Ischemic colitis: Difference between revisions

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In [[medicine]], '''ischemic''' colitis is "inflammation of the [[colon]] due to colonic [[ischemia]] resulting from alterations in systemic circulation or local vasculature."<ref>{{MeSH}}</ref>
In [[medicine]], '''ischemic''' colitis is "inflammation of the [[colon]] due to colonic [[ischemia]] resulting from alterations in systemic circulation or local vasculature."<ref>{{MeSH}}</ref>
[[Mesenteric ischemia]] is ischemnia of the small intestine.


==Diagnosis==
==Diagnosis==


===Signs and symptoms===
===Signs and symptoms===
Three progressive phases of ischemic colitis have been described:<ref>Boley, SJ, Brandt, LJ, Veith, FJ. Ischemic disorders of the intestines. Curr Probl Surg 1978; 15:1.</ref><ref>{{cite journal | author = Hunter G, Guernsey J | title = Mesenteric ischemia. | journal = Med Clin North Am | volume = 72 | issue = 5 | pages = 1091–115 | year = 1988 | pmid = 3045452}}</ref>
*A ''hyperactive'' phase occurs first, in which the primary symptoms are severe abdominal pain and the passage of bloody stools. Many patients get better and do not progress beyond this phase.
*A ''paralytic'' phase can follow if ischemia continues; in this phase, the abdominal pain becomes more widespread, the belly becomes more tender to the touch, and bowel [[motility]] decreases, resulting in abdominal bloating, no further bloody stools, and absent bowel sounds on exam.
*Finally, a ''shock'' phase can develop as fluids start to leak through the damaged colon lining. This can result in [[Shock (circulatory)|shock]] and [[metabolic acidosis]] with [[dehydration]], [[hypotension|low blood pressure]], [[tachycardia|rapid heart rate]], and confusion. Patients who progress to this phase are often critically ill and require [[intensive care]].
Symptoms of ischemic colitis vary depending on the severity of the ischemia. The most common early signs of ischemic colitis include [[abdominal pain]] (often left-sided), with mild to moderate amounts of [[lower gastrointestinal bleeding|rectal bleeding]].<ref name="Greenwald">{{cite journal | author = Greenwald D, Brandt L, Reinus J | title = Ischemic bowel disease in the elderly. | journal = Gastroenterol Clin North Am | volume = 30 | issue = 2 | pages = 445–73 | year = 2001 | pmid = 11432300 | doi = 10.1016/S0889-8553(05)70190-4}}</ref> The sensitivity of findings among 73 patients were:<ref name="pmid17071206">{{cite journal |author=Huguier M, Barrier A, Boelle PY, Houry S, Lacaine F |title=Ischemic colitis |journal=Am. J. Surg. |volume=192 |issue=5 |pages=679–84 |year=2006 |pmid=17071206 | doi=10.1016/j.amjsurg.2005.09.018}}</ref>
Symptoms of ischemic colitis vary depending on the severity of the ischemia. The most common early signs of ischemic colitis include [[abdominal pain]] (often left-sided), with mild to moderate amounts of [[lower gastrointestinal bleeding|rectal bleeding]].<ref name="Greenwald">{{cite journal | author = Greenwald D, Brandt L, Reinus J | title = Ischemic bowel disease in the elderly. | journal = Gastroenterol Clin North Am | volume = 30 | issue = 2 | pages = 445–73 | year = 2001 | pmid = 11432300 | doi = 10.1016/S0889-8553(05)70190-4}}</ref> The sensitivity of findings among 73 patients were:<ref name="pmid17071206">{{cite journal |author=Huguier M, Barrier A, Boelle PY, Houry S, Lacaine F |title=Ischemic colitis |journal=Am. J. Surg. |volume=192 |issue=5 |pages=679–84 |year=2006 |pmid=17071206 | doi=10.1016/j.amjsurg.2005.09.018}}</ref>
* abdominal pain (78%)
* abdominal pain (78%)
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* The white blood cell count was more than 15,000/mm3 in 20 patients (27%)
* The white blood cell count was more than 15,000/mm3 in 20 patients (27%)
* The serum bicarbonate level was less than 24&nbsp;mmol/L in 26 patients (36%)
* The serum bicarbonate level was less than 24&nbsp;mmol/L in 26 patients (36%)
A [[systematic review]] concluded that [[D-dimer]] is not helpful, but newer serologic tests such as [[D-lactate]], [[glutathione S-transferase]] (GST), [[intestinal fatty-acid binding protein]] (i-FABP) may be helpful.<ref name="pmid19424744">{{cite journal |author=Evennett NJ, Petrov MS, Mittal A, Windsor JA |title=Systematic review and pooled estimates for the diagnostic accuracy of serological markers for intestinal ischemia |journal=World J Surg |volume=33 |issue=7 |pages=1374–83 |year=2009 |month=July |pmid=19424744 |doi=10.1007/s00268-009-0074-7 |url=http://dx.doi.org/10.1007/s00268-009-0074-7 |issn=}}</ref>


