What is the management of ischemic colitis?

From the Guidelines

Management of ischemic colitis typically involves supportive care and addressing the underlying cause, with most cases being mild and resolving with conservative treatment, but severe cases may require prompt surgical intervention, such as laparoscopy or laparotomy, to prevent significant morbidity and mortality, as recommended by the most recent guidelines 1.

Key Components of Management

• Supportive care, including bowel rest, intravenous fluids, and pain management with acetaminophen or opioids
• Antibiotics to prevent bacterial translocation, such as ciprofloxacin and metronidazole, or broad-spectrum antibiotics like piperacillin-tazobactam
• Avoidance of medications that can worsen intestinal blood flow, such as vasopressors, diuretics, and NSAIDs
• Gradual reintroduction of oral intake as symptoms improve, starting with clear liquids and advancing to a low-fiber diet

Surgical Intervention

• Prompt laparoscopy or laparotomy is recommended for patients with overt peritonitis or severe cases with peritoneal signs, significant bleeding, or perforation, as it allows for direct assessment of bowel viability and resection of non-viable intestine 1
• The goal of surgical intervention is to re-establish blood supply to the ischemic bowel, resect non-viable regions, and preserve viable bowel

Importance of Early Diagnosis and Treatment

• Early diagnosis and timely treatment are crucial to reduce the high mortality associated with ischemic colitis, with mortality rates ranging from 50% to 70% if left untreated or diagnosed late 1
• The use of CT angiography and other imaging techniques can help establish an early diagnosis and guide treatment decisions

Recent Guidelines and Recommendations

• The most recent guidelines from the World Society of Emergency Surgery recommend prompt surgical intervention for severe cases of ischemic colitis, as well as the use of endovascular approaches and modern imaging techniques to improve outcomes 1

From the Research

Diagnosis of Ischemic Colitis

• Ischemic colitis is diagnosed based on a combination of clinical suspicion, radiographic, endoscopic, and histological findings 2
• Colonoscopy is the procedure of choice for diagnosis, and computed tomography may have suggestive findings 3
• Emergent CT-scan and rectosigmoidoscopy are required for diagnosis confirmation, surgical decision, and prognosis analysis 4

Management of Ischemic Colitis

• Supportive care with intravenous fluids, optimization of hemodynamic status, avoidance of vasoconstrictive drugs, bowel rest, and empiric antibiotics will produce clinical improvement within 1 to 2 days in most patients 3
• Surgical treatment is required in 20% of cases, and consists of extended colectomy without continuity restoration and prophylactic cholecystectomy 4
• Surgery is critical in patients with gangrenous colitis, and prompt recognition and surgical intervention is necessary to minimize adverse outcomes 5, 6

Types and Severity of Ischemic Colitis

• Ischemic colitis can be classified into two types: severe IC, with transmural colonic ischemia and/or multi-organ failure, and mild IC, without multi-organ failure and spontaneous favourable evolution in most cases 4
• The disease can present either as an occlusive or a non-occlusive form, and the etiology is multifactorial 2
• Gangrenous ischemic colitis is associated with high morbidity and mortality, and urgent operative intervention is necessary 2

Outcome and Complications

• Most cases of non-gangrenous ischemic colitis are transient and resolve spontaneously without complications 2
• Complications of ischemic colitis can include bowel perforation, peritonitis, persistent bleeding, protein-losing colopathy, and symptomatic intestinal strictures 6
• Continuity restoration is feasible in one third of survivors, who are exposed to a high risk of severe cardiovascular events 4