Ischemic Colitis

Background

Ischemic colitis is caused by hypoxemia to the terminal vascular distribution of the intestines.

OUTLINE

Epidemiology

Disease Associations

Pathogenesis

Laboratory/Radiologic/Other Diagnostic Testing

Gross Appearance and Clinical Variants

Histopathological Features and Variants

Differential Diagnosis

Prognosis and Treatment

Commonly Used Terms

Internet Links

EPIDEMIOLOGY CHARACTERIZATION

AGE RANGE-MEDIAN Usually over 5th decade

SEX (M:F)
Equal

DISEASE ASSOCIATIONS CHARACTERIZATION

AORTOILIAC SURGERY

Risk factors for intestinal ischaemia after aortoiliac surgery: a combined cohort and case-control study of 2824 operations.

Bjorck M, Troeng T, Bergqvist D.

Department of Surgery, Skelleftea District Hospital, Sweden.

Eur J Vasc Endovasc Surg 1997 Jun;13(6):531-9 Abstract quote
OBJECTIVE: To identify risk factors for intestinal ischaemia after aortoiliac surgery.

MATERIALS AND METHODS: Among 2824 patients operated on during 1987-93 and registered prospectively in the Swedish Vascular Registry, 62 cases of postoperative intestinal ischaemia were identified. They were compared with the remaining 2762 patients through the registry and with a random sample of 127 controls through patient records. Multivariate analysis was performed.

RESULTS: Patients in shock operated on for ruptured aneurysms were at greatest risk of developing postoperative intestinal ischaemia. Excluding patients in shock, operation for aneurysmal disease and for occlusive disease carried the same risk. Renal disease, emergency surgery, age, type of hospital, aortobifemoral graft, operating time, cross-clamping time and ligation of one or both internal iliac arteries were independent risk factors.

CONCLUSIONS: Patient-related haemodynamic risk factors together with surgical skill and decision making defines the risk for this serious complication.

COCAINE

Cocaine-associated ischemic colitis.

Linder JD, Monkemuller KE, Raijman I, Johnson L, Lazenby AJ, Wilcox CM.

Department of Medicine, University of Alabama at Birmingham, USA.

South Med J 2000 Sep;93(9):909-13 Abstract quote
Cocaine use can result in various gastrointestinal complications, including gastric ulcerations, retroperitoneal fibrosis, visceral infarction, intestinal ischemia, and gastrointestinal tract perforation.

We report cocaine-associated colonic ischemia in three patients and review the literature. Including ours, 28 cases have been reported, with a mean patient age of 32.6 years (range, 23 to 47 years); 53.5% were men and 46.5% were women. The interval between drug ingestion and onset of symptoms varied from 1 hour to 2 days.

Cocaine is a potentially life-threatening cause of ischemic colitis and should be included in the differential diagnosis of any young adult or middle-aged patient with abdominal pain and bloody diarrhea, especially in the absence of estrogen use or systemic disorders that can cause thromboembolic events, such as atrial fibrillation.

HEART DISEASE

Prevalence of electrocardiographic and echocardiographic abnormalities in ambulatory ischemic colitis.

Collet T, Even C, Bouin M, Lecluse E, Piquet MA, Crampon D, Grollier G, Dao T, Verwaerde JC.

Department of Hepatology and Gastroenterology, CHU, Caen, France.
Dig Dis Sci 2000 Jan;45(1):23-5 Abstract quote
The aim of this study was to evaluate the prevalence of cardiac arrhythmia and intracardiac embolic process in ambulatory ischemic colitis. From November 1994 to November 1997, 33 consecutive cases of ambulatory ischemic colitis were detected.

This study included 21 women and 12 men with a mean age of 71 years. All patients underwent a cardiovascular investigation including questioning, electrocardiogram, 24-hr ambulatory electrocardiography and transthoracic echocardiography. A prior history of ischemic colitis was found in four cases (12%).

Cardiac arrhythmia was detected in eight cases. Transthoracic echocardiography showed an intracardiac process, potentially responsible for a peripheral embolism, in four cases. In conclusion, the aggregate, in 33% of the patients, there was potential cardiac etiology. This suggests that when ambulatory ischemic colitis occurs, it is necessary to perform an exhaustive cardiovascular evaluation similar to those performed in other ischemic diseases.

IDIOPATHIC ENTEROCOLIC LYMPHOCYTIC PHLEBITIS

Idiopathic enterocolic lymphocytic phlebitis: a rare cause of ischemic colitis.

Tuppy H, Haidenthaler A, Schandalik R, Oberhuber G.

Department of Pathology, Krankenhaus Wels, University of Vienna, Austria.
Mod Pathol 2000 Aug;13(8):897-9 Abstract quote
We report on a 74-year-old female patient who was admitted to the hospital because of abdominal pain. She underwent a colonoscopy and a stenosing mass was found in the cecum.

Histologic findings in the biopsy specimens were consistent with ischemic colitis. Due to clinical symptoms and the endoscopic and radiologic findings that roused the suspicion that the patient was suffering from a malignant tumor, a right hemicolectomy was performed. Histology of the resection specimen disclosed an inflammation of the veins. It was characterized by a predominantly lymphocytic infiltration of the vessels affecting the veins of the colonic wall and the mesentery. Furthermore, secondary thrombosis with focal venous occlusion was observed. The colon showed extensive ischemic colitis with focal transmural coagulation necrosis.

