Evaluation and Treatment of Ischemic Colitis
The management of ischemic colitis requires prompt diagnosis through colonoscopy with biopsy, CT imaging with IV contrast, and laboratory testing, followed by a severity-based treatment approach of either conservative management for non-gangrenous disease or surgical intervention for gangrenous disease. 1
Diagnostic Approach
Clinical Presentation
- Acute abdominal pain (often left-sided)
- Hematochezia or bloody diarrhea
- Symptoms often out of proportion to physical examination findings
Initial Laboratory Evaluation
- Complete blood count (may show leukocytosis)
- C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR)
- Stool studies (fecal calprotectin or lactoferrin)
- Basic metabolic panel
- Stool cultures to rule out infectious causes
Imaging
- CT scan with IV contrast is the preferred initial imaging modality 1, 2
- Look for: bowel wall thickening, "target sign," mesenteric vessel engorgement
- Triple-phase study (non-contrast, arterial and portal venous phases) is important for identifying underlying cause and complications 2
- Plain abdominal radiographs have limited sensitivity but may show "thumbprinting" (mucosal edema) 1
Endoscopy
- Colonoscopy is the gold standard diagnostic test with >90% diagnostic accuracy 1
- Should be performed within 48 hours of presentation in non-fulminant cases 3
- Characteristic findings include:
- Segmental involvement
- Petechial hemorrhages
- Longitudinal ulcerations
- Pale and edematous mucosa
- Sharply demarcated areas of involvement
Histology
- Biopsies should be obtained during colonoscopy
- Findings may include:
- Mucosal and submucosal hemorrhage
- Inflammatory infiltrates
- Necrosis
- Ghost cells
Treatment Algorithm
Severity Assessment
- Non-gangrenous (mild to moderate): No signs of transmural ischemia or multi-organ failure
- Gangrenous (severe): Evidence of transmural ischemia, peritoneal signs, or multi-organ failure 4
Management of Non-gangrenous Ischemic Colitis
- Conservative/supportive treatment is the mainstay of therapy 3, 5
- Bowel rest (NPO status)
- Intravenous fluid resuscitation to maintain adequate hydration
- Broad-spectrum antibiotics (covering gram-negative and anaerobic bacteria)
- Correction of precipitating factors (e.g., hypotension, cardiac arrhythmias)
- Close monitoring of vital signs and abdominal examination
- Serial laboratory tests to track inflammatory markers
Management of Gangrenous Ischemic Colitis
- Immediate surgical consultation
- Surgical intervention with extended colectomy without primary anastomosis 4
- Continuity restoration may be considered in survivors after recovery (approximately one-third of cases) 4
Monitoring and Follow-up
- Daily physical examination to evaluate for peritoneal signs
- Serial laboratory tests (CBC, CRP, lactate)
- Repeat imaging if clinical deterioration occurs
- Follow-up colonoscopy in 3-6 months to assess for healing and rule out underlying pathology
Special Considerations
Risk Factors to Identify
- Advanced age
- Cardiovascular disease (atrial fibrillation, heart failure)
- Recent vascular procedures (especially aortic surgery)
- Hypercoagulable states
- Vasculitis
- Medications (vasoconstrictors, oral contraceptives, NSAIDs)
Prognostic Indicators for Poor Outcomes
- Right-sided colonic involvement
- Peritoneal signs
- Shock or hypotension
- Tachycardia
- Elevated lactate levels
- Male gender
- Requirement for surgical intervention
Common Pitfalls to Avoid
- Delaying diagnosis and appropriate imaging
- Failure to consider ischemic colitis in patients with acute abdominal pain and bloody diarrhea
- Overreliance on laboratory values alone
- Delaying surgical consultation in patients with peritoneal signs or clinical deterioration
- Misdiagnosing as inflammatory bowel disease or infectious colitis
Emerging Therapies
Research on potential drug therapies includes phosphodiesterase type 5 inhibitors, pentoxifylline, rebamipide, prostaglandin E1, and polydeoxyribonucleotide, though these remain investigational 6.
Most cases of non-gangrenous ischemic colitis are transient and resolve spontaneously without complications, while gangrenous ischemic colitis carries high morbidity and mortality requiring urgent surgical intervention 5, 7.