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

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==Overview==
==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.
Ischemic colitis can span a wide [[spectrum]] of severity. Majority of patients are treated supportively and [[Healing|recover]] fully, while a minority with very severe [[ischemia]] may develop [[sepsis]] and become critically ill. Most patients make a full recovery. As the disease progresses, [[Submucosa|submucosal]] [[Bleeding|hemorrhage]] or [[edema]] may result in focal [[Mucous membrane|mucosal]] thickening, known as “[[thumbprinting]].” [[Pneumatosis intestinalis]] may occur if [[Mucous membrane|mucosal]] damage has taken place with passage of [[gas]] into the [[Intestine|bowel]] wall. Occasionally, after severe [[ischemia]], patients may develop long-term complications such as a [[stricture]] or chronic [[colitis]].


==Natural History==
==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.
The [[Natural history of disease|natural history]] of ischemic colitis is as follows:<ref name="pmid3045452">{{cite journal |vauthors=Hunter GC, Guernsey JM |title=Mesenteric ischemia |journal=Med. Clin. North Am. |volume=72 |issue=5 |pages=1091–115 |year=1988 |pmid=3045452 |doi= |url=}}</ref><ref name="NikolicKeck2017">{{cite journal|last1=Nikolic|first1=Amanda L.|last2=Keck|first2=James O.|title=Ischaemic colitis: uncertainty in diagnosis, pathophysiology and management|journal=ANZ Journal of Surgery|year=2017|issn=14451433|doi=10.1111/ans.14237}}</ref><ref name="MontoroBrandt2010">{{cite journal|last1=Montoro|first1=Miguel A.|last2=Brandt|first2=Lawrence J.|last3=Santolaria|first3=Santos|last4=Gomollon|first4=Fernando|last5=Puértolas|first5=Belén Sánchez|last6=Vera|first6=Jesús|last7=Bujanda|first7=Luis.|last8=Cosme|first8=Angel|last9=Cabriada|first9=José Luis|last10=Durán|first10=Margarita|last11=Mata|first11=Laura|last12=Santamaría|first12=Ana|last13=Ceña|first13=Gloria|last14=Blas|first14=Jose Manuel|last15=Ponce|first15=Julio|last16=Ponce|first16=Marta|last17=Rodrigo|first17=Luis|last18=Ortiz|first18=Jacobo|last19=Muñoz|first19=Carmen|last20=Arozena|first20=Gloria|last21=Ginard|first21=Daniel|last22=López-Serrano|first22=Antonio|last23=Castro|first23=Manuel|last24=Sans|first24=Miquel|last25=Campo|first25=Rafael|last26=Casalots|first26=Alex|last27=Orive|first27=Víctor|last28=Loizate|first28=Alberto|last29=Titó|first29=Lluçia|last30=Portabella|first30=Eva|last31=Otazua|first31=Pedro|last32=Calvo|first32=M.|last33=Botella|first33=Maria Teresa|last34=Thomson|first34=Concepción|last35=Mundi|first35=Jose Luis|last36=Quintero|first36=Enrique|last37=Nicolás|first37=David|last38=Borda|first38=Fernando|last39=Martinez|first39=Benito|last40=Gisbert|first40=Javier P.|last41=Chaparro|first41=María|last42=Bernadó|first42=Alfredo Jimenez|last43=Gómez-Camacho|first43=Federico|last44=Cerezo|first44=Antonio|last45=Nuñez|first45=Enrique Casal|title=Clinical patterns and outcomes of ischaemic colitis: Results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study)|journal=Scandinavian Journal of Gastroenterology|volume=46|issue=2|year=2010|pages=236–246|issn=0036-5521|doi=10.3109/00365521.2010.525794}}</ref><ref>{{cite journal|doi=10.3109/10.3748/wjg.14.7302}}</ref><ref name="O’NeillElder2011">{{cite journal|last1=O’Neill|first1=Stephen|last2=Elder|first2=Kenny|last3=Harrison|first3=Sarah J.|last4=Yalamarthi|first4=Satheesh|title=Predictors of severity in ischaemic colitis|journal=International Journal of Colorectal Disease|volume=27|issue=2|year=2011|pages=187–191|issn=0179-1958|doi=10.1007/s00384-011-1301-x}}</ref><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>
* As the disease progresses, [[Submucosa|submucosal]] [[Bleeding|hemorrhage]] or [[edema]] may result in focal [[Mucous membrane|mucosal]] thickening, known as “[[thumbprinting]]” 
* [[Pneumatosis intestinalis]] may occur if [[Mucous membrane|mucosal]] damage has taken place with passage of [[gas]] into the [[Intestine|bowel]] wall
* The symptoms of ischemic colitis usually develop in the sixth decade of life and start with [[Symptom|symptoms]] such as [[abdominal pain]], [[Dysentery|bloody diarrhea]], and [[Nausea and vomiting|vomiting]]
* Ischemic colitis can progress to different stages depending on the elapsed time:
**Reversible ischemic colopathy
**Reversible ischemic colopathy
***This type is characterized by submucosal haemorrhage at endoscopy, with involvement of superficial mucosa.
*** Characterized by [[Submucosa|submucosal]] [[Bleeding|hemorrhage]] at [[endoscopy]], with involvement of [[Superficial (human anatomy)|superficial]] [[Mucous membrane|mucosa]].
***It is typically self-limiting.
*** Self-limiting
**Transient: the most common form
**Transient: the most common form
***These patients present with abdominal pain, per-rectal bleeding and full-thickness involvement of the mucosa.
*** Present with [[abdominal pain]], [[rectal bleeding]] and full-thickness involvement of the [[Mucous membrane|mucosa]].
**Chronic segmental or chronic ulcerative  
**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.
*** Persistent symptoms or recurrent episodes of [[pain]], [[rectal bleeding]], [[diarrhea]], and segmental colitis on [[imaging]]
***Resection is often curative.
*** [[Resection]] is usually curative
**Ischaemic colonic stricture  
**[[Ischemia|Ischemic]] colonic [[Stenosis|stricture]]
***This may be detected acutely, however, more frequently is found at follow-up endoscopy.
*** Found at follow-up [[endoscopy]]
**Gangrenous colitis
**[[Gangrene|Gangrenous]] colitis
***This should be suspected when there is increasing abdominal pain, signs of local or generalized peritonitis, fevers or associated ileus.
*** Suspected when there is increasing [[abdominal pain]], [[Medical sign|signs]] of local or generalized [[peritonitis]], [[Fever|fevers]] or [[ileus]]
**Universal fulminant pancolitis  
**Universal [[fulminant]] [[pancolitis]]
***This presents acutely with severe symptoms, progressive transmural infarction and necrosis of the entire colon, resultant sepsis and perforation.
*** Presents acutely with severe symptoms, progressive transmural [[infarction]] and [[necrosis]] of the entire [[Colon (anatomy)|colon]], resultant [[sepsis]] and [[perforation]]
***75% mortality rate.
*** 75% [[mortality rate]]
***These patients present with sepsis, severe abdominal pain, peritonitis and per-rectal bleeding.
*** [[Symptom|Symptoms]] include [[sepsis]], severe [[abdominal pain]], [[peritonitis]] and [[rectal bleeding]]