The disease was considered to be idiopathic lymphocytic phlebitis, which is a rare disease of unknown origin. Our patient is well and alive after more than 1 year, supporting the notion that the disease shows a benign course after surgery.

ORAL CONTRACEPTIVES

Ischemic colitis during pregnancy and contraceptive medication.

Frossard JL, Spahr L, Queneau PE, Armenian B, Brundler MA, Hadengue A.

Division of Gastroenterology, Geneva University Hospital, Geneva, Switzerland
Digestion 2001;64(2):125-7 Abstract quote
Ischemic bowel disease is generally considered a disease of the elderly and usually consists of reversible colopathy. Nonocclusive causes of ischemic colitis include low-flow states due to cardiac dysfunction and hypovolemia and use of certain medications including progestational medication.

We report 2 cases of ischemic colitis in young women. The first one occurred in a young patient who developed three consecutive episodes of ischemic colitis during her pregnancy, whereas the second woman presented with ischemic colitis in relation with the estrogen use. Each episode had a favorable outcome. Having ruled out an infectious cause, or a low blood flow state and in the absence of known thrombogenic disease, we hypothesized the etiology of these ischemic episodes to a high level of circulating estrogens due to pregnancy in the first case and oral contraceptive medication in the second.

Physicians treating hemorrhagic colitis in young women should consider the use of contraceptive medication containing estrogens or pregnancy as possible causes.

RENAL FAILURE

Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis.

Flobert C, Cellier C, Berger A, Ngo A, Cuillerier E, Landi B, Marteau P, Cugnenc PH, Barbier JP.

Digestive Disease Department, Laennec and Georges Pompidou European Hospital, AP-HP, University Rene Descartes, Paris, France.
Am J Gastroenterol 2000 Jan;95(1):195-8 Abstract quote
OBJECTIVE: The aim of this study was to identify factors associated with severe outcome in patients with ischemic colitis.

METHODS: The files of 60 consecutive inpatients (34 women, 26 men, mean age 67 yr) with ischemic colitis were reviewed. The following data were analyzed: age, sex, smoking, medications, history of cardiovascular disease, metabolic disease, chronic renal failure and hemodialysis, the time elapsed between the first symptoms and the diagnosis, and the site and extension of their colonic involvement. Patients were divided into two groups according to outcome: those with severe disease, including those who died from ischemic colitis (n = 3) or who required surgical resection (n = 21); and those with mild forms of colitis who were treated successfully without surgery (n = 36). The two groups were compared by means of univariate and multivariate analysis to identify factors associated with unfavorable outcomes. Only patients who had a complete examination of the colon (n = 51) were entered into the statistical analysis.

RESULTS: By univariate analysis, chronic renal failure (p = 0.03), hemodialysis (p = 0.01), short delay between symptoms and diagnosis (p = 0.01), and right colonic involvement (p = 0.002) were significantly more common in the patients with severe colitis. By logistic regression, right colonic involvement was the only factor independently associated with severity (p = 0.01). Right-sided lesions were present in 82% of patients on dialysis but in only 26% of patients not on dialysis (p = 0.0005).

CONCLUSIONS: Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis.

PATHOGENESIS CHARACTERIZATION

EXPERIMENTAL

Is intestinal ischemia a risk of laparoscopy? An experimental study in rabbits.

Emir H, Akman M, Belce A, Gumustas K, Soylet Y.

Department of Pediatric Surgery and Biochemistry, Cerrahpasa Medical Faculty, University of Istanbul, Turkey.
Eur J Pediatr Surg 2001 Jun;11(3):158-62 Abstract quote
BACKGROUND AND PURPOSE: In the literature, there are few reports documenting intra-abdominal organ necrosis following laparoscopic procedures. This experimental study was planned to investigate whether intestinal ischemia develops during laparoscopic procedures and if laparoscopy could cause intestinal necrosis.

MATERIAL AND METHODS: Two experimental groups, each consisting of 10 adult New-Zealand rabbits, were used in this study. The first group comprised the study group which had pneumoperitoneum, the second group comprised the normal animals serving as the controls. A cervical tracheostomy was performed to achieve successful general anesthesia in both groups. In the study group, intraperitoneal CO2 insufflation was carried out and intraabdominal pressure (IAP) was adjusted so as not to exceed the arterial blood pressure. After 20 min high IAP period, the intraabdominal gas was aspirated. Five minutes later, samples of both small intestine and colon tissue were taken. In the control group, tissue samples were taken 25 min after anesthesia was achieved. Xanthine oxidase (XO) and malondialdehyde (MDA) levels were measured as indicators of intestinal ischemia and lipid peroxidation in the intestinal tissues. Statistical analysis was done to compare the XO and MDA levels of the small intestines and colons of both groups.

RESULTS: The mean colonic XO levels were 1.323+/-1.17 and 0.217+/-0.27 (U/mg protein) in study and control groups, respectively. This difference was statistically significant (t = 2.60, p<0.05). The other comparisons with regard to XO and MDA levels were statistically not significant.

CONCLUSION: Our results demonstrate that intraperitoneal CO2 insufflation in which intraabdominal pressure was adjusted to be lower than arterial blood pressure may affect oxygenization of the colon.

LABORATORY/
RADIOLOGIC/
OTHER TESTS
CHARACTERIZATION

RADIOLOGIC

Ischemic colitis: CT evaluation of 54 cases.

