What is the management of ischemic colitis?

From the Guidelines

The management of ischemic colitis should prioritize supportive care, addressing the underlying cause, and considering endovascular interventions as the first line of treatment, given their association with lower morbidity and mortality rates compared to surgical approaches, as supported by the most recent evidence 1.

Overview of Ischemic Colitis Management

The approach to managing ischemic colitis involves a combination of conservative management and, in severe cases, intervention to restore blood flow to the affected area of the colon. Conservative management includes:

• Bowel rest
• Intravenous fluids for hydration
• Correction of precipitating factors such as hypotension or medications that reduce blood flow to the colon
• Broad-spectrum antibiotics to prevent bacterial translocation, though their use is somewhat controversial
• Pain management with acetaminophen or opioids if necessary
• Avoidance of medications that can worsen intestinal blood flow, including vasoconstrictors, diuretics, and NSAIDs

Role of Endovascular Interventions

Endovascular interventions, such as angiography and aspiration embolectomy, have emerged as a preferred initial approach for managing acute mesenteric ischemia, including ischemic colitis, due to their minimally invasive nature and potential for reducing morbidity and mortality compared to open surgery 1. These interventions aim to rapidly restore inline arterial flow to the affected bowel, which is critical for preventing life-threatening complications.

Considerations for Surgical Intervention

While endovascular interventions are increasingly favored, surgical intervention may still be necessary in cases where there is significant bowel ischemia, peritoneal signs, or failure of endovascular treatment. Surgical treatment typically involves laparotomy, assessment of intestinal viability, resection of nonviable intestine, and intensive care. The decision between endovascular and surgical approaches should be made on a case-by-case basis, considering the patient's overall condition, the extent of ischemia, and the availability of expertise in endovascular interventions.

Importance of Close Monitoring and Follow-Up

Close monitoring of vital signs, abdominal examination, and laboratory values is essential in the management of ischemic colitis. Follow-up colonoscopy is recommended 4-6 weeks after the acute episode to confirm healing and rule out other pathologies. The underlying pathophysiology of ischemic colitis involves temporary reduction in blood flow to the colon, most commonly affecting the "watershed" areas with limited collateral circulation.

Evidence-Based Recommendations

The most recent and highest quality study 1 supports the use of endovascular interventions as the initial treatment for ischemic colitis, highlighting their potential to reduce morbidity and mortality. This approach is in line with the goal of prioritizing interventions that improve morbidity, mortality, and quality of life outcomes for patients with ischemic colitis.

From the Research

Management of Ischemic Colitis

The management of ischemic colitis (IC) involves a combination of medical and surgical approaches, depending on the severity of the condition.

• The mainstay of medical management is conservative/supportive treatment, with bowel rest, fluid resuscitation, and antibiotics 2.
• Specific laboratory, radiological, and endoscopic features are recognized to correlate with more severe disease, higher rates of surgical intervention, and ultimately worse outcomes 2.
• CT with intravenous contrast is the imaging modality of choice, and it can support clinical diagnosis, define the severity and distribution of ischemia, and has prognostic value 2, 3.
• Lower gastrointestinal endoscopy should be performed within 48 hours to reach the distal-most extent of the disease, providing endoscopic (and histological) confirmation 2.

Surgical Management

• Surgical treatment is required in approximately 20% of cases, and it consists of extended colectomy without continuity restoration and prophylactic cholecystectomy 3, 4.
• Surgery is indicated in cases of colonic necrosis with deep ischemia and/or multi-organ failure (MOF) 3.
• Continuity restoration is feasible in one-third of survivors, who are exposed to a high risk of severe cardiovascular events 3.

Diagnosis and Treatment

• The diagnosis of ischemic colitis is based on a combination of clinical suspicion, radiographic, endoscopic, and histological findings 5.
• Therapy and outcome depend on the severity of the disease, with most cases of the non-gangrenous form being transient and resolving spontaneously without complications 5.
• High morbidity and mortality and urgent operative intervention are the hallmarks of gangrenous ischemic colitis 5.