Advertisement

Current Treatment Options in Gastroenterology

, Volume 14, Issue 1, pp 128–139 | Cite as

Update on the Diagnosis and Management of Colon Ischemia

  • Ann D. FlynnEmail author
  • John F. Valentine
Colon (C Kahi, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Colon

Opinion statement

Colonic ischemia is the most common ischemic disorder of the gastrointestinal tract. The condition occurs more commonly in women, and risk increases with advancing age. Presenting symptoms include abdominal pain, bowel urgency, and passage of bloody diarrhea; however, nearly one half of patients do not present with this classic triad of symptoms. Abdominal pain without bloody diarrhea or non-bloody diarrhea should raise concern for an isolated right colon pattern of ischemia. An isolated right colon distribution is associated with more severe outcomes, including need for surgical intervention and increased mortality. Patients that present with symptoms concerning for ischemia should undergo computed tomography (CT) scan of the abdomen and pelvis with oral and IV contrast and laboratory testing. Colonoscopy should be performed in patients without evidence of peritonitis. Medical history should be obtained to identify possible etiologies of ischemia. Thrombophilia workup should be considered in young patients and those with recurrent ischemia, but is not required universally. In cases of isolated right colon ischemia, evaluation of the mesenteric vasculature is particularly important, for exclusion of concurrent acute mesenteric ischemia. Treatment of ischemic colitis is supportive in less severe cases, with intravenous fluids and bowel rest. Broad-spectrum antibiotics should be initiated, and surgical consultation should be obtained in cases of severe disease, pancolonic ischemia, and isolated right colonic ischemia. Surgery should be performed for peritonitis, hemodynamic instability, or failure of non-operative management. This article will review colonic ischemia diagnosis, evaluation, and treatment.