Balthazar EJ, Yen BC, Gordon RB.

Department of Radiology, New York University-Bellevue Medical Center, NY 10016, USA.
Radiology 1999 May;211(2):381-8 Abstract quote
PURPOSE: To review the computed tomographic (CT) scans and medical records of 54 patients with proved ischemic colitis, define the spectrum of CT findings, and assess the effect of CT imaging on treatment.

MATERIALS AND METHODS: The mean age of the patients was 72 years. CT scans were analyzed for the presence of colonic abnormalities and associated findings. Ischemia was clinically unsuspected in 16 patients (30%).

RESULTS: Segmental involvement was seen in 48 patients (89%), with a mean length of involvement of 19 cm (range, 5-38 cm). Wall thickness varied between 2 and 20 mm (mean, 8 mm). All parts of the colon were involved. The CT appearance of the colonic wall varied: (a) A wet appearance with heterogeneous areas of edema was seen in 33 patients (61%). (b) A dry appearance with mild homogeneous thickening was seen in 18 patients (33%). (c) Intramural air was present in three patients (6%). Ischemia resolved in 41 patients (76%), and complications occurred in 13 patients (24%).

CONCLUSION: CT can be used to confirm the clinical suspicion of ischemic colitis, to suggest ischemia when it is unsuspected, and to diagnose complications. Intrinsic colonic abnormalities cannot be used to diagnose or predict the development of infarction.

Nonocclusive ischemic colitis in a 12-year-old girl: value of unenhanced spiral computed tomography.

Wiesner W, Willi UV.

Institute of Diagnostic Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.
Int J Colorectal Dis 2001 Feb;16(1):55-7 Abstract quote
A 12-year-old girl was hit by a car and arrived in the emergency room in hemorrhagic shock. Contrast-enhanced computed tomography of the abdomen showed traumatic rupture of the liver and large amounts of intraperitoneal hemorrhage.

Unenhanced computed tomography showed a hyperdense thickening of the wall of the descending colon. This finding was consistent with a nonocclusive ischemic colitis, which was confirmed some days later by endoscopy, at a time when the patient had already developed Gram-negative bacteremia.

We discuss the pathogenesis of nonocclusive ischemic colitis, computed tomography findings, and the value of unenhanced computed tomography.

LABORATORY MARKERS

GROSS APPEARANCE/
CLINICAL VARIANTS CHARACTERIZATION

GENERAL

Reevaluation of clinical features of ischemic colitis. Analysis of 68 consecutive cases diagnosed by early colonoscopy.

Habu Y, Tahashi Y, Kiyota K, Matsumura K, Hirota M, Inokuchi H, Kawai K.

Dept. of Gastroenterology, Saiseikai Noe Hospital, Osaka, Japan.

Scand J Gastroenterol 1996 Sep;31(9):881-6 Abstract quote
BACKGROUND: Ischemic colitis (IC) is generally considered a disease of elderly patients who have associated diseases. The aim of the present study was to reevaluate the clinical features of IC.

METHODS: We retrospectively analyzed the clinical characteristics, background, and endoscopic and histologic changes in 68 consecutive patients (16 men and 52 women) with this disease diagnosed by early colonoscopy.

RESULTS: The patients' age ranged from 22 to 98 years (mean, 55 years). Twenty-three patients (34%, including 19 women) were less than 50 years of age. The classical predisposing factors were not discernible in patients younger than 50. Chronic constipation and prior history of abdominal surgery were common in both young and old patients. Early colonoscopy (especially by the 3rd day from onset) showed endoscopic and histologic findings consistent with the characteristics of IC.

CONCLUSIONS: IC is not limited only to the elderly, and it should be considered in the differential diagnosis of colitis with melena in younger patients, especially females, who do not have any predisposing factors. Chronic constipation and prior history of abdominal surgery were commonly associated in both young and old patients. Early colonoscopy, especially by the 3rd day from the clinical onset, is essential for the accurate diagnosis of IC.

VARIANTS

SEGMENTAL

Cecal necrosis: infrequent variant of ischemic colitis. Report of five cases.

Schuler JG, Hudlin MM.

Department of Surgery, Mount Auburn Hospital, and the Harvard Medical School, Cambridge, Massachusetts, USA.

Dis Colon Rectum 2000 May;43(5):708-12 Abstract quote
PURPOSE: Spontaneous nonocclusive ischemic colitis involving only the right colon is an infrequent occurrence. Because this problem is less recognized than its counterpart involving the left colon, the correct diagnosis may not be considered. The purpose of this article was to describe the presentation and management of this unusual clinical problem.

METHODS: Five cases of nonocclusive ischemic cecal necrosis are described. Four of the patients presented with right-sided abdominal pain, tenderness, and leukocytosis. The preoperative diagnosis was incorrect in all patients, although cecal necrosis was considered in one. Two patients were thought to have. appendicitis, two were thought to have carcinoma, and one was thought to have a perforated viscus. Each patient underwent a right hemicolectomy and four survived.

RESULTS: Each of the patients had ischemic cecal necrosis without evidence of emboli or vasculitis. Although cecal gangrene may occur after systemic hypotension, no such event preceded these patients' presentation. We believe that the patients we treated had a form of nonocclusive ischemic colitis, which occasionally affects only the right colon.

