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; 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> 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 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==
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>
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>
 
* As the disease progresses, [[Submucosa|submucosal]] [[Bleeding|hemorrhage]] or [[edema]] may result in focal [[Mucous membrane|mucosal]] thickening, known as “[[thumbprinting]]” 
*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.
* [[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]]
*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.
* Ischemic colitis can progress to different stages depending on the elapsed time:
 
**Reversible ischemic colopathy
*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]].
*** Characterized by [[Submucosa|submucosal]] [[Bleeding|hemorrhage]] at [[endoscopy]], with involvement of [[Superficial (human anatomy)|superficial]] [[Mucous membrane|mucosa]].
*** Self-limiting
**Transient: the most common form
*** Present with [[abdominal pain]], [[rectal bleeding]] and full-thickness involvement of the [[Mucous membrane|mucosa]].
**Chronic segmental or chronic ulcerative
*** Persistent symptoms or recurrent episodes of [[pain]], [[rectal bleeding]], [[diarrhea]], and segmental colitis on [[imaging]]
*** [[Resection]] is usually curative
**[[Ischemia|Ischemic]] colonic [[Stenosis|stricture]]
*** Found at follow-up [[endoscopy]]
**[[Gangrene|Gangrenous]] colitis
*** Suspected when there is increasing [[abdominal pain]], [[Medical sign|signs]] of local or generalized [[peritonitis]], [[Fever|fevers]] or [[ileus]]
**Universal [[fulminant]] [[pancolitis]]
*** Presents acutely with severe symptoms, progressive transmural [[infarction]] and [[necrosis]] of the entire [[Colon (anatomy)|colon]], resultant [[sepsis]] and [[perforation]]
*** 75% [[mortality rate]]
*** [[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>
* 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 [[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 [[Intestine|bowel]]


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.
* 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  
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>
** 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==
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.
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 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


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>
* 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==
==References==
{{Reflist|2}}
{{Reflist|2}}


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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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