Ischemic colitis natural history, complications and prognosis
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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 natural history of ischemic colitis is as follows:[1][2][3][4][5][6][7][8][9][10]
- 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:
- 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.
- Reversible ischemic colopathy
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.
- 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:[15][16]
- 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
- ↑ Hunter GC, Guernsey JM (1988). "Mesenteric ischemia". Med. Clin. North Am. 72 (5): 1091–115. PMID 3045452.
- ↑ 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.
- ↑ 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.
- ↑ . doi:10.3109/10.3748/wjg.14.7302. Missing or empty
|title=(help) - ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Boley, SJ, Brandt, LJ, Veith, FJ. Ischemic disorders of the intestines. Curr Probl Surg 1978; 15:1.
- ↑ Hunter G, Guernsey J (1988). "Mesenteric ischemia". Med Clin North Am. 72 (5): 1091–115. PMID 3045452.
- ↑ Cappell M (1998). "Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia". Gastroenterol Clin North Am. 27 (4): 827–60, vi. PMID 9890115.
- ↑ Cappell M (1998). "Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia". Gastroenterol Clin North Am. 27 (4): 827–60, vi. PMID 9890115.
- ↑ 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.
- ↑ Oz M, Forde K (1990). "Endoscopic alternatives in the management of colonic strictures". Surgery. 108 (3): 513–9. PMID 2396196.
- ↑ 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.
- ↑ Longo W, Ballantyne G, Gusberg R (1992). "Ischemic colitis: patterns and prognosis". Dis Colon Rectum. 35 (8): 726–30. PMID 1643995.
- ↑ Parish K, Chapman W, Williams L (1991). "Ischemic colitis. An ever-changing spectrum?". Am Surg. 57 (2): 118–21. PMID 1992867.