CONCLUSION: Ischemic necrosis of the cecum is an infrequent variant of ischemic colitis that should be considered in the differential diagnosis of the elderly patient presenting with right lower quadrant pain.

YOUNG PATIENTS

Ischemic colitis in young adults: a single-institution experience.

Preventza OA, Lazarides K, Sawyer MD.

Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minn., U.S.A.
J Gastrointest Surg 2001 Jul-Aug;5(4):388-92 Abstract quote
Ischemic colitis is not well characterized in the young adult population, despite its commonness in older patients.

The aim of this study was to investigate the demographics, etiology, clinical features, and prognosis of ischemic colitis in young adults. We conducted a retrospective study of 39 young adults (<50 years of age) diagnosed with ischemic colitis over a period of 9 years (1990 to 1998). The mean age at diagnosis was 38 +/- 2 years (range 18 to 49 years); the female:male ratio was 1.8. Fifty-two percent (13 of 25) of women were using oral contraceptives at the time of diagnosis. Other potential associations identified were vascular thromboembolism (4 of 39), vasoactive drugs (4 of 39), hypovolemia (4 of 39), and vasculitis (2 of 39); 19 patients (49%) had no identifiable predisposing factors. Dominant presenting symptoms were abdominal pain (77%), bloody diarrhea (54%), and hematochezia (51%). Most patients were diagnosed at colonoscopy, and most disease was left sided. Twenty-nine patients were successfully managed with intravenous fluids, broad-spectrum antibiotics, and bowel rest; 10 patients required surgery. There was one disease-related death in the operative group.

We found a strong female predominance and an association with oral contraceptive use, but almost half of the patients did not have an identifiable etiology. Mortality from ischemic colitis in this patient population is low.

HISTOLOGICAL TYPES CHARACTERIZATION

GENERAL
Mild lesions show dilated capillaries, hemorrhage, superficial epithelial necrosis and variable neutrophils

Healing phase evidence of epithelial regeneration and variable fibroplasia are seen

Severe ischemic insults can result in full thickness mucosal necrosis making the lesion difficult to distinguish from other necrotizing colitides

VARIANTS

BIZARRE STROMAL CELLS

Bizarre stromal cells in ischemic bowel disease.

Serra S, Chetty R.

Department of Pathology, University Health Network/Toronto Medical Laboratories, Toronto, ON, Canada M5G 2M9.

Ann Diagn Pathol. 2005 Aug;9(4):193-6. Abstract quote

The presence of bizarre stromal cells has been reported in gastrointestinal and extraintestinal lesions.

We describe, for the first time, the presence of bizarre stromal cells with a cytomegalovirus (CMV)-like appearance or ganglion-like cells in 3 cases of ischemic colitis. The 3 patients were males ranging in age from 62 to 78 years, showed varying degrees of cardiovascular insufficiency, and were diagnosed with ischemic colitis. Colonic biopsies showed changes of ischemic colitis of variable severity. Common to all 3 cases, within the granulation tissue, stromal cells showed a broad spectrum of morphologic alterations, ranging from just nuclear enlargement to striking atypical features, large pleomorphic, hyperchromic nuclei, and eccentric prominent nucleoli. Occasionally, these cells displayed an eosinophilic oval nuclear inclusion, surrounded by a clear halo, resembling CMV inclusions.

In conclusion, the etiopathogenesis of these cells can be partially explained by hypoxia, inflammation, regeneration/repair, and cell turnover alone or, more probably, in combination in the granulation tissue response to injury. The morphologic spectrum of bizarre stromal cells and ganglion-like cells suggests an obvious differential diagnosis, which includes carcinoma and sarcoma. The finding of enlarged cells with eccentric intranuclear eosinophilic inclusions requires the exclusion of CMV. However, immunohistochemistry, together with an awareness of those atypical stromal cells, can occur in the setting of ulceration and/or polypoid lesions, preventing an incorrect diagnosis.

DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES

GENERAL

The importance of clinicopathological correlation in the diagnosis of inflammatory conditions of the colon: histological patterns with clinical implications.

Carpenter HA, Talley NJ.

Department of Laboratory Medicine and Pathology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA.
Am J Gastroenterol 2000 Apr;95(4):878-96 Abstract quote
Histological reaction patterns within the colon are not disease-specific but reflect mechanisms of injury and duration of disease. By correlating these patterns with known causes of colonic inflammation, we provide guidelines to enhance the diagnostic value of colonoscopic samples.

Normal histological features are reviewed, and the sequence of inflammation and repair is used as the basis for appreciating pathological deviations. The common histological patterns of acute colitis with and without features of pseudomembranous or ischemic colitis and the morphological features of chronic colitis with and without crypt destruction are collated with clinical and endoscopic features to emphasize the importance of dialogue between the pathologist and gastroenterologist.

Less common patterns, including eosinophilic colitis, graft-versus-host disease, chronic mucosal prolapse, portal hypertensive colopathy, and nonspecific or idiopathic ulcer, illustrate variations in the basic reaction patterns. Difficulties in differential diagnosis are underscored, and biopsy strategies are suggested.

FOCAL ACTIVE COLITIS

The clinical significance of a biopsy-based diagnosis of focal active colitis: a clinicopathologic study of 31 cases.

Volk EE, Shapiro BD, Easley KA, Goldblum JR.