Plain [[X-ray]]s are often normal or show non-specific findings.<ref>{{cite journal | author = Smerud M, Johnson C, Stephens D | title = Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases. | journal = AJR Am J Roentgenol | volume = 154 | issue = 1 | pages = 99–103 | year = 1990 | pmid = 2104734}}</ref> In a series of 73 patients, plain abdominal radiography (56%) showing colic distension in 53% or a pneumoperitoneum in 3%.<ref name="pmid17071206"/>
Plain [[X-ray]]s are often normal or show non-specific findings.<ref>{{cite journal | author = Smerud M, Johnson C, Stephens D | title = Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases. | journal = AJR Am J Roentgenol | volume = 154 | issue = 1 | pages = 99–103 | year = 1990 | pmid = 2104734}}</ref> In a series of 73 patients, plain abdominal radiography (56%) showing colic distension in 53% or a pneumoperitoneum in 3%.<ref name="pmid17071206"/>


[[CT scan]]s are often used in the evaluation of abdominal pain and rectal bleeding, and may suggest the diagnosis of ischemic colitis, pick up complications, or suggest an alternate diagnosis.<ref>{{cite journal | author = Alpern M, Glazer G, Francis I | title = Ischemic or infarcted bowel: CT findings. | journal = Radiology | volume = 166 | issue = 1 Pt 1 | pages = 149–52 | year = 1988 | pmid = 3336673}}</ref>
[[CT scan]]s are often used in the evaluation of abdominal pain and rectal bleeding, and may suggest the diagnosis of ischemic colitis, pick up complications, or suggest an alternate diagnosis.<ref>{{cite journal | author = Alpern M, Glazer G, Francis I | title = Ischemic or infarcted bowel: CT findings. | journal = Radiology | volume = 166 | issue = 1 Pt 1 | pages = 149–52 | year = 1988 | pmid = 3336673}}</ref><ref>{{cite journal | author = Balthazar E, Yen B, Gordon R | title = Ischemic colitis: CT evaluation of 54 cases. | journal = Radiology | volume = 211 | issue = 2 | pages = 381–8 | year = 1999 | pmid = 10228517}}</ref>


