;16:31–4.PubMedGoogle Scholar
  22. 22.
    Larrey D, Lainey E, Blanc P,et al. Acute colitis associated with prolonged administration of neuroleptics. J Clin Gastroenterol 1992;14:64–7.PubMedGoogle Scholar
  23. 23.
    Bower TC. Ischemic colitis. Surg Clin North Am 1993;73:1037–53.PubMedGoogle Scholar
  24. 24.
    Glotzer DJ, Roth SI, Welch CE. Colonic ulceration proximal to obstructing carcinoma. Surgery 1964;56:950–6.PubMedGoogle Scholar
  25. 25.
    Halligan MS, Saunders P, Thomas BM, Phillips RK. Ischaemic colitis in association with sigmoid carcinoma: a report of two cases. Clin Radiol 1994;49:183–4.PubMedGoogle Scholar
  26. 26.
    Seow-Choen F, Chua TL, Goh HS. Ischaemic colitis and colorectal cancer: some problems and pitfalls. Int J Colorectal Dis 1993;8:210–2.PubMedGoogle Scholar
  27. 27.
    Mallet L, Verdier D. Should subdivision of regressive ischemic colitis be envisaged? Ann Gastroenterol Hepatol (Paris) 1992;28:194–8.Google Scholar
  28. 28.
    Williams LF, Wittenberg J. Ischemic colitis: a useful clinical diagnosis, but is it ischemic? Ann Surg 1975;182:439–48.PubMedGoogle Scholar
  29. 29.
    Kvietys PR, Granger DN. Regulation of colonic blood flow. Fed Proc 1982;41:2106–10.PubMedGoogle Scholar
  30. 30.
    Brandt LJ, Boley SJ. Nonocclusive mesenteric ischemia. Annu Rev Med 1991;42:107–17.PubMedGoogle Scholar
  31. 31.
    Douglas DM, Russell JC, Goren D, Dempsey S, Das DK. Evidence of free radical (FR) involvement in ischemic colitis. Agents Actions 1989;27:435–7.PubMedGoogle Scholar
  32. 32.
    Price AB. Ischaemic colitis. Curr Top Pathol 1990;81:229–46.PubMedGoogle Scholar
  33. 33.
    Brandt LJ, Boley SJ. Colonic ischemia. Surg Clin North Am 1992;72:203–29.PubMedGoogle Scholar
  34. 34.
    Boley SJ. Colonic ischemia—25 years later. Am J Gastroenterol 1990;85:931–4.PubMedGoogle Scholar
  35. 35.
    Fitzgerald SF, Kaminski DL. Ischemic colitis. Semin Colon Rectal Surg 1993;4:222–8.Google Scholar
  36. 36.
    Kaleya RN, Boley SJ. Colonic ischemia. Perspect Colon Rectal Surg 1990;3:62–81.Google Scholar
  37. 37.
    Reeders JW, Tytgat GN, Rosenbusch G, Gramata S. Ischemic colitis. The Hague: Martinus Nijoff, 1984: 17–28, 145–151.Google Scholar
  38. 38.
    Guttormson NL, Bubrick MP. Mortality from Ischemic colitis. Dis Colon Rectum 1989;32:469–72.PubMedGoogle Scholar
  39. 39.
    Landreneau RJ, Fry WJ. The right colon as a target organ of nonocclusive mesenteric ischemia. Arch Surg 1990;125:591–4.PubMedGoogle Scholar
  40. 40.
    Longo WE, Ballantyne GH, Gusberg RJ. Ischemic colitis: patterns and prognosis. Dis Colon Rectum 1992;35:726–30.PubMedGoogle Scholar
  41. 41.
    Boley SJ, Brandt LJ, Veith FJ. Ischemic disorders of the intestines. Curr Probl Surg 1978;15:53–7.Google Scholar
  42. 42.
    Schoetz DJ Jr. Ischemic colitis. Probl Gen Surg 1992;9:710–6.Google Scholar
  43. 43.
    Iida M, Matsui T, Fuchigami T, Iwashita A, Yao T, Fujishima M. Clinical features of nongangrenous ischemic colitis: a comparison of stricturing and transient forms. J Clin Gastroenterol 1986;8:635–9.PubMedGoogle Scholar
  44. 44.
    Barcewicz PA, Welch JP. Ischemic colitis in young adult patients. Dis Colon Rectum 1980;23:109–14.PubMedGoogle Scholar
  45. 45.
    Judge JS, Hoffman NE, Levitt MD. Transient ischemic colitis in young adults. Aust N Z J Surg 1994;64:721–2.PubMedGoogle Scholar
  46. 46.
    Gage TP, Gagnier JM. Ischemic colitis complicating sickle cell crisis. Gastroenterology 1983;84:171–4.PubMedGoogle Scholar