Department of Anatomic Pathology, The Cleveland Clinic Foundation, Ohio, USA.
Mod Pathol 1998 Aug;11(8):789-94 Abstract quote
Focal active colitis (FAC) is a common pattern of injury in colorectal biopsy specimens. Recently, FAC was found to be a marker of an infectious colitis-like diarrheal illness and ischemic colitis but not of Crohn's disease.

We evaluated 31 cases of FAC at the Cleveland Clinic Foundation, Cleveland. Ohio, between 1982 and 1992, to assess the clinical significance of this histologic finding. We evaluated the degree of neutrophil-mediated crypt epithelial injury, the degree of neutrophil-mediated surface epithelial injury, and the lamina propria cellularity and cell type. In each biopsy specimen, all of the above features were scored as 1+ (involving < 10%), 2+ (10-25%), or 3+ (26-50%) of the specimen. Clinical follow-up for the 31 patients ranged from 1 to 51 months (mean, 26 mo). Clinical diagnoses included infectious-type colitis (15 cases, 48%); incidental FAC (9 cases, 29%), occurring in asymptomatic patients undergoing screening for colonic neoplasia; ischemic colitis (3 cases, 10%); and Crohn's disease (4 cases, 13%).

Histologically, all of the cases had some degree of cryptitis, and 24 (77%) of the 31 had neutrophil-mediated surface epithelial injury. In 13 (42%) of the 31, there was an expansion of the lamina propria by neutrophils, in 12 (39%) by eosinophils, and in 11 (35%) by plasma cells. None of the histologic features correlated with specific clinical diagnostic categories (Fisher's exact test).

In conclusion, FAC most commonly correlates clinically with an infectious-type of colitis. On occasion, FAC might be a harbinger of Crohn's disease. Histologic features are not useful in predicting specific clinical diagnoses as a correlate to FAC.

PSEUDOMEMBRANOUS COLITIS

Can ischemic colitis be differentiated from C difficile colitis in biopsy specimens?

Dignan CR, Greenson JK.

Department of Pathology, University of Michigan Hospitals, Ann Arbor 48109-0054, USA.
Am J Surg Pathol 1997 Jun;21(6):706-10 Abstract quote
Pseudomembranous colitis is often caused by Clostridium difficile; however, it may also be due to ischemia.

To determine if any histologic features could be used to differentiate C difficile from ischemia, 49 biopsies of pseudomembranous colitis (25 from patients with C difficile colitis and 24 from patients with ischemic colitis) were coded, randomized, and evaluated for the presence of numerous variables, including the amount and distribution of mucosal necrosis, lamina propria hyalinization, and atrophic "micro-crypts." Hyalinization of the lamina propria was seen in 19 cases of ischemia but not in C difficile colitis (p < 0.0001). Atrophic-appearing micro-crypts were seen in 18 ischemic cases and 6 C difficile cases (p < 0.0006). Lamina propria hemorrhage, full-thickness mucosal necrosis, and a diffuse microscopic distribution of pseudomembranes were significantly more common in ischemia than C difficile.

Endoscopic examination identified pseudomembranes significantly more often with C difficile than ischemia, while the endoscopic appearance of masses or polyps was seen exclusively in cases of ischemia.

The presence of a hyalinized lamina propria appeared to be a specific and sensitive marker for ischemia in colon biopsies with pseudomembranes. The presence of atrophic micro-crypts, lamina propria hemorrhage, full-thickness mucosal necrosis, diffuse involvement of all the surface of all biopsies by pseudomembranes, and the endoscopic impression of a localized process, polyp, or mass were also markers of ischemia, while the endoscopic identification of diffuse pseudomembranes favored the diagnosis of C difficile.

PROGNOSIS AND TREATMENT CHARACTERIZATION

PROGNOSTIC FACTORS

GENERAL

Prognosis of ischemic colitis: comparison of color doppler sonography with early clinical and laboratory findings.

Danse EM, Van Beers BE, Jamart J, Hoang P, Laterre PF, Thys FC, Kartheuser A, Pringot J.

Department of Radiology, Universite Catholique de Louvain, St-Luc University Hospital, Avenue Hippocrate 10, B-1200 Brussels, Belgium.

AJR Am J Roentgenol 2000 Oct;175(4):1151-4 Abstract quote
OBJECTIVE. The objective of this study was to compare the value of color Doppler sonography with early clinical and laboratory findings in determining the prognosis of patients with ischemic colitis.

SUBJECTS AND METHODS. We reviewed the early clinical, laboratory, and color Doppler sonographic data of 24 patients with ischemic colitis. The patients were divided into two groups on the basis of their outcome. The first group comprised the patients with transient ischemia who recovered uneventfully, and the second group included the patients who needed surgery because of symptomatic transmural colic gangrene or colic stricture. Clinical data and laboratory values were compared with color Doppler sonographic findings including colic wall thickness, presence of stratification, and arterial flow in the bowel wall.

RESULTS. At univariate analysis, increased age (p = 0.007), leukocyte count (p = 0.030), lactate dehydrogenase level (p = 0.030), blood lactate level (p = 0.041), and absence of vascular flow in the colic wall (p<0.001) were significantly related to complicated ischemic colitis. At multivariate analysis, absence of arterial flow was the only significant predictor of complicated ischemic colitis (p = 0.002), with a sensitivity of 82%, a specificity of 92%, a positive predictive value of 90%, and a negative predictive value of 86%.