Keywords

Colon ischemia Reperfusion Acute mesenteric ischemia 

Notes

Compliance with Ethical Standards

Conflict of Interest

Ann D. Flynn and John F. Valentine declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran’s gastrointestinal and liver disease pathophysiology, diagnosis, management. 10th ed. London: Elsevier Health Sciences 2015:1 online resource (3313 p.).Google Scholar
  2. 2.
    Longstreth GF, Yao JF. Epidemiology, clinical features, high-risk factors, and outcome of acute large bowel ischemia. Clin Gastroenterol Hepatol 2009;7:1075–80 e1-2; quiz 23.Google Scholar
  3. 3.
    Mosli M, Parfitt J, Gregor J. Retrospective analysis of disease association and outcome in histologically confirmed ischemic colitis. J Dig Dis. 2013;14:238–43.CrossRefPubMedGoogle Scholar
  4. 4.
    Montoro MA, Brandt LJ, Santolaria S, et al. Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study). Scand J Gastroenterol. 2011;46:236–46.CrossRefPubMedGoogle Scholar
  5. 5.
    Cole JA, Cook SF, Sands BE, Ajene AN, Miller DP, Walker AM. Occurrence of colon ischemia in relation to irritable bowel syndrome. Am J Gastroenterol. 2004;99:486–91.CrossRefPubMedGoogle Scholar
  6. 6.
    Walker AM, Bohn RL, Cali C, Cook SF, Ajene AN, Sands BE. Risk factors for colon ischemia. Am J Gastroenterol. 2004;99:1333–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Chavalitdhamrong D, Jensen DM, Kovacs TO, et al. Ischemic colitis as a cause of severe hematochezia: risk factors and outcomes compared with other colon diagnoses. Gastrointest Endosc. 2011;74:852–7.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.••
    Yadav S, Dave M, Edakkanambeth Varayil J, et al. A population-based study of incidence, risk factors, clinical spectrum, and outcomes of ischemic colitis. Clin Gastroenterol Hepatol. 2015;13:731–8 e1-6; quiz e41. This article is a retrospective population-based study from Olmsted County, Minnesota, describing the incidence, risk, and natural history of ischemic colitis in this population, 1976 to 2009.CrossRefPubMedGoogle Scholar
  9. 9.••
    Feuerstadt P, Aroniadis O, Brandt LJ. Features and outcomes of patients with ischemia isolated to the right side of the colon when accompanied or followed by acute mesenteric ischemia. Clin Gastroenterol Hepatol 2015. This article is a retrospective study examining patients admitted to a single center with isolated right colon ischemia with concurrent or subsequent development of acute mesenteric ischemia, with characterization of disease course and clinical outcomes.Google Scholar
  10. 10.
    Brandt LJ, Feuerstadt P, Blaszka MC. Anatomic patterns, patient characteristics, and clinical outcomes in ischemic colitis: a study of 313 cases supported by histology. Am J Gastroenterol. 2010;105:2245–52. quiz 53.CrossRefPubMedGoogle Scholar
  11. 11.
    Flobert C, Cellier C, Berger A, et al. Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis. Am J Gastroenterol. 2000;95:195–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Sotiriadis J, Brandt LJ, Behin DS, Southern WN. Ischemic colitis has a worse prognosis when isolated to the right side of the colon. Am J Gastroenterol. 2007;102:2247–52.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Sun MY, Maykel JA. Ischemic colitis. Clin Colon Rectal Surg. 2007;20:5–12.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Elder K, Lashner BA, Al SF. Clinical approach to colonic ischemia. Cleve Clin J Med. 2009;76:401–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Suh DC, Kahler KH, Choi IS, Shin H, Kralstein J, Shetzline M. Patients with irritable bowel syndrome or constipation have an increased risk for ischaemic colitis. Aliment Pharmacol Ther. 2007;25:681–92.CrossRefPubMedGoogle Scholar
  16. 16.
    Higgins PD, Davis KJ, Laine L. Systematic review: the epidemiology of ischaemic colitis. Aliment Pharmacol Ther. 2004;19:729–38.CrossRefPubMedGoogle Scholar
  17. 17.
    Kimura T, Shinji A, Horiuchi A, et al. Clinical characteristics of young-onset ischemic colitis. Dig Dis Sci. 2012;57:1652–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Longstreth GF, Yao JF. Diseases and drugs that increase risk of acute large bowel ischemia. Clin Gastroenterol Hepatol. 2010;8:49–54.CrossRefPubMedGoogle Scholar
  19. 19.
    Mapel DW, Dedrick D, Davis K. Trends and cardiovascular co-morbidities of COPD patients in the Veterans Administration Medical System, 1991–1999. COPD 2005;2:35–41.Google Scholar
  20. 20.
    Chang L, Kahler KH, Sarawate C, Quimbo R, Kralstein J. Assessment of potential risk factors associated with ischaemic colitis. Neurogastroenterol Motil. 2008;20:36–42.PubMedGoogle Scholar
  21. 21.
    Herve S, Beaugerie L, Bouhnik Y, et al. Irritable bowel syndrome is more frequent in patients hospitalized for ischaemic colitis: results of a case–control study. Neurogastroenterol Motil. 2009;21:1170–e102.CrossRefPubMedGoogle Scholar
  22. 22.
    Hass DJ, Kozuch P, Brandt LJ. Pharmacologically mediated colon ischemia. Am J Gastroenterol. 2007;102:1765–80.CrossRefPubMedGoogle Scholar
  23. 23.
    Miller DP, Alfredson T, Cook SF, Sands BE, Walker AM. Incidence of colonic ischemia, hospitalized complications of constipation, and bowel surgery in relation to use of alosetron hydrochloride. Am J Gastroenterol. 2003;98:1117–22.CrossRefPubMedGoogle Scholar