  47. 47.
    Beaumont AC, Teare JP. Subtotal colectomy following marathon running in a female patient. J R Soc Med 1991;84:439–40.PubMedGoogle Scholar
  48. 48.
    Heer M, Repond F, Hany A, Sulser H, Kehl O, Jager K. Acute ischaemic colitis in a female long distance runner. Gut 1987;28:896–9.PubMedGoogle Scholar
  49. 49.
    Brown DN, Rosenholtz MJ, Marshall JB. Ischemic colitis related to cocaine abuse. Am J Gastroenterol 1994;89:1158–61.Google Scholar
  50. 50.
    Scholz FJ. Ischemic bowel disease. Radiol Clin North Am 1993;31:1197–218.PubMedGoogle Scholar
  51. 51.
    Philpotts LE, Heiken JP, Westcott MA, Gore RM. Colitis: use of CT findings in differential diagnosis. Radiology 1994;190:445–9.PubMedGoogle Scholar
  52. 52.
    Ranschaert E, Verhille R, Marchal G, Rigauts H, Ponette E. Sonographic diagnosis of ischemic colitis. J Belge Radiol 1994;77:166–8.PubMedGoogle Scholar
  53. 53.
    Brandt LJ, Boley SJ, Sammartano RJ. Carbon dioxide and room air insufflation of the colon: effects on colonic blood flow and intraluminal pressure in the dog. Gastrointest Endosc 1986;32:324–9.PubMedGoogle Scholar
  54. 54.
    Wheeldon NM, Grundman MJ. Ischaemic colitis as a complication of colonoscopy. BMJ 1990;301:1080–1.PubMedGoogle Scholar
  55. 55.
    Schneider TA, Longo WE, Ure T, Vernava AM. Mesenteric ischemia. Dis Colon Rectum 1994;37:1163–74.PubMedGoogle Scholar
  56. 56.
    Prasad CN, Wade TP. Mesenteric venous thrombosis. Semin Colon Rectal Surg 1993;4:218–21.Google Scholar
  57. 57.
    Robert JH, Mentha G, Rohner A. Ischaemic colitis: two distinct patterns of severity. Gut 1993;34:4–6.PubMedGoogle Scholar
  58. 58.
    Herrmann VM, Keltner RM. Intraoperative assessment of intestinal viability. Semin Colon Rectal Surg 1994;4:198–204.Google Scholar
  59. 59.
    Fiddian-Green RG, Amelin PM, Herrmann JB,et al. Prediction of the development of sigmoid ischemia on the day of aortic operations. Arch Surg 1986;121:654–60.PubMedGoogle Scholar
  60. 60.
    Bergman RT, Gloviczki P, Welch TJ,et al. Role of intravenous fluorescein in detection of colon ischemia during aortic reconstruction. Ann Vasc Surg 1992;61:74–9.Google Scholar
  61. 61.
    West BR, Ray JE, Gathright JB. Comparison of transient ischemic colitis with that requiring surgical treatment. Surg Gynecol Obstet 1980;151:366–8.PubMedGoogle Scholar
  62. 62.
    Abel ME, Russell TR. Ischemic colitis: comparison of surgical and non-operative management. Dis Colon Rectum 1983;26:113–5.PubMedGoogle Scholar
  63. 63.
    Parish KL, Chapman WC, Williams LF. Ischemic colitis: an ever-changing spectrum? Am Surg 1991;57:118–21.PubMedGoogle Scholar
  64. 64.
    Barnett MG, Longo WE. Intestinal ischemia after aortic surgery. Semin Colon Rectal Surg 1993;4:229–34.Google Scholar
  65. 65.
    Launer DP, Miscall BG, Beil AB. Colorectal infarction following resection of abdominal aortic aneurysms. Dis Colon Rectum 1978;21:613–7.PubMedGoogle Scholar
  66. 66.
    Maupin GE, Rimar SD, Villalba M. Ischemic colitis following abdominal aortic reconstruction for ruptured aneurysm: a 10-year experience. Am Surg 1989;55:378–80.PubMedGoogle Scholar
  67. 67.
    Ottinger LW, Darling RC, Nathan MJ, Linton RR. Left colon ischemia complicating aorto-iliac reconstruction: causes, diagnosis, management and prevention. Arch Surg 1972;105:841–6.PubMedGoogle Scholar
  68. 68.