CONCLUSION. Absence of arterial flow in the wall of the ischemic colon on initial color Doppler sonography is suggestive of an unfavorable outcome and is more closely associated with outcome than early clinical and laboratory findings.

TREATMENT

Rosai J. Ackerman's Surgical Pathology. Eight Edition. Mosby 1996.
Sternberg S. Diagnostic Surgical Pathology. Third Edition. Lipincott Williams and Wilkins 1999.
Robbins Pathologic Basis of Disease. Sixth Edition. WB Saunders 1999.

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DISEASE ASSOCIATIONS	CHARACTERIZATION
AORTOILIAC SURGERY
Risk factors for intestinal ischaemia after aortoiliac surgery: a combined cohort and case-control study of 2824 operations. Bjorck M, Troeng T, Bergqvist D. Department of Surgery, Skelleftea District Hospital, Sweden.	Eur J Vasc Endovasc Surg 1997 Jun;13(6):531-9 Abstract quote OBJECTIVE: To identify risk factors for intestinal ischaemia after aortoiliac surgery. MATERIALS AND METHODS: Among 2824 patients operated on during 1987-93 and registered prospectively in the Swedish Vascular Registry, 62 cases of postoperative intestinal ischaemia were identified. They were compared with the remaining 2762 patients through the registry and with a random sample of 127 controls through patient records. Multivariate analysis was performed. RESULTS: Patients in shock operated on for ruptured aneurysms were at greatest risk of developing postoperative intestinal ischaemia. Excluding patients in shock, operation for aneurysmal disease and for occlusive disease carried the same risk. Renal disease, emergency surgery, age, type of hospital, aortobifemoral graft, operating time, cross-clamping time and ligation of one or both internal iliac arteries were independent risk factors. CONCLUSIONS: Patient-related haemodynamic risk factors together with surgical skill and decision making defines the risk for this serious complication.
COCAINE
Cocaine-associated ischemic colitis. Linder JD, Monkemuller KE, Raijman I, Johnson L, Lazenby AJ, Wilcox CM. Department of Medicine, University of Alabama at Birmingham, USA.	South Med J 2000 Sep;93(9):909-13 Abstract quote Cocaine use can result in various gastrointestinal complications, including gastric ulcerations, retroperitoneal fibrosis, visceral infarction, intestinal ischemia, and gastrointestinal tract perforation. We report cocaine-associated colonic ischemia in three patients and review the literature. Including ours, 28 cases have been reported, with a mean patient age of 32.6 years (range, 23 to 47 years); 53.5% were men and 46.5% were women. The interval between drug ingestion and onset of symptoms varied from 1 hour to 2 days. Cocaine is a potentially life-threatening cause of ischemic colitis and should be included in the differential diagnosis of any young adult or middle-aged patient with abdominal pain and bloody diarrhea, especially in the absence of estrogen use or systemic disorders that can cause thromboembolic events, such as atrial fibrillation.
HEART DISEASE
Prevalence of electrocardiographic and echocardiographic abnormalities in ambulatory ischemic colitis. Collet T, Even C, Bouin M, Lecluse E, Piquet MA, Crampon D, Grollier G, Dao T, Verwaerde JC. Department of Hepatology and Gastroenterology, CHU, Caen, France.	Dig Dis Sci 2000 Jan;45(1):23-5 Abstract quote The aim of this study was to evaluate the prevalence of cardiac arrhythmia and intracardiac embolic process in ambulatory ischemic colitis. From November 1994 to November 1997, 33 consecutive cases of ambulatory ischemic colitis were detected. This study included 21 women and 12 men with a mean age of 71 years. All patients underwent a cardiovascular investigation including questioning, electrocardiogram, 24-hr ambulatory electrocardiography and transthoracic echocardiography. A prior history of ischemic colitis was found in four cases (12%). Cardiac arrhythmia was detected in eight cases. Transthoracic echocardiography showed an intracardiac process, potentially responsible for a peripheral embolism, in four cases. In conclusion, the aggregate, in 33% of the patients, there was potential cardiac etiology. This suggests that when ambulatory ischemic colitis occurs, it is necessary to perform an exhaustive cardiovascular evaluation similar to those performed in other ischemic diseases.
IDIOPATHIC ENTEROCOLIC LYMPHOCYTIC PHLEBITIS
Idiopathic enterocolic lymphocytic phlebitis: a rare cause of ischemic colitis. Tuppy H, Haidenthaler A, Schandalik R, Oberhuber G. Department of Pathology, Krankenhaus Wels, University of Vienna, Austria.	Mod Pathol 2000 Aug;13(8):897-9 Abstract quote We report on a 74-year-old female patient who was admitted to the hospital because of abdominal pain. She underwent a colonoscopy and a stenosing mass was found in the cecum. Histologic findings in the biopsy specimens were consistent with ischemic colitis. Due to clinical symptoms and the endoscopic and radiologic findings that roused the suspicion that the patient was suffering from a malignant tumor, a right hemicolectomy was performed. Histology of the resection specimen disclosed an inflammation of the veins. It was characterized by a predominantly lymphocytic infiltration of the vessels affecting the veins of the colonic wall and the mesentery. Furthermore, secondary thrombosis with focal venous occlusion was observed. The colon showed extensive ischemic colitis with focal transmural coagulation necrosis. The disease was considered to be idiopathic lymphocytic phlebitis, which is a rare disease of unknown origin. Our patient is well and alive after more than 1 year, supporting the notion that the disease shows a benign course after surgery.
ORAL CONTRACEPTIVES
Ischemic colitis during pregnancy and contraceptive medication. Frossard JL, Spahr L, Queneau PE, Armenian B, Brundler MA, Hadengue A. Division of Gastroenterology, Geneva University Hospital, Geneva, Switzerland	Digestion 2001;64(2):125-7 Abstract quote Ischemic bowel disease is generally considered a disease of the elderly and usually consists of reversible colopathy. Nonocclusive causes of ischemic colitis include low-flow states due to cardiac dysfunction and hypovolemia and use of certain medications including progestational medication. We report 2 cases of ischemic colitis in young women. The first one occurred in a young patient who developed three consecutive episodes of ischemic colitis during her pregnancy, whereas the second woman presented with ischemic colitis in relation with the estrogen use. Each episode had a favorable outcome. Having ruled out an infectious cause, or a low blood flow state and in the absence of known thrombogenic disease, we hypothesized the etiology of these ischemic episodes to a high level of circulating estrogens due to pregnancy in the first case and oral contraceptive medication in the second. Physicians treating hemorrhagic colitis in young women should consider the use of contraceptive medication containing estrogens or pregnancy as possible causes.
RENAL FAILURE
Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis. Flobert C, Cellier C, Berger A, Ngo A, Cuillerier E, Landi B, Marteau P, Cugnenc PH, Barbier JP. Digestive Disease Department, Laennec and Georges Pompidou European Hospital, AP-HP, University Rene Descartes, Paris, France.	Am J Gastroenterol 2000 Jan;95(1):195-8 Abstract quote OBJECTIVE: The aim of this study was to identify factors associated with severe outcome in patients with ischemic colitis. METHODS: The files of 60 consecutive inpatients (34 women, 26 men, mean age 67 yr) with ischemic colitis were reviewed. The following data were analyzed: age, sex, smoking, medications, history of cardiovascular disease, metabolic disease, chronic renal failure and hemodialysis, the time elapsed between the first symptoms and the diagnosis, and the site and extension of their colonic involvement. Patients were divided into two groups according to outcome: those with severe disease, including those who died from ischemic colitis (n = 3) or who required surgical resection (n = 21); and those with mild forms of colitis who were treated successfully without surgery (n = 36). The two groups were compared by means of univariate and multivariate analysis to identify factors associated with unfavorable outcomes. Only patients who had a complete examination of the colon (n = 51) were entered into the statistical analysis. RESULTS: By univariate analysis, chronic renal failure (p = 0.03), hemodialysis (p = 0.01), short delay between symptoms and diagnosis (p = 0.01), and right colonic involvement (p = 0.002) were significantly more common in the patients with severe colitis. By logistic regression, right colonic involvement was the only factor independently associated with severity (p = 0.01). Right-sided lesions were present in 82% of patients on dialysis but in only 26% of patients not on dialysis (p = 0.0005). CONCLUSIONS: Right colonic involvement is associated with severe forms of ischemic colitis and occurs frequently in patients with chronic renal failure requiring hemodialysis.