  24. 24.
    Salk A, Stobaugh DJ, Deepak P, Ehrenpreis ED. Ischemic colitis with type I interferons used in the treatment of hepatitis C and multiple sclerosis: an evaluation from the food and drug administration adverse event reporting system and review of the literature. Ann Pharmacother. 2013;47:537–42.CrossRefPubMedGoogle Scholar
  25. 25.
    Salk A, Stobaugh DJ, Deepak P, Ehrenpreis ED. Ischaemic colitis in rheumatoid arthritis patients receiving tumour necrosis factor-alpha inhibitors: an analysis of reports to the US FDA Adverse Event Reporting System. Drug Saf. 2013;36:329–34.CrossRefPubMedGoogle Scholar
  26. 26.
    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;204:597–602.CrossRefPubMedGoogle Scholar
  27. 27.
    Koutroubakis IE, Sfiridaki A, Theodoropoulou A, Kouroumalis EA. Role of acquired and hereditary thrombotic risk factors in colon ischemia of ambulatory patients. Gastroenterology. 2001;121:561–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Sanchez LD, Tracy JA, Berkoff D, Pedrosa I. Ischemic colitis in marathon runners: a case-based review. J Emerg Med. 2006;30:321–6.CrossRefPubMedGoogle Scholar
  29. 29.
    Cohen DC, Winstanley A, Engledow A, Windsor AC, Skipworth JR. Marathon-induced ischemic colitis: why running is not always good for you. Am J Emerg Med. 2009;27:255 e5–7.CrossRefGoogle Scholar
  30. 30.
    Paterno F, McGillicuddy EA, Schuster KM, Longo WE. Ischemic colitis: risk factors for eventual surgery. Am J Surg. 2010;200:646–50.CrossRefPubMedGoogle Scholar
  31. 31.
    Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: systematic review and meta-analysis. Radiology. 2010;256:93–101.CrossRefPubMedGoogle Scholar
  32. 32.
    Mazzei MA, Guerrini S, Cioffi Squitieri N, et al. Magnetic resonance imaging: is there a role in clinical management for acute ischemic colitis? World J Gastroenterol. 2013;19:1256–63.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.••
    Brandt LJ, Feuerstadt P, Longstreth GF, Boley SJ, American College of G. ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia (CI). Am J Gastroenterol 2015;110:18–44; quiz 5. This article is an American College of Gastroenterology clinical guideline and review of the literature.Google Scholar
  34. 34.
    Iacobellis F, Berritto D, Somma F, et al. Magnetic resonance imaging: a new tool for diagnosis of acute ischemic colitis? World J Gastroenterol. 2012;18:1496–501.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Wolff JH, Rubin A, Potter JD, et al. Clinical significance of colonoscopic findings associated with colonic thickening on computed tomography: is colonoscopy warranted when thickening is detected? J Clin Gastroenterol. 2008;42:472–5.CrossRefPubMedGoogle Scholar
  36. 36.
    Balthazar EJ, Yen BC, Gordon RB. Ischemic colitis: CT evaluation of 54 cases. Radiology. 1999;211:381–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Alturkistany S, Artho G, Maheshwari S, Blaichman J, Kao E, Mesurolle B. Transmural colonic ischemia: clinical features and computed tomography findings. Clin Imaging. 2012;36:35–40.CrossRefPubMedGoogle Scholar
  38. 38.•
    Castleberry AW, Turley RS, Hanna JM, et al. A 10-year longitudinal analysis of surgical management for acute ischemic colitis. J Gastrointest Surg. 2013;17:784–92. This article is a single center review of experience with surgical resection for acute ischemic colitis, and development of risk stratification methods for patients with ischemic colitis requiring surgery.CrossRefPubMedGoogle Scholar
  39. 39.
    O’Neill S, Elder K, Harrison SJ, Yalamarthi S. Predictors of severity in ischaemic colitis. Int J Colorectal Dis. 2012;27:187–91.CrossRefPubMedGoogle Scholar
  40. 40.
    Brandt LJ, Boley SJ, Sammartano R. 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.CrossRefPubMedGoogle Scholar
  41. 41.
    Beppu K, Osada T, Nagahara A, et al. Relationship between endoscopic findings and clinical severity in ischemic colitis. Intern Med. 2011;50:2263–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Zuckerman GR, Prakash C, Merriman RB, Sawhney MS, DeSchryver-Kecskemeti K, Clouse RE. The colon single-stripe sign and its relationship to ischemic colitis. Am J Gastroenterol. 2003;98:2018–22.CrossRefPubMedGoogle Scholar
  43. 43.
    Yoshiya K, Lapchak PH, Thai TH, et al. Depletion of gut commensal bacteria attenuates intestinal ischemia/reperfusion injury. Am J Physiol Gastrointest Liver Physiol. 2011;301:G1020–30.CrossRefPubMedGoogle Scholar
  44. 44.
    Joo M, Odze RD. Rectal sparing and skip lesions in ulcerative colitis: a comparative study of endoscopic and histologic findings in patients who underwent proctocolectomy. Am J Surg Pathol. 2010;34:689–96.PubMedGoogle Scholar
  45. 45.
    Reissfelder C, Sweiti H, Antolovic D, et al. Ischemic colitis: who will survive? Surgery. 2011;149:585–92.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2016

Authors and Affiliations

  1. 1.Division of Gastroenterology, Hepatology, and NutritionUniversity of Utah School of MedicineSalt LakeUSA

Personalised recommendations