There are devices which test the sufficiency of oxygen delivery to the colon. The first device approved by the U.S. FDA in 2004 uses visible light spectroscopy to analyze capillary oxygen levels. Use during Aortic Aneurysm repair detected when colon oxygen levels fell below sustainable levels, allowing real-time repair. In several studies, Specificity has been 90% or higher for acute colonic ischemia, and 83% for chronic mesenteric ischemia, with a sensitivity of 71%-92%. This device must be placed using endoscopy, however.<ref>{{cite journal | author = Lee ES, Bass A, Arko FR, et. al. | title = Intraoperative colon mucosal oxygen saturation during aortic surgery. | volume = 136 | issue = 1 | pages = 19–24 | year = 2006| pmid = 16978651}}</ref>,<ref>{{cite journal | author = Friedland S, Benaron D, Coogan S, et. al. | title = Diagnosis of chronic mesenteric ischemia by visible light spectroscopy during endoscopy. | journal = Gastrointest Endosc | volume = 65| issue = 2 | pages = 294–300 | year = 2007| pmid = 17137857 | doi = 10.1016/j.gie.2006.05.007 }}</ref>,<ref>{{cite journal | author = Lee ES, Pevec WC, Link DP, et. al. | title = Use of T-Stat to predict colonic ischemia during and after endovascular aneurysm repair. | journal = J Vasc Surg | volume = 47| issue = 3 | pages = 632–634 | year = 2008| pmid = 18295116 | doi = 10.1016/j.jvs.2007.09.037}}</ref>
There are devices which test the sufficiency of oxygen delivery to the colon. The first device approved by the U.S. FDA in 2004 uses visible light spectroscopy to analyze capillary oxygen levels. Use during Aortic Aneurysm repair detected when colon oxygen levels fell below sustainable levels, allowing real-time repair. In several studies, Specificity has been 90% or higher for acute colonic ischemia, and 83% for chronic mesenteric ischemia, with a sensitivity of 71%-92%. This device must be placed using endoscopy, however.<ref>{{cite journal | author = Lee ES, Bass A, Arko FR, et. al. | title = Intraoperative colon mucosal oxygen saturation during aortic surgery. | volume = 136 | issue = 1 | pages = 19–24 | year = 2006| pmid = 16978651}}</ref>,<ref>{{cite journal | author = Friedland S, Benaron D, Coogan S, et. al. | title = Diagnosis of chronic mesenteric ischemia by visible light spectroscopy during endoscopy. | journal = Gastrointest Endosc | volume = 65| issue = 2 | pages = 294–300 | year = 2007| pmid = 17137857 | doi = 10.1016/j.gie.2006.05.007 }}</ref>,<ref>{{cite journal | author = Lee ES, Pevec WC, Link DP, et. al. | title = Use of T-Stat to predict colonic ischemia during and after endovascular aneurysm repair. | journal = J Vasc Surg | volume = 47| issue = 3 | pages = 632–634 | year = 2008| pmid = 18295116 | doi = 10.1016/j.jvs.2007.09.037}}</ref>
==Treatment==
[[Clinical practice guideline]]s address the management.<ref name="pmid10784595">{{cite journal |author= |title=American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia |journal=Gastroenterology |volume=118 |issue=5 |pages=951–3 |year=2000 |month=May |pmid=10784595 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S001650850031681X |issn=}}</ref>
20% of patients will need surgery.<ref name="pmid20531399">{{cite journal| author=Brandt LJ, Feuerstadt P, Blaszka MC| title=Anatomic patterns, patient characteristics, and clinical outcomes in ischemic colitis: a study of 313 cases supported by histology. | journal=Am J Gastroenterol | year= 2010 | volume= 105 | issue= 10 | pages= 2245-52; quiz 2253 | pmid=20531399 | doi=10.1038/ajg.2010.217 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20531399  }} </ref>


==References==
==References==
<references/>
<references/>

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In medicine, ischemic colitis is "inflammation of the colon due to colonic ischemia resulting from alterations in systemic circulation or local vasculature."[1]

Mesenteric ischemia is ischemnia of the small intestine.

Diagnosis

Signs and symptoms

Symptoms of ischemic colitis vary depending on the severity of the ischemia. The most common early signs of ischemic colitis include abdominal pain (often left-sided), with mild to moderate amounts of rectal bleeding.[2] The sensitivity of findings among 73 patients were:[3]

  • abdominal pain (78%)
  • lower digestive bleeding (62%)
  • diarrhea (38%)
  • Fever higher than 38°C (34%) (38°C equals approximately 100.4°F)

Physical examination[3]

  • abdominal pain (77%)
  • abdominal tenderness (21%)

Diagnostic tests

Regarding blood tests, the sensitivity of tests among 73 patients were:[3]

  • The white blood cell count was more than 15,000/mm3 in 20 patients (27%)
  • The serum bicarbonate level was less than 24 mmol/L in 26 patients (36%)