LABORATORY/ RADIOLOGIC/ OTHER TESTS	CHARACTERIZATION
RADIOLOGIC
Ischemic colitis: CT evaluation of 54 cases. Balthazar EJ, Yen BC, Gordon RB. Department of Radiology, New York University-Bellevue Medical Center, NY 10016, USA.	Radiology 1999 May;211(2):381-8 Abstract quote PURPOSE: To review the computed tomographic (CT) scans and medical records of 54 patients with proved ischemic colitis, define the spectrum of CT findings, and assess the effect of CT imaging on treatment. MATERIALS AND METHODS: The mean age of the patients was 72 years. CT scans were analyzed for the presence of colonic abnormalities and associated findings. Ischemia was clinically unsuspected in 16 patients (30%). RESULTS: Segmental involvement was seen in 48 patients (89%), with a mean length of involvement of 19 cm (range, 5-38 cm). Wall thickness varied between 2 and 20 mm (mean, 8 mm). All parts of the colon were involved. The CT appearance of the colonic wall varied: (a) A wet appearance with heterogeneous areas of edema was seen in 33 patients (61%). (b) A dry appearance with mild homogeneous thickening was seen in 18 patients (33%). (c) Intramural air was present in three patients (6%). Ischemia resolved in 41 patients (76%), and complications occurred in 13 patients (24%). CONCLUSION: CT can be used to confirm the clinical suspicion of ischemic colitis, to suggest ischemia when it is unsuspected, and to diagnose complications. Intrinsic colonic abnormalities cannot be used to diagnose or predict the development of infarction.
Nonocclusive ischemic colitis in a 12-year-old girl: value of unenhanced spiral computed tomography. Wiesner W, Willi UV. Institute of Diagnostic Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.	Int J Colorectal Dis 2001 Feb;16(1):55-7 Abstract quote A 12-year-old girl was hit by a car and arrived in the emergency room in hemorrhagic shock. Contrast-enhanced computed tomography of the abdomen showed traumatic rupture of the liver and large amounts of intraperitoneal hemorrhage. Unenhanced computed tomography showed a hyperdense thickening of the wall of the descending colon. This finding was consistent with a nonocclusive ischemic colitis, which was confirmed some days later by endoscopy, at a time when the patient had already developed Gram-negative bacteremia. We discuss the pathogenesis of nonocclusive ischemic colitis, computed tomography findings, and the value of unenhanced computed tomography.
LABORATORY MARKERS

