Ischaemic colitis: uncertainty in diagnosis, pathophysiology and management.

Ischaemic colitis is the most common form of gastrointestinal ischaemia, but may be confused with acute mesenteric ischaemia, inflammatory bowel disease or infectious colitis. This review article outlines the current classification, epidemiology and risk factors, as well as approaches about diagnosis and management to guide clinical practice. It also identifies areas for further research.

CT findings in acute, subacute, and chronic ischemic colitis: suggestions for diagnosis.

PURPOSE: This paper aims at evaluating CT findings of occlusive and nonocclusive ischemic colitis (IC), in correlation with the etiology and the different phases of the disease. MATERIALS AND METHODS: CT examination and clinical history of 32 patients with proven IC were retrospectively reviewed. The CT findings were analyzed according to the different phases of the disease (acute, subacute, and chronic). RESULTS: Among the 32 CT examinations performed in the acute phase, 62.5% did not present signs of occlusion of the superior mesenteric artery (SMA) or inferior mesenteric artery (IMA), whereas IMA occlusion was detected in 37.5% of CT examinations. In the acute phase, the presence of pericolic fluid was found in 100% of patients undergoing progressive resorption from acute to subacute phase if an effective reperfusion occurred; the bowel wall thickening was observed in 28.1% patients in acute phase and in 86.4% patients evaluated in subacute phase. The unthickened colonic wall was found in all conditions where ischemia was not followed by effective reperfusion (71.9% of cases), and it was never found in chronic phase, when the colon appeared irregularly thickened. CONCLUSION: CT allows determining the morphofunctional alterations associated with the IC discriminating the occlusive forms from the nonocclusive forms. CT, furthermore, allows estimating the timing of ischemic damage.

Relationship between endoscopic findings and clinical severity in ischemic colitis.

BACKGROUND AND AIM: The incidence of ischemic colitis (IC) in Japan has been increasing due to the westernization of diet and the aging population. The aim of this study was to evaluate the relationship between endoscopic findings and clinical severity in IC. METHODS: This retrospective analysis included 106 cases diagnosed with IC that were divided into two groups based on endoscopic findings in the acute stage: redness and erosion (RE) versus longitudinal and circumferential ulcers (LCU). The clinical variables were compared between the two groups. In addition, we investigated the risk factors of IC associated with the severity of the endoscopic findings by multivariate logistic regression analysis. RESULTS: The percentage of cases presenting abdominal pain was significantly higher in the LCU group than that in the RE group (p=0.002), as were the baseline serum CRP levels (p=0.0001). The periods of hospitalization in LCU group were longer than in the RE group (p=0.0001). Multivariate logistic regression analysis indicated that ischemic heart disease (IHD) and connective tissue disease were the independent explanatory factor associated with the endoscopic severity of IC (p<0.05). CONCLUSION: We showed clearly that the two endoscopic classifications were accurate indicators of severity and could be used to anticipate severity of IC. Furthermore, we confirmed that IHD and connective tissue disease were the exacerbating factor associated with the severity of endoscopic findings in IC.

The spectrum of ischaemic colitis.

OBJECTIVE: Ischaemic colitis is generally considered a disease of the elderly with considerable cardiovascular morbidity. We aimed to determine the effect of age, co-morbidity and clinical presentation on type, severity and anatomy of involvement of ischaemic colitis. Thrombophilic tendencies have been poorly studied and coagulation status was performed in available patients. DESIGN: Retrospective case identification with prospective follow-up. SETTING: University teaching hospital. PARTICIPANTS: Twenty-four patients (16 female, mean age 64 years) with ischaemic colitis. INTERVENTIONS: Blood analysis for clotting tendencies. MAIN OUTCOME MEASURES: Operation rates, death rates and frequency of clotting abnormalities. RESULTS: Five patients (21%) were below the age of 45, and seven of the 24 had died by the time of follow-up. Four had died of ischaemic colitis during the acute episode. The four patients that died of ischaemic colitis had a more extensive and more severe type of disease and presented with worse clinical features. The main predisposing factors were ischaemic heart disease in 12 (50%) and malignancy in five (21%). Six of the 24 cases (25%) had right-sided lesions and this conferred a good prognosis. Shock, peritonism, extensive disease and uncontrolled atrial fibrillation were all poor prognostic factors. Clotting factor abnormalities could be detected in three of nine patients despite a time lapse between assay and episode of ischaemic colitis. CONCLUSIONS: Ischaemic colitis appears to have two patterns of severity. Anatomical distribution is more variable than a developmental explanation of the vascular supply. Clotting abnormalities may be detected in a minority even on retrospective testing.

Ischemic colitis.

Ischemic colitis represents the most common form of gastrointestinal ischemia. The presumed etiologies are numerous; however, it typically develops "spontaneously," in the absence of major vasculature occlusion, and in the presence of viable intestine elsewhere. It is most usefully classified into gangrenous and nongangrenous forms, the latter of which may be subdivided into transient and chronic types. Ischemic colitis may develop in people who are otherwise healthy, although a variety of clinical settings, such as shock, predispose to its occurrence. It usually presents as an acute abdominal illness with bloody diarrhea. Diagnosis is confirmed by colonoscopy. Therapy and outcome are dependent on the severity of disease. Nongangrenous colonic ischemia usually requires only medical management and is associated with a good prognosis. The chronic subtype may lead to the sequelae of persistent segmental colitis or colonic strictures, occasionally requiring surgery. Urgent operative intervention and a high morbidity and mortality are the hallmarks of gangrenous colonic ischemia. Special considerations must be given to those patients in whom ischemic colitis develops in the context of colon carcinoma or obstructing colon lesions, after abdominal aortic surgery, and following cardiopulmonary bypass. This review will discuss the clinical spectrum of ischemic colitis.

[Localized cecal ischemia of primary appearance. A re-appraisal]. / Ischémies caecales localisées d'apparence primitive. Réappréciation.

Localized ischemic lesions of the caecum should be classified among ischemic colitis. However, a separate study is justified to their original clinical presentation due to the fact that these lesions are, on one hand small, and on the other hand, sit in the right lower quadrant of the abdomen. For each of an appendicitis, operation will be performed quicker than in ischemic colitis in their usual presentation. The treatment is variable, including abstention, localized excision-suture, right hemicolectomy. Results are usually good. Coelioscopy in the future may have a place as in one of our three observations and must be evaluated.

[Should subdivision of regressive ischemic colitis be envisaged?]. / Faut-il envisager un démembrement des colites ischémiques régressives?

The term "regressive ischemic colitis" is generally accepted and refers to acute hemorrhagic colitis which may occur at any age and recovers spontaneously in most cases, sometimes leaving colonic stenosis due to scarring. Critical analysis of the literature reveals that there is no formal diagnostic criterion for this condition and no real proof that the mechanism is ischemic, particularly in young subjects who have no vascular disorder or hemodynamic triggering factor. The number of clinical, radiological, endoscopic and even histological similarities between regressive ischemic colitis and some forms of infectious colitis, particularly due to enterohemorrhagic E. coli O157:H7 and hemorrhagic colitis due to penicillin derivatives and non-steroid anti-inflammatory drugs is also striking. These observations logically lead us to wonder whether the term "regressive ischemic colitis" does really correspond to a well-defined entity rather than to a group of acute colitis of miscellaneous etiology but with many common features.