==Complications==
==Complications==
The complications of ischemic colitis are as follows:<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><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>{{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>
The complications of ischemic colitis are as follows:<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><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>{{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>
* About 20% of patients with acute ischemic colitis may develop a long-term complication known as chronic ischemic colitis.
* About 20% of patients with [[Acute (medicine)|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]].
** Symptoms can include recurrent [[Infection|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.
** Chronic ischemic colitis is often treated with surgical removal of the chronically diseased portion of the [[Intestine|bowel]]


* 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.
* A [[stricture|colonic stricture]] is a band of [[scar tissue]] which forms as a result of the [[Ischemia|ischemic]] injury and narrows the [[lumen (anatomy)|lumen]] of the [[Colon (anatomy)|colon]]
** [[Strictures]] are often treated observantly; they may heal spontaneously over 12-24 months.
** [[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 [[stent]]ing have also been employed.
** If a [[bowel obstruction]] develops as a result of the [[Stenosis|stricture]], surgical [[resection]] is the usual treatment although [[Endoscopy|endoscopic]] [[Dilation|dilatation]] and [[stent]]ing have also been employed


==Prognosis==
==Prognosis==
The prognosis of ischemic colitis is as follows:<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><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>
The prognosis of ischemic colitis is as follows:<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><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>
* Majority of patients with ischemic colitis recovery fully, although the prognosis depends on the severity of the ischemia.
* Majority of patients with ischemic colitis recover 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.
* 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%.
* 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.
** 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.
** [[Mortality rate]] is almost 100% without surgical intervention


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 14:29, 5 February 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. As the disease progresses, submucosal hemorrhage or edema may result in focal mucosal thickening, known as “thumbprinting.” Pneumatosis intestinalis may occur if mucosal damage has taken place with passage of gas into the bowel wall. Occasionally, after severe ischemia, patients may develop long-term complications such as a stricture or chronic colitis.

Natural History

The natural history of ischemic colitis is as follows:[1][2][3][4][5][6][7][8][9][10]

Complications

The complications of ischemic colitis are as follows:[11][12][13][14]

  • About 20% of patients with acute ischemic colitis may develop a long-term complication known as chronic ischemic colitis

Prognosis

The prognosis of ischemic colitis is as follows:[15][16]

  • Majority of patients with ischemic colitis recover 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

References

  1. ↑ Hunter GC, Guernsey JM (1988). "Mesenteric ischemia". Med. Clin. North Am. 72 (5): 1091–115. PMID 3045452.
  2. ↑ Nikolic, Amanda L.; Keck, James O. (2017). "Ischaemic colitis: uncertainty in diagnosis, pathophysiology and management". ANZ Journal of Surgery. doi:10.1111/ans.14237. ISSN 1445-1433.
  3. ↑ Montoro, Miguel A.; Brandt, Lawrence J.; Santolaria, Santos; Gomollon, Fernando; Puértolas, Belén Sánchez; Vera, Jesús; Bujanda, Luis.; Cosme, Angel; Cabriada, José Luis; Durán, Margarita; Mata, Laura; Santamaría, Ana; Ceña, Gloria; Blas, Jose Manuel; Ponce, Julio; Ponce, Marta; Rodrigo, Luis; Ortiz, Jacobo; Muñoz, Carmen; Arozena, Gloria; Ginard, Daniel; López-Serrano, Antonio; Castro, Manuel; Sans, Miquel; Campo, Rafael; Casalots, Alex; Orive, Víctor; Loizate, Alberto; Titó, Lluçia; Portabella, Eva; Otazua, Pedro; Calvo, M.; Botella, Maria Teresa; Thomson, Concepción; Mundi, Jose Luis; Quintero, Enrique; Nicolás, David; Borda, Fernando; Martinez, Benito; Gisbert, Javier P.; Chaparro, María; Bernadó, Alfredo Jimenez; Gómez-Camacho, Federico; Cerezo, Antonio; Nuñez, Enrique Casal (2010). "Clinical patterns and outcomes of ischaemic colitis: Results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study)". Scandinavian Journal of Gastroenterology. 46 (2): 236–246. doi:10.3109/00365521.2010.525794. ISSN 0036-5521.
  4. ↑ . doi:10.3109/10.3748/wjg.14.7302. Missing or empty |title= (help)
  5. ↑ O’Neill, Stephen; Elder, Kenny; Harrison, Sarah J.; Yalamarthi, Satheesh (2011). "Predictors of severity in ischaemic colitis". International Journal of Colorectal Disease. 27 (2): 187–191. doi:10.1007/s00384-011-1301-x. ISSN 0179-1958.
  6. ↑ 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.
  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. ↑ Boley, SJ, Brandt, LJ, Veith, FJ. Ischemic disorders of the intestines. Curr Probl Surg 1978; 15:1.
  9. ↑ Hunter G, Guernsey J (1988). "Mesenteric ischemia". Med Clin North Am. 72 (5): 1091–115. PMID 3045452.
  10. ↑ Cappell M (1998). "Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia". Gastroenterol Clin North Am. 27 (4): 827–60, vi. PMID 9890115.
  11. ↑ Cappell M (1998). "Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia". Gastroenterol Clin North Am. 27 (4): 827–60, vi. PMID 9890115.
  12. ↑ 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.
  13. ↑ Oz M, Forde K (1990). "Endoscopic alternatives in the management of colonic strictures". Surgery. 108 (3): 513–9. PMID 2396196.
  14. ↑ 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.
  15. ↑ Longo W, Ballantyne G, Gusberg R (1992). "Ischemic colitis: patterns and prognosis". Dis Colon Rectum. 35 (8): 726–30. PMID 1643995.
  16. ↑ 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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