GROSS APPEARANCE/ CLINICAL VARIANTS	CHARACTERIZATION
GENERAL
Reevaluation of clinical features of ischemic colitis. Analysis of 68 consecutive cases diagnosed by early colonoscopy. Habu Y, Tahashi Y, Kiyota K, Matsumura K, Hirota M, Inokuchi H, Kawai K. Dept. of Gastroenterology, Saiseikai Noe Hospital, Osaka, Japan.	Scand J Gastroenterol 1996 Sep;31(9):881-6 Abstract quote BACKGROUND: Ischemic colitis (IC) is generally considered a disease of elderly patients who have associated diseases. The aim of the present study was to reevaluate the clinical features of IC. METHODS: We retrospectively analyzed the clinical characteristics, background, and endoscopic and histologic changes in 68 consecutive patients (16 men and 52 women) with this disease diagnosed by early colonoscopy. RESULTS: The patients' age ranged from 22 to 98 years (mean, 55 years). Twenty-three patients (34%, including 19 women) were less than 50 years of age. The classical predisposing factors were not discernible in patients younger than 50. Chronic constipation and prior history of abdominal surgery were common in both young and old patients. Early colonoscopy (especially by the 3rd day from onset) showed endoscopic and histologic findings consistent with the characteristics of IC. CONCLUSIONS: IC is not limited only to the elderly, and it should be considered in the differential diagnosis of colitis with melena in younger patients, especially females, who do not have any predisposing factors. Chronic constipation and prior history of abdominal surgery were commonly associated in both young and old patients. Early colonoscopy, especially by the 3rd day from the clinical onset, is essential for the accurate diagnosis of IC.
VARIANTS
SEGMENTAL
Cecal necrosis: infrequent variant of ischemic colitis. Report of five cases. Schuler JG, Hudlin MM. Department of Surgery, Mount Auburn Hospital, and the Harvard Medical School, Cambridge, Massachusetts, USA.	Dis Colon Rectum 2000 May;43(5):708-12 Abstract quote PURPOSE: Spontaneous nonocclusive ischemic colitis involving only the right colon is an infrequent occurrence. Because this problem is less recognized than its counterpart involving the left colon, the correct diagnosis may not be considered. The purpose of this article was to describe the presentation and management of this unusual clinical problem. METHODS: Five cases of nonocclusive ischemic cecal necrosis are described. Four of the patients presented with right-sided abdominal pain, tenderness, and leukocytosis. The preoperative diagnosis was incorrect in all patients, although cecal necrosis was considered in one. Two patients were thought to have. appendicitis, two were thought to have carcinoma, and one was thought to have a perforated viscus. Each patient underwent a right hemicolectomy and four survived. RESULTS: Each of the patients had ischemic cecal necrosis without evidence of emboli or vasculitis. Although cecal gangrene may occur after systemic hypotension, no such event preceded these patients' presentation. We believe that the patients we treated had a form of nonocclusive ischemic colitis, which occasionally affects only the right colon. CONCLUSION: Ischemic necrosis of the cecum is an infrequent variant of ischemic colitis that should be considered in the differential diagnosis of the elderly patient presenting with right lower quadrant pain.
YOUNG PATIENTS
Ischemic colitis in young adults: a single-institution experience. Preventza OA, Lazarides K, Sawyer MD. Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minn., U.S.A.	J Gastrointest Surg 2001 Jul-Aug;5(4):388-92 Abstract quote Ischemic colitis is not well characterized in the young adult population, despite its commonness in older patients. The aim of this study was to investigate the demographics, etiology, clinical features, and prognosis of ischemic colitis in young adults. We conducted a retrospective study of 39 young adults (<50 years of age) diagnosed with ischemic colitis over a period of 9 years (1990 to 1998). The mean age at diagnosis was 38 +/- 2 years (range 18 to 49 years); the female:male ratio was 1.8. Fifty-two percent (13 of 25) of women were using oral contraceptives at the time of diagnosis. Other potential associations identified were vascular thromboembolism (4 of 39), vasoactive drugs (4 of 39), hypovolemia (4 of 39), and vasculitis (2 of 39); 19 patients (49%) had no identifiable predisposing factors. Dominant presenting symptoms were abdominal pain (77%), bloody diarrhea (54%), and hematochezia (51%). Most patients were diagnosed at colonoscopy, and most disease was left sided. Twenty-nine patients were successfully managed with intravenous fluids, broad-spectrum antibiotics, and bowel rest; 10 patients required surgery. There was one disease-related death in the operative group. We found a strong female predominance and an association with oral contraceptive use, but almost half of the patients did not have an identifiable etiology. Mortality from ischemic colitis in this patient population is low.

DIFFERENTIAL DIAGNOSIS	KEY DIFFERENTIATING FEATURES
GENERAL
The importance of clinicopathological correlation in the diagnosis of inflammatory conditions of the colon: histological patterns with clinical implications. Carpenter HA, Talley NJ. Department of Laboratory Medicine and Pathology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA.	Am J Gastroenterol 2000 Apr;95(4):878-96 Abