Ischemic colitis overview: Difference between revisions
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{{Ischemic colitis}} | {{Ischemic colitis}} | ||
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==Overview== | ==Overview== | ||
Ischemic colitis is a medical condition in which [[inflammation]] and injury of the [[large intestine]] result from inadequate blood supply. | Ischemic colitis is a [[Disease|medical condition]] in which [[inflammation]] and injury of the [[large intestine]] result from inadequate [[blood]] supply. Ischemic colitis may be classified on the degree of the [[Histopathology|histopathological]] damage in the [[Colon (anatomy)|colonic]] wall: reversible colopathy ([[Submucosa|submucosal]] or intramural bleeding), transient colitis, chronic segmental [[ischemia]], [[Gangrene|gangrenous]] [[colitis]], and universal [[fulminant]] [[colitis]]. Also, based on its clinical course into two types: [[Acute (medicine)|acute]] [[Ischemia|ischemic]] [[colitis]] or [[Chronic (medical)|chronic]] [[Ischemia|ischemic]] [[colitis]]. Ischemic colitis is the result of a sudden, temporary, reduction in [[blood]] flow that is insufficient to meet the [[Metabolism|metabolic]] demands of the region of [[Colon (anatomy)|colon]]. [[Ischemia|Ischemic]] change will subsequently extend from the [[Mucous membrane|mucosa]] to the [[Serous membrane|serosa]]. [[Mucous membrane|Mucosal]]<nowiki/>injury will develop in 20 minutes to 1 hour, and transmural infarction occurs within 8 to 16 hours. [[Reperfusion injury]] can occur with the release of [[reactive oxygen species]], which cause [[lipid peroxidation]] within [[Cell membrane|cell membranes]], causing [[Cell (biology)|cell]] [[necrosis]]. schemic colitis is characterized by [[abdominal pain]] which is out of proportion to [[Physical examination|physical]] findings. There is a sudden onset of crampy [[abdominal pain]], [[diarrhea]], and an urge to [[Defecation|defecate]]. The [[pain]] is mild, located over the affected [[Intestine|bowel]], and usually to the left side of the lower [[abdomen]]. Mild [[rectal bleeding]] can be noticed within 24 hours. The [[blood]] may be bright red or maroon mixed with the [[Human feces|stools]]. [[X-rays]] are mainly used to check for organ [[perforation]] and [[pneumoperitoneum]] in ischemic colitis. Other noticable signs on [[X-rays|x-ray]] include [[Colon (anatomy)|colonic]] [[thumbprinting]] from [[Mural cell|mural]] thickening, pneumatosis [[coli]], a sign of advanced disease, and [[dilation]] or air-fluid levels. Ischemic colitis is usually treated with supportive care. Treatment is determined by its severity and include [[intravenous fluids]], [[Intestine|bowel]] rest, nasogastric tube, and [[total parenteral nutrition]]. | ||
== Historical Perspective == | == Historical Perspective == | ||
In 1963, Boley et al first described ischemic colitis in animal studies as vascular occlusion of the colon. In 1966, Marston et al coined the term ischemic colitis. | In 1963, Boley et al first described ischemic colitis in animal studies as [[vascular]] [[occlusion]] of the [[Colon (anatomy)|colon]]. In 1966, Marston et al coined the term ischemic colitis. | ||
== Classification == | == Classification == | ||
Ischemic colitis may be classified | Ischemic colitis may be classified on the degree of the [[Histopathology|histopathological]] damage in the [[Colon (anatomy)|colonic]] wall: reversible colopathy ([[Submucosa|submucosal]] or intramural bleeding), transient colitis, chronic segmental [[ischemia]], [[Gangrene|gangrenous]] [[colitis]], and universal [[fulminant]] [[colitis]]. Also, based on its clinical course into two types: [[Acute (medicine)|acute]] [[Ischemia|ischemic]] [[colitis]] or [[Chronic (medical)|chronic]] [[Ischemia|ischemic]] [[colitis]]. | ||
== Pathophysiology == | == Pathophysiology == | ||
Ischemic colitis is the result of a sudden, temporary, reduction in [[blood]] flow that is insufficient to meet the [[Metabolism|metabolic]] demands of the region of [[Colon (anatomy)|colon]]. [[Ischemia|Ischemic]] change will subsequently extend from the [[Mucous membrane|mucosa]] to the [[Serous membrane|serosa]]. [[Mucous membrane|Mucosal]]<nowiki/>injury will develop in 20 minutes to 1 hour, and transmural infarction occurs within 8 to 16 hours. [[Reperfusion injury]] can occur with the release of [[reactive oxygen species]], which cause [[lipid peroxidation]] within [[Cell membrane|cell membranes]], causing [[Cell (biology)|cell]] [[necrosis]]. | |||
