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Colonic ischemia (CI)

Discuss colonic ischaemia?

  • CI comprises a spectrum;
    • Reversible colopathy-submucosal or intramural haemorrhage
    • Transient colitis
    • Chronic colitis
    • Stricture
    • Gangrene
    • Fulminant colitis.
  • Majority of the patients are > 60 years old. In most cases, no specific cause for ischemia is identified.
  • The left colon is most commonly affected. Rectum is spared as it has a dual blood supply from systemic and portal circulation.
  • The mildest form of injury is mucosal and submucosal haemorrhage and oedema. With more severe injury, chronic ulcerations, crypt abscesses and pseudo-polyps develop-changes mimicking IBD. Pseudo membranes may also be seen.

Discuss the clinical presentation?

Abdominal pain and bleeding PR. Bleeding is usually not sufficient to require transfusion.

Discuss the diagnosis?

  • Clinical presentation
  • AXR- Submucosal haemorrhages cause thumb printing on AXR. There may be free air under the diaphragm in case of perforation.
  • Endoscopy- segmental distribution of disease (haemorrhagic nodules-these are submucosal bleed with or without ulceration) is highly suggestive of CI.

Discuss the management of CI?

Generally (>50%), the symptoms resolve within 48 hrs and the colon heals in 1-2 weeks. It may lead to segmental colitis or stricture formation.

  • Urgent laparotomy and colonic resection is indicated in presence of peritonitis suggesting gangrene or perforation or if the patient fails to settle on conservative treatment
  • If there are no signs of peritonism- patients are treated conservatively with
    • NPO for 48-72hrs and IV fluids.
    • Broad spectrum antibiotics are given to cover the faecal flora.
    • Stop medications that cause mesenteric vasoconstriction- e.g. digitalis & vasopressors.
  • Segmental colitis- symptoms- recurrent fever and sepsis, continuing or recurrent bloody diarrhoea and persistent or chronic diarrhoea with protein loosing colopathy. They are at high risk of perforation and early resection is indicated. Patients with segmental colitis may be misdiagnosed with IBD however it responds poorly to steroids.

Discuss the follow up of CI?

A repeat colonoscopy or barium enema should be considered once symptoms settle to look for segment colitis or a stricture. If these are present and symptomatic, resection should be considered.


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