What is the treatment for ischemic colitis?

Treatment of Ischemic Colitis

Most cases of non-gangrenous ischemic colitis resolve with supportive medical management including bowel rest, aggressive IV fluid resuscitation, and broad-spectrum antibiotics, while gangrenous disease requires immediate surgical intervention. 1

Initial Risk Stratification and Assessment

The first critical step is distinguishing non-gangrenous from gangrenous disease, as this determines the entire treatment pathway:

Warning signs requiring immediate surgical consultation: 1, 2

• Frank peritonitis with rebound tenderness, guarding, or rigidity
• Hemodynamic instability with tachycardia, hypotension, or shock
• CT findings of pneumatosis intestinalis, portal venous gas, or free intraperitoneal air
• Persistent lactic acidosis suggesting transmural ischemia
• Abdominal pain out of proportion to physical examination findings

Medical Management for Non-Gangrenous Disease

The cornerstone of treatment is supportive care with close monitoring: 1

Immediate Interventions

• Absolute bowel rest (NPO status) with nasogastric decompression if needed 2
• Aggressive IV fluid resuscitation to correct hypovolemia and optimize intestinal perfusion 1, 2
• Broad-spectrum antibiotics initiated immediately due to high risk of bacterial translocation, continued for at least 4 days 1
• Correction of electrolyte abnormalities and anemia, as severe metabolic acidosis and hyperkalemia can result from intestinal infarction 3, 1

Pharmacologic Considerations

• Thromboprophylaxis with subcutaneous low-molecular-weight heparin is recommended 3, 1
• Systemic anticoagulation with unfractionated heparin may be considered unless contraindicated 1
• Discontinue all vasoconstrictive medications including NSAIDs, vasopressin, and norepinephrine when possible 3

Nutritional Support

• Enteral nutrition is strongly preferred over parenteral nutrition if the patient is malnourished (9% vs 35% complication rate) 3, 1

Intensive Monitoring Protocol

Close monitoring is essential with joint medical and surgical management: 3

• Serial abdominal examinations every 4-6 hours to detect clinical deterioration 2
• Vital signs monitoring four times daily or more frequently if deterioration noted 3
• Stool chart documenting frequency, character, and presence of blood 3
• Serial laboratory studies including lactate levels, complete blood count, and metabolic panel 3
• Serial imaging with plain abdominal radiographs if colonic dilatation (transverse colon >5.5 cm) is detected 3
• Low threshold for repeat CT if clinical deterioration is observed 3

Surgical Management for Gangrenous Disease

Immediate surgery is indicated for: 1

• Frank peritonitis or perforation
• Hemodynamic instability despite resuscitation
• Intestinal necrosis on imaging

Urgent surgery within 24-48 hours is indicated for: 1

• Absence of clinical improvement or deterioration despite optimal medical treatment
• Persistent lactic acidosis suggesting transmural ischemia

Surgical Technique

• Laparotomy with complete exploration and resection of frankly necrotic intestine 1
• Consider subtotal colectomy with ileostomy in severe cases 1
• Plan a "second look" procedure 24-48 hours after initial surgery to reassess intestinal viability and avoid excessive resection 3, 1

Special Considerations for Nonocclusive Mesenteric Ischemia (NOMI)

• Correct the precipitating cause by optimizing cardiac output and eliminating vasopressors when possible 2
• Consider catheter-directed papaverine infusion into the superior mesenteric artery 2
• Judicious selection of vasopressors with preference for noradrenaline and dobutamine over vasopressin to minimize negative impact on intestinal microcirculation 1

Prognostic Considerations

The mortality difference between non-gangrenous and gangrenous disease is stark: 2

• Non-gangrenous disease: <5% mortality with medical management
• Gangrenous disease: 50-85% mortality even with surgical intervention

Common pitfall: Isolated right colon ischemia is associated with more severe outcomes and higher mortality compared to left-sided disease, requiring lower threshold for surgical consultation and evaluation of mesenteric vasculature to exclude concurrent acute mesenteric ischemia. 4