==Causes== | ==Causes== | ||
Ischemic colitis causes of reduced [[blood]] flow can include changes in the systemic circulation such as [[Hypotension|low blood pressure]] or local factors such as [[Vasoconstriction|constriction of blood vessels]], a [[blood clot]], or drugs. In most cases, no specific cause can be identified. | |||
==Differentiating Ischemic Colitis from other Diseases== | ==Differentiating Ischemic Colitis from other Diseases== | ||
Ischemic colitis must be differentiated from the many other causes of [[abdominal pain]], [[Lower gastrointestinal bleeding|rectal bleeding]], | Ischemic colitis must be differentiated from the many other causes of [[abdominal pain]], [[Lower gastrointestinal bleeding|rectal bleeding]], and [[diarrhea]] such as [[infection]], [[inflammatory bowel disease]], [[diverticulosis]], or [[colon cancer]]. It is also important to differentiate ischemic colitis, which often resolves on its own, from the more immediately life-threatening condition of [[acute mesenteric ischemia]] of the [[small bowel]]. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Ischemic colitis occurs with greater frequency in the [[Old age|elderly]], and is the most common form of [[Intestine|bowel]] [[ischemia]]. Ischemic colitis is responsible for about 50 out of 100,000 [[hospital]] admissions, and is seen on about 100 in 100,000 [[Endoscopy|endoscopies]]. | |||
== Risk factors == | == Risk factors == | ||
Risk factors associated with ischemic colitis are [[cardiovascular]] and [[pulmonary]] diseases such as [[atherosclerosis]] and [[atrial fibrillation]], [[gastrointestinal]] disease like [[diarrhea]], surgical history and [[medications]]. | [[Risk factor|Risk factors]] associated with ischemic colitis are [[cardiovascular]] and [[pulmonary]] diseases such as [[atherosclerosis]] and [[atrial fibrillation]], [[gastrointestinal]] disease like [[diarrhea]], surgical history and [[medications]]. | ||
== Screening == | == Screening == | ||
There is insufficient evidence to recommend routine screening for ischemic colitis. | There is insufficient evidence to recommend routine [[Screening (medicine)|screening]] for ischemic colitis. | ||
==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
Ischemic colitis can span a | 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]]<nowiki/>into the [[Intestine|bowel]] wall. Occasionally, after severe [[ischemia]], patients may develop long-term complications such as a [[stricture]] or chronic [[colitis]]. | ||
==Diagnosis== | ==Diagnosis== | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
Ischemic colitis is characterized | Ischemic colitis is characterized by [[abdominal pain]] which is out of proportion to [[Physical examination|physical]] findings. There is a sudden onset of crampy [[abdominal pain]], [[diarrhea]], and an urge to [[Defecation|defecate]]. The [[pain]] is mild, located over the affected [[Intestine|bowel]], and usually to the left side of the lower [[abdomen]]. Mild [[rectal bleeding]] can be noticed within 24 hours. The [[blood]] may be bright red or maroon mixed with the [[Human feces|stools]]. | ||
===Physical Examination=== | ===Physical Examination=== | ||
Ischemic colitis is characterized by [[abdominal pain]] which is out of proportion to physical findings, specifically excruciating abdominal pain despite limited focal tenderness. | Ischemic colitis is characterized by [[abdominal pain]] which is out of proportion to [[Physical examination|physical findings]], specifically excruciating [[abdominal pain]] despite limited focal [[tenderness]]. | ||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
There are no | There are no specific [[Blood test|blood tests]] for ischemic colitis, but an [[elevated white blood cell count]] may be present. Other [[Medical laboratory|laboratory]] findings in ischemic colitis include [[Electrolyte disturbance|electrolyte]] and [[Kidney|renal]] abnormalities secondary to [[dehydration]], [[metabolic acidosis]], and [[Lactic acid|lactate]] level may be elevated due to any [[Tissue (biology)|tissue]] [[Hypoxemia|hypoxia]]. | ||
===Abdominal X Ray=== | ===Abdominal X Ray=== | ||
Among patients with ischemic colitis, the plain [[X-ray|X-rays]] are often normal or show non-specific findings. X-rays are mainly used to check for | Among patients with ischemic colitis, the plain [[X-ray|X-rays]] are often normal or show non-specific findings. [[X-rays]] are mainly used to check for organ [[perforation]] and [[pneumoperitoneum]] in ischemic colitis. Other noticable signs on [[X-rays|x-ray]] include [[Colon (anatomy)|colonic]] [[thumbprinting]] from [[Mural cell|mural]] thickening, pneumatosis [[coli]], a sign of advanced disease, and [[dilation]] or air-fluid levels. | ||
