A review of ischemic colitis: is our clinical recognition and management adequate?

Abstract

Ischemic colitis is a common cause of hospital admissions; however it is frequently confused intellectually with mesenteric ischemia and often misdiagnosed as infectious diarrhea or Clostridium difficile colitis. Ischemic colitis is caused by non-occlusive insult to the small vessels supplying the colon without a clear precipitating factor. It is more common in females and in patients above 60 years of age. The classic presentation includes sudden onset of lower abdominal pain followed by the urge to defecate and bloody diarrhea. Focal right-sided ischemic colitis has more pain and a worse prognosis. Choosing the correct diagnostic studies is challenging and requires proficient knowledge of the disease. Management is usually conservative, however around 10–20% of the patients will require surgery. Acute ischemic colitis usually resolves; nevertheless some patients may develop chronic segmental colitis or a stricture. One ischemic colitis caveat is that it may be the first sign of undiagnosed cardiac disease. A firm grasp on this common yet little discussed condition is valuable to a gastrointestinal consultant and hospitalist alike.

Keywords::

• colitis
• diarrhea
• ischemia
• rectal bleeding
• vascular disease

Acknowledgements

The authors thank Amy Pallotti (UConn Health Center) for her assistance with formatting and submitting the article.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Ischemic colitis is the most common form of intestinal ischemia. It is commonly under-diagnosed. It can be confused with the more serious condition mesenteric ischemia and clinically is often mistaken for infectious diarrhea. Risk factors include female sex, age >60 years, diabetes, chronic obstructive pulmonary disease and irritable bowel syndrome.

• • Ischemic colitis usually is a mild disease and resolves in 80% of cases. Nevertheless, some patients have a severe transmural form requiring surgery. Isolated right-sided disease is also more severe. About 5–20% of patients develop chronic disease with complications of chronic segmental colitis or a stricture.

• • Management therapy consists of intravenous fluids, bowel rest, bowel decompression (nasogastric tube and/or rectal tube based on the clinical situation), stabilization and optimization of the underlying cardiopulmonary status and avoiding harmful medication. Steroids should not be given and antibiotics should only be given in severe cases.