What are the symptoms and management of ischemic colitis?

Symptoms of Ischemic Colitis

The primary symptoms of ischemic colitis include abdominal pain (typically left-sided), bloody diarrhea, and tenderness, which require prompt evaluation to prevent progression to bowel necrosis and perforation. 1

Common Clinical Presentation

• Abdominal pain is a hallmark symptom, typically localized to the left side of the abdomen, and often described as cramping or discomfort 2, 1
• Bloody diarrhea is a characteristic feature, with blood ranging from streaks to frank bleeding 2, 3
• Rectal bleeding is common and may present with varying severity 2, 3
• Tenderness on abdominal examination, particularly over the affected colonic segment 1, 3
• Urgency to defecate is frequently reported by patients 4, 2
• Fever may indicate more severe inflammation or progression to necrosis 2, 1
• Nausea and vomiting can accompany more severe cases 3, 5

Severity Classification

• Mild ischemic colitis: Presents with minimal symptoms, including mild abdominal discomfort and small amounts of blood in stool 4, 5
• Moderate ischemic colitis: Features increased bowel movements (4-6 per day above baseline), moderate abdominal pain, and more significant bleeding 4, 2
• Severe ischemic colitis: Characterized by significant increase in bowel movements (>6 per day above baseline), severe abdominal pain, marked bleeding, and potentially hemodynamic instability 4, 6

Warning Signs of Severe Disease

• Abdominal pain out of proportion to physical examination findings should raise immediate concern for mesenteric ischemia 6, 7
• Peritoneal signs including rebound tenderness and guarding suggest bowel necrosis or perforation 6, 7
• Hemodynamic instability with tachycardia, hypotension, and shock indicates severe disease requiring urgent intervention 4, 5
• Lactic acidosis is associated with transmural ischemia and bowel necrosis 6, 1
• Marked leukocytosis suggests significant inflammation or infection 6, 7

Diagnostic Approach

• CT angiography (CTA) of the abdomen and pelvis is the first-line imaging test for suspected ischemic colitis, with high sensitivity for detecting vascular abnormalities and signs of bowel ischemia 6, 5
• Colonoscopy is the gold standard for diagnosis, allowing direct visualization of the colonic mucosa and tissue sampling 1, 3
• Laboratory studies including complete blood count, comprehensive metabolic panel, lactate, and inflammatory markers should be obtained, though none are specific for ischemic colitis 6, 3
• Stool evaluation to rule out infectious causes is essential in the diagnostic workup 2, 3

Management Considerations

• Supportive care with intravenous fluids, optimization of hemodynamic status, and bowel rest is the mainstay of treatment for mild to moderate cases 1, 5
• Avoidance of vasoconstrictive medications is crucial to prevent worsening ischemia 2, 5
• Empiric antibiotics are recommended for moderate to severe cases to prevent bacterial translocation 1, 7
• Surgical intervention is necessary for patients with peritonitis, perforation, or persistent symptoms despite conservative management 5, 7
• Close monitoring for clinical improvement, which typically occurs within 1-2 days with appropriate supportive care 1, 5

Prognosis

• Most cases of ischemic colitis are transient and resolve with conservative management 1, 3
• Late diagnosis or severe ischemia can be associated with high rates of complications and mortality 1, 7
• Complications may include bowel perforation, peritonitis, persistent bleeding, and stricture formation 3, 7