===CT=== | ===CT=== | ||
Among patients with ischemic colitis, the [[CT scan]] shows mild to moderate diffuse bowel wall thickening and marked hyperenhancement of the mucosa. | Among patients with ischemic colitis, the [[CT scan]] shows mild to moderate [[diffuse]] [[Intestine|bowel]] wall thickening and marked hyperenhancement of the [[Mucous membrane|mucosa]]. | ||
=== MRI === | === MRI === | ||
Magnetic resonance imaging (MRI) findings in ischemic colitis of | [[Magnetic resonance imaging]] ([[Magnetic resonance imaging|MRI]]) findings in ischemic colitis of [[Colon (anatomy)|colonic]] [[Pneumatosis intestinalis|pneumatosis]] and portomesenteric [[Vein|venous]] gas can be used to predict the presence of transmural colonic [[infarction]]. | ||
=== Ultrasound === | === Ultrasound === | ||
In ischemic colitis ultrasound has limited use because of bowel gas, but may show luminal thickening over the affected segment and hypoechoic wall due to [[edema]]. Limited use due to overlying bowel gas, operator-dependent quality, and poor sensitivity for low flow vessel disease. | In ischemic colitis [[ultrasound]] has limited use because of [[Intestine|bowel]] gas, but may show luminal thickening over the affected segment and hypoechoic wall due to [[edema]]. Limited use due to overlying [[Intestine|bowel]] gas, operator-dependent quality, and poor sensitivity for low flow vessel disease. | ||
=== Other imaging finding === | === Other imaging finding === | ||
[[Fluoroscopy]] [[barium]] studies rarely used in diagnosis of ischemic colitis. Contrast [[enema]] is abnormal in 90% of patients but is rarely used for diagnostic purposes. Barium enema should be avoided in cases where there is a suspicion of gangrene or perforation. Also, barium enema makes the later use of angiography or endoscopy more difficult because of residual contrast agent. | [[Fluoroscopy]] [[barium]] studies rarely used in diagnosis of ischemic colitis. Contrast [[enema]] is abnormal in 90% of patients but is rarely used for diagnostic purposes. [[Barium]] [[enema]] should be avoided in cases where there is a suspicion of [[gangrene]] or [[perforation]]. Also, [[barium]] [[enema]] makes the later use of [[Angiogram|angiography]] or [[endoscopy]] more difficult because of residual [[Contrast medium|contrast]] agent. | ||
=== Other Diagnostic studies === | === Other Diagnostic studies === | ||
Among patients with a suspicion of ischemic colitis, [[Endoscopy|endoscopic]] evaluation, via [[colonoscopy]] | Among patients with a suspicion of ischemic colitis, [[Endoscopy|endoscopic]] evaluation, via [[colonoscopy]] or [[Flexible sigmoidoscopy|flexible]] [[sigmoidoscopy]], is the [[Diagnosis|diagnostic]] procedure of choice if the [[diagnosis]] remains unclear after other [[imaging]] studies. [[Colonoscopy]] is sensitive and allows visualization of colonic [[Mucous membrane|mucosa]] and [[Histology|histological]] analysis of [[Biopsy|biopsies]]. [[Colonoscopy]] requires to be performed within 48 hours for [[diagnosis]] of ischemic colitis. | ||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
Ischemic colitis is usually treated with supportive care. Treatment is determined by its severity and include [[intravenous fluids]], [[Intestine|bowel]] rest, nasogastric tube, and [[total parenteral nutrition]]. Patients with [[Megacolon|colonic dilatation]] are managed with insertion of a [[rectal]] tube or [[Endoscopy|endoscopic]] [[decompression]]. There is no evidence about the role of [[Anticoagulant|anticoagulation]] or [[Antiplatelet drug|antiplatelet]] therapy. [[Steroid|Steroids]] have not been shown to improve outcomes. | |||
===Surgery=== | ===Surgery=== | ||
The mainstay of treatment for ischemic colitis is medical therapy. Surgery | The mainstay of treatment for ischemic colitis is medical therapy. [[Surgery]] is usually reserved for patients with either [[sepsis]], persistent [[fever]] and [[leukocytosis]], [[Peritoneum|peritoneal]] irritation, protracted [[pain]], [[diarrhea]] or [[bleeding]], protein-losing colopathy for more than 14 days, free intra-[[Abdomen|abdominal]] air, or [[Endoscopy|endoscopically]]-proved extensive [[gangrene]]. [[Laparotomy]] confirms the [[diagnosis]] and all affected bowel is resected. 20% of patients with acute ischemic colitis will require surgery with an associated [[mortality rate]] of up to 60%. Ileocolostomy is performed in patients with right-sided ischemic colitis with viable [[ileum]] and [[Anatomical terms of location|transverse]] [[Colon (anatomy)|colon]]. | ||