    Zelenock GB, Strodel WE, Knol JA,et al. A prospective study of clinically and endoscopically documented colonic ischemia in 100 patients undergoing aortic reconstructive surgery with aggressive colonic and direct pelvic revascularization, compared with historic controls. Surgery 1989;106:771–80.PubMedGoogle Scholar
  69. 69.
    Hagihara PF, Ernst CB, Griffen WO Jr. Incidence of ischemic colitis following abdominal aortic reconstruction. Surg Gynec Obstet 1979;149:571–3.PubMedGoogle Scholar
  70. 70.
    Meissner MH, Johansen KH. Colon infarction after ruptured abdominal aortic aneurysm. Arch Surg 1992;127:979–85.PubMedGoogle Scholar
  71. 71.
    Welling RE, Roedersheimer LR, Arbaugh JJ. Ischemic colitis following repair of ruptured abdominal aortic aneurysm. Arch Surg 1985;120:1368–70.PubMedGoogle Scholar
  72. 72.
    Seeger JM, Coe DA, Kaelin LD, Flynn TC. Routine reimplantation of patent inferior mesenteric arteries limits colon infarction after aortic reconstruction. J Vasc Surg 1992;15:635–41.PubMedGoogle Scholar
  73. 73.
    Willman VL. Intestinal ischemia after cardiopulmonary bypass. Semin Colon Rectal Surg 1993;4:235–9.Google Scholar
  74. 74.
    Allen KB, Salam AA, Lumsden AB. Acute mesenteric ischemia after cardiopulmonary bypass. J Vasc Surg 1992;16:391–6.PubMedGoogle Scholar
  75. 75.
    Gennaro M, Ascer E, Matano R, Jacobowitz IJ, Cunningham JN Jr, Uceda P. Acute mesenteric ischemia after cardiopulmonary bypass. Am J Surg 1993;166:231–6.PubMedGoogle Scholar
  76. 76.
    Huddy SP, Joyce WP, Pepper JR. Gastrointestinal complications in 4473 patients who underwent cardiopulmonary bypass surgery. Br J Surg 1991;78:293–6.PubMedGoogle Scholar
  77. 77.
    Mercado PD, Farid H, O'Connell TX, Sintek CF, Pfeffer T, Khonsari S. Gastrointestinal complications associated with cardiopulmonary bypass procedures. Am Surg 1994;60:789–92.PubMedGoogle Scholar
  78. 78.
    Welling RE, Rath R, Albers JE, Glaser RS. Gastrointestinal complications after cardiac surgery. Arch Surg 1986;121:1178–80.PubMedGoogle Scholar
  79. 79.
    Downing SW, Edmunds LH Jr. Release of vasoactive substances during cardiopulmonary bypass. Ann Thorac Surg 1992;4:291–6.Google Scholar
  80. 80.
    Moore RM, Bertone AL, Muir W, Stromberg PC, Beard WL. Histopathologic evidence of reperfusion injury in the large colon of horses after low-flow ischemia. Am J Vet Res 1994;55:1434–43.PubMedGoogle Scholar
  81. 81.
    Moore RM, Muir W, Bertone AL, Beard WL. Characterization of the hemodynamic and metabolic alterations in the large colon of horses during low-flow ischemia and reperfusion. Am J Vet Res 1994;55:1444–53.PubMedGoogle Scholar
  82. 82.
    Fiorito JJ, Schoen RE, Brandt LJ. Pseudo-obstruction associated with colonic ischemia: successful management with colonoscopic decompression. Am J Gastroenterol 1991;86:1472–6.PubMedGoogle Scholar
  83. 83.
    Scott B, Isbister WH. Ischaemic colitis as a complication of left-sided large bowel obstruction: a case report. Aust N Z J Surg 1991;61:73–5.PubMedGoogle Scholar
  84. 84.
    Welch GH, Shearer MG, Imrie CW, Anderson JR, Gilmour DG. Total colonic ischemia. Dis Colon Rectum 1986;29:410–2.PubMedGoogle Scholar

Copyright information

© American Society of Colon and Rectal Surgeons 1996

Authors and Affiliations

  • Sanjiv K. Gandhi
    • 1
  • Morin M. Hanson
    • 1
  • Anthony M. Vernava
    • 1
  • Donald L. Kaminski
    • 1
  • Walter E. Longo
    • 1
  1. 1.Department of Surgery, Section of Colon and Rectal SurgerySt. Louis University School of MedicineSt. Louis

Personalised recommendations