Ischemic colitis

Pearls

• Consider ischemic colitis as the possible cause of acute-onset abdominal pain with rectal bleeding in patients age 50 and older with cardiovascular morbidities.
• For patients with peritoneal signs, radiographs should be considered for evaluation of ileus (air fluid levels), thumbprinting, pneumatosis coli, or pneumoperitoneum.
• Consider ordering a CTA as first-line imaging, especially if there is any suggestion of mesenteric ischemia, right sided tenderness without hematochezia, or if you suspect severe disease. If resources do not allow, order a CT with oral and IV contrast. If IRCI is incidentally found on initial CT, then CTA can be deferred to the inpatient setting and obtained prior to discharge.
• Give antibiotics in suspected ischemic colitis if the patient has any of the factors associated with severe disease.
• Place an emergent surgical consultation for any patient with peritoneal signs on physical exam or pneumatosis coli, portal venous gas, pan-colonic distribution, or isolated right-colon ischemia on imaging.

Intestinal Ischemic Disorder Types

• Ischemic colitis
  • Accounts for 80-85% of intestinal ischemia
  • Due to non-occlusive disease with decreased blood flow to the colon.
  • Causes decreased perfusion leading to sub-mucosal or mucosal ischemia only.
  • Typical to the "watershed areas" of the colon (Splenic flexure or Sigmoid)

• Acute mesenteric ischemia
  • Due to complete occlusion of mesenteric vessels
  • Complete transmural ischemia

• Mesenteric venous thrombosis
• Chronic mesenteric ischemia ("intestinal angina")

Differential Diagnosis

Colitis

• Infectious colitis
• Ischemic colitis
• Ulcerative colitis
• CMV colitis
• Crohn's colitis
• Toxic colitis (antineoplastic agents)
• Pseudomembranous colitis
• Fibrosing colonopathy (Cystic fibrosis)

Diffuse Abdominal pain

• Abdominal aortic aneurysm
  • Aortocaval fistula
• Acute gastroenteritis
• Aortoenteric fisulta
• Appendicitis (early)
• Bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Small bowel obstruction
  • Malignant bowel obstruction
• Bowel perforation
• Diabetic ketoacidosis
• Gastroparesis
• Hernia
• Hypercalcemia
• Inflammatory bowel disease
• Mesenteric ischemia
  • Mesenteric vein thrombosis
• Pancreatitis
• Peritonitis
• Sickle cell crisis
• Spontaneous bacterial peritonitis
• Volvulus

External Links

• Shannon Thompson. Ischemic Colitis: ED Presentations, Evaluation, and Management emDOCs.net

See Also

• Colitis
• Mesenteric ischemia