===Primary prevention=== | |||
There are no established measures for the primary prevention of ischemic colitis, but one can prevent the risk factors leading to ischemic colitis by not smoking, exercising regularly, and maintaining a healthy diet. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Gastroenterology]] | |||
[[Category:Surgery]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category: | [[Category:Medicine]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
Latest revision as of 15:58, 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], Mehrian Jafarizade, M.D [3]
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Overview
Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply. Ischemic colitis may be classified on the degree of the histopathological damage in the colonic wall: reversible colopathy (submucosal or intramural bleeding), transient colitis, chronic segmental ischemia, gangrenous colitis, and universal fulminant colitis. Also, based on its clinical course into two types: acute ischemic colitis or chronic ischemic colitis. Ischemic colitis is the result of a sudden, temporary, reduction in blood flow that is insufficient to meet the metabolic demands of the region of colon. Ischemic change will subsequently extend from the mucosa to the serosa. Mucosalinjury will develop in 20 minutes to 1 hour, and transmural infarction occurs within 8 to 16 hours. Reperfusion injury can occur with the release of reactive oxygen species, which cause lipid peroxidation within cell membranes, causing cell necrosis. schemic colitis is characterized by abdominal pain which is out of proportion to physical findings. There is a sudden onset of crampy abdominal pain, diarrhea, and an urge to defecate. The pain is mild, located over the affected bowel, and usually to the left side of the lower abdomen. Mild rectal bleeding can be noticed within 24 hours. The blood may be bright red or maroon mixed with the stools. X-rays are mainly used to check for organ perforation and pneumoperitoneum in ischemic colitis. Other noticable signs on x-ray include colonic thumbprinting from mural thickening, pneumatosis coli, a sign of advanced disease, and dilation or air-fluid levels. Ischemic colitis is usually treated with supportive care. Treatment is determined by its severity and include intravenous fluids, bowel rest, nasogastric tube, and total parenteral nutrition.
Historical Perspective
In 1963, Boley et al first described ischemic colitis in animal studies as vascular occlusion of the colon. In 1966, Marston et al coined the term ischemic colitis.
Classification
Ischemic colitis may be classified on the degree of the histopathological damage in the colonic wall: reversible colopathy (submucosal or intramural bleeding), transient colitis, chronic segmental ischemia, gangrenous colitis, and universal fulminant colitis. Also, based on its clinical course into two types: acute ischemic colitis or chronic ischemic colitis.
Pathophysiology
Ischemic colitis is the result of a sudden, temporary, reduction in blood flow that is insufficient to meet the metabolic demands of the region of colon. Ischemic change will subsequently extend from the mucosa to the serosa. Mucosalinjury will develop in 20 minutes to 1 hour, and transmural infarction occurs within 8 to 16 hours. Reperfusion injury can occur with the release of reactive oxygen species, which cause lipid peroxidation within cell membranes, causing cell necrosis.
Causes
Ischemic colitis causes of reduced blood flow can include changes in the systemic circulation such as low blood pressure or local factors such as constriction of blood vessels, a blood clot, or drugs. In most cases, no specific cause can be identified.
Differentiating Ischemic Colitis from other Diseases
Ischemic colitis must be differentiated from the many other causes of abdominal pain, rectal bleeding, and diarrhea such as infection, inflammatory bowel disease, diverticulosis, or colon cancer. It is also important to differentiate ischemic colitis, which often resolves on its own, from the more immediately life-threatening condition of acute mesenteric ischemia of the small bowel.
