Ischemic Colitis

WHAT IS ISCHEMIC COLITIS?

Ischemic colitis is injury of the large intestine that results from an interruption of its blood supply. The term "ischemic colitis" can be broken down into ischemia (referring to lack of oxygen) and colitis (referring to inflammation of the colon). In people suffering from ischemic colitis, the inner lining of the colon becomes irritated, inflamed and ulcerated due to a shortage of oxygen-rich blood in the affected area.

Ischemic colitis is similar in nature to coronary artery disease: Both conditions are caused by poor blood flow, one in the colon and the other in the heart. Thus, some of the major risk factors for ischemic colitis are similar to those for heart disease: high blood pressure, smoking and high cholesterol.


Ischemic colitis may result from sudden (acute) or, more commonly, long-term (chronic) blockage of blood flow through arteries that supply the large intestine. Blood clots can produce acute blockage; deposits of fatty material (atherosclerosis) can lead to chronic blockage. Damage of the inside lining and inner layers of the wall of the large intestine results; the degree of damage depends on the duration and severity of the blockage. The damage produces ulcers (sores) in the lining of the large intestine. Ischemic colitis affects primarily people who are 50 or older.


WHAT ARE THE SYMPTOMS OF ISCHEMIC COLITIS?

Usually, the person experiences abdominal pain. The pain is felt more often on the left side, but it can occur anywhere in the abdomen. The person frequently passes loose stools that are often accompanied by dark red clots. Sometimes bright red blood is passed without stool. Low-grade fevers (usually below 100° F [37.7° C]) are common.

A doctor may suspect ischemic colitis on the basis of the symptoms, especially in a person older than 50. An abdomen that is tender when pressed gently is further evidence of ischemic colitis. A colonoscopy or barium enema is needed to distinguish ischemic colitis from other forms of inflammation, such as infection or inflammatory bowel disease.


HOW TO TREAT ISCHEMIC COLITIS?

Very mild cases of Ischemic Colitis can be managed on an outpatient basis with liquid
diet, close observation, and antibiotics.

For inpatients, a combination of intravenous fluids and bowel rest is recommended
to reduce intestinal oxygen requirements. Parenteral nutrition should be considered for
patients who do not respond immediately and intestinal perfusion. Therefore, digitalis and other vasopressors are withdrawn or minimized, if possible, and cardiac output is maximized by adequate fluid resuscitation. Steroids have no role in the treatment of
acute ischemia, and they serve only to mask the development of peritoneal signs and delay a necessary laparotomy. Likewise, oral cathartics and bowel preparations should not be given because of the risk of precipitating colonic perforation
or toxic dilation of the colon.


MANAGING CHRONIC COLONIC ISCHEMIA

Chronic colonic ischemia is increasingly being recognized in the population at large.
The patients are older and describe a history of bloody diarrhea associated with crampy or constant episodes of abdominal pain. Endoscopy may suggest segmental colitis.
Biopsy specimens of bullae show sub mucosal hemorrhage and edema, while intervening areas reveal nonspecific inflammation. Venous congestion, mucus depletion, and injury to the crypt architecture and surface epithelial cells are also common.
The diagnosis is not always easy, however, and chronic ischemic colitis can easily be mistaken for inflammatory bowel disease. Compounding the difficulty, pseudopolyposis
may be present in patients with ischemic colitis. Patients may also develop ischemic strictures, which are classically smoother than neoplastic strictures; however, differentiation is not always easy and resection may be required, both for treatment of symptoms and to obtain a definitive histopathologic diagnosis. Mildly symptomatic chronic disease frequently responds to supportive management. In contrast to acute ischemia, chronic ischemia may respond to topical steroid preparations. Resectional surgery is generally reserved for patients for whom conservative supportive therapy fails and for those with recurrent episodes of colitis or with symptomatic strictures. As in surgery for acute ischemia, the respected specimen must be examined to confirm
that the mucosa is normal at the resection margins, and pulsatile bleeding must be
noted from the bowel ends. Surgery in patients with chronic ischemia usually is curative,
and development of further ischemic disease is rare.
 

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