A systematic review concluded that D-dimer is not helpful, but newer serologic tests such as D-lactate, glutathione S-transferase (GST), intestinal fatty-acid binding protein (i-FABP) may be helpful.[4]

Plain X-rays are often normal or show non-specific findings.[5] In a series of 73 patients, plain abdominal radiography (56%) showing colic distension in 53% or a pneumoperitoneum in 3%.[3]

CT scans are often used in the evaluation of abdominal pain and rectal bleeding, and may suggest the diagnosis of ischemic colitis, pick up complications, or suggest an alternate diagnosis.[6][7]

There are devices which test the sufficiency of oxygen delivery to the colon. The first device approved by the U.S. FDA in 2004 uses visible light spectroscopy to analyze capillary oxygen levels. Use during Aortic Aneurysm repair detected when colon oxygen levels fell below sustainable levels, allowing real-time repair. In several studies, Specificity has been 90% or higher for acute colonic ischemia, and 83% for chronic mesenteric ischemia, with a sensitivity of 71%-92%. This device must be placed using endoscopy, however.[8],[9],[10]

Treatment

Clinical practice guidelines address the management.[11]

20% of patients will need surgery.[12]

References

  1. ↑ Anonymous (2024), Ischemic colitis (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Greenwald D, Brandt L, Reinus J (2001). "Ischemic bowel disease in the elderly.". Gastroenterol Clin North Am 30 (2): 445–73. DOI:10.1016/S0889-8553(05)70190-4. PMID 11432300. Research Blogging.
  3. ↑ 3.0 3.1 3.2 3.3 Huguier M, Barrier A, Boelle PY, Houry S, Lacaine F (2006). "Ischemic colitis". Am. J. Surg. 192 (5): 679–84. DOI:10.1016/j.amjsurg.2005.09.018. PMID 17071206. Research Blogging.
  4. ↑ Evennett NJ, Petrov MS, Mittal A, Windsor JA (July 2009). "Systematic review and pooled estimates for the diagnostic accuracy of serological markers for intestinal ischemia". World J Surg 33 (7): 1374–83. DOI:10.1007/s00268-009-0074-7. PMID 19424744. Research Blogging.
  5. ↑ Smerud M, Johnson C, Stephens D (1990). "Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases.". AJR Am J Roentgenol 154 (1): 99–103. PMID 2104734.
  6. ↑ Alpern M, Glazer G, Francis I (1988). "Ischemic or infarcted bowel: CT findings.". Radiology 166 (1 Pt 1): 149–52. PMID 3336673.
  7. ↑ Balthazar E, Yen B, Gordon R (1999). "Ischemic colitis: CT evaluation of 54 cases.". Radiology 211 (2): 381–8. PMID 10228517.
  8. ↑ Lee ES, Bass A, Arko FR, et. al. (2006). "Intraoperative colon mucosal oxygen saturation during aortic surgery." 136 (1): 19–24. PMID 16978651.
  9. ↑ Friedland S, Benaron D, Coogan S, et. al. (2007). "Diagnosis of chronic mesenteric ischemia by visible light spectroscopy during endoscopy.". Gastrointest Endosc 65 (2): 294–300. DOI:10.1016/j.gie.2006.05.007. PMID 17137857. Research Blogging.
  10. ↑ Lee ES, Pevec WC, Link DP, et. al. (2008). "Use of T-Stat to predict colonic ischemia during and after endovascular aneurysm repair.". J Vasc Surg 47 (3): 632–634. DOI:10.1016/j.jvs.2007.09.037. PMID 18295116. Research Blogging.
  11. ↑ (May 2000) "American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia". Gastroenterology 118 (5): 951–3. PMID 10784595. [e]
  12. ↑ Brandt LJ, Feuerstadt P, Blaszka MC (2010). "Anatomic patterns, patient characteristics, and clinical outcomes in ischemic colitis: a study of 313 cases supported by histology.". Am J Gastroenterol 105 (10): 2245-52; quiz 2253. DOI:10.1038/ajg.2010.217. PMID 20531399. Research Blogging.
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