Epidemiology and Demographics
Ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Ischemic colitis is responsible for about 50 out of 100,000 hospital admissions, and is seen on about 100 in 100,000 endoscopies.
Risk factors
Risk factors associated with ischemic colitis are cardiovascular and pulmonary diseases such as atherosclerosis and atrial fibrillation, gastrointestinal disease like diarrhea, surgical history and medications.
Screening
There is insufficient evidence to recommend routine screening for ischemic colitis.
Natural History, Complications and Prognosis
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 gasinto the bowel wall. Occasionally, after severe ischemia, patients may develop long-term complications such as a stricture or chronic colitis.
Diagnosis
History and Symptoms
Ischemic colitis is characterized by abdominal pain which is out of proportion to physical findings. There is a sudden onset of crampy abdominal pain, diarrhea, and an urge to defecate. The pain is mild, located over the affected bowel, and usually to the left side of the lower abdomen. Mild rectal bleeding can be noticed within 24 hours. The blood may be bright red or maroon mixed with the stools.
Physical Examination
Ischemic colitis is characterized by abdominal pain which is out of proportion to physical findings, specifically excruciating abdominal pain despite limited focal tenderness.
Laboratory Findings
There are no specific blood tests for ischemic colitis, but an elevated white blood cell count may be present. Other laboratory findings in ischemic colitis include electrolyte and renal abnormalities secondary to dehydration, metabolic acidosis, and lactate level may be elevated due to any tissue hypoxia.
Abdominal X Ray
Among patients with ischemic colitis, the plain X-rays are often normal or show non-specific findings. X-rays are mainly used to check for organ perforation and pneumoperitoneum in ischemic colitis. Other noticable signs on x-ray include colonic thumbprinting from mural thickening, pneumatosis coli, a sign of advanced disease, and dilation or air-fluid levels.
CT
Among patients with ischemic colitis, the CT scan shows mild to moderate diffuse bowel wall thickening and marked hyperenhancement of the mucosa.
MRI
Magnetic resonance imaging (MRI) findings in ischemic colitis of colonic pneumatosis and portomesenteric venous gas can be used to predict the presence of transmural colonic infarction.
Ultrasound
In ischemic colitis ultrasound has limited use because of bowel gas, but may show luminal thickening over the affected segment and hypoechoic wall due to edema. Limited use due to overlying bowel gas, operator-dependent quality, and poor sensitivity for low flow vessel disease.
Other imaging finding
Fluoroscopy barium studies rarely used in diagnosis of ischemic colitis. Contrast enema is abnormal in 90% of patients but is rarely used for diagnostic purposes. Barium enema should be avoided in cases where there is a suspicion of gangrene or perforation. Also, barium enema makes the later use of angiography or endoscopy more difficult because of residual contrast agent.
Other Diagnostic studies
Among patients with a suspicion of ischemic colitis, endoscopic evaluation, via colonoscopy or flexible sigmoidoscopy, is the diagnostic procedure of choice if the diagnosis remains unclear after other imaging studies. Colonoscopy is sensitive and allows visualization of colonic mucosa and histological analysis of biopsies. Colonoscopy requires to be performed within 48 hours for diagnosis of ischemic colitis.
Treatment
Medical Therapy
Ischemic colitis is usually treated with supportive care. Treatment is determined by its severity and include intravenous fluids, bowel rest, nasogastric tube, and total parenteral nutrition. Patients with colonic dilatation are managed with insertion of a rectal tube or endoscopic decompression. There is no evidence about the role of anticoagulation or antiplatelet therapy. Steroids have not been shown to improve outcomes.
Surgery
The mainstay of treatment for ischemic colitis is medical therapy. Surgery is usually reserved for patients with either sepsis, persistent fever and leukocytosis, peritoneal irritation, protracted pain, diarrhea or bleeding, protein-losing colopathy for more than 14 days, free intra-abdominal air, or endoscopically-proved extensive gangrene. Laparotomy confirms the diagnosis and all affected bowel is resected. 20% of patients with acute ischemic colitis will require surgery with an associated mortality rate of up to 60%. Ileocolostomy is performed in patients with right-sided ischemic colitis with viable ileum and transverse colon.
Primary prevention
There are no established measures for the primary prevention of ischemic colitis, but one can prevent the risk factors leading to ischemic colitis by not smoking, exercising regularly, and maintaining a healthy diet.