What is the next step in managing a patient with abdominal pain and a computed tomography (CT) scan showing ischemic colitis?

From the Guidelines

For a patient with abdominal pain and CT findings of ischemic colitis, immediate surgical exploration is necessary to assess bowel viability, re-establish vascular flow, and resect non-viable bowel, as recommended by the most recent guidelines 1. The patient should be managed in a multidisciplinary approach, with a focus on rapid resuscitation, and careful assessment of the CTA to determine the best course of action.

• Initial treatment includes bowel rest (nothing by mouth) and intravenous fluid resuscitation to maintain adequate perfusion.
• Broad-spectrum antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or ciprofloxacin 400mg IV every 12 hours plus metronidazole 500mg IV every 8 hours should be administered to prevent bacterial translocation.
• Pain management with opioids may be required, avoiding NSAIDs which can worsen intestinal ischemia.
• Continuous vital sign monitoring, serial physical examinations, and laboratory tests (CBC, electrolytes, lactate) should be performed to assess for clinical deterioration. The underlying cause of ischemia should be investigated and treated, which may include cardiac evaluation, anticoagulation if thromboembolism is suspected, or correction of hypotension, as suggested by previous guidelines 1. However, the most recent guidelines 1 prioritize a multidisciplinary approach and surgical exploration to improve outcomes, and this should be the primary focus of treatment.

From the Research

Diagnosis and Initial Management

• The patient's CT scan showing ischemic colitis indicates the need for prompt and appropriate investigation, ideally involving both gastroenterology and surgery 2.
• The mainstay of medical management is conservative/supportive treatment, with bowel rest, fluid resuscitation, and antibiotics 2, 3, 4.
• Lower gastrointestinal endoscopy should be performed within 48 hours to reach the distal-most extent of the disease and provide endoscopic and histological confirmation 2.

Treatment and Prognosis

• Treatment of ischemic colitis is supportive in less severe cases, with intravenous fluids and bowel rest, and broad-spectrum antibiotics should be initiated 3, 4.
• Surgical consultation should be obtained in cases of severe disease, pancolonic ischemia, and isolated right colonic ischemia, and surgery should be performed for peritonitis, hemodynamic instability, or failure of non-operative management 2, 3.
• The prognosis of ischemic colitis varies widely depending on the degree of ischemia, and timely imaging evaluation by CT and early diagnosis can help improve the prognosis 5.

Specific Considerations

• Isolated right colon ischemia is associated with more severe outcomes, including need for surgical intervention and increased mortality, and evaluation of the mesenteric vasculature is particularly important in these cases 3.
• Contrast-induced ischemic colitis is a rare but possible cause of abdominal pain after cardiovascular interventional procedures with contrast media, and should be considered in the differential diagnosis 5.
• Patients in intensive care units with ischemic colitis are often under-diagnosed, and bedside colonoscopy and diagnostic laparoscopy may be reliable and promising options for diagnosis in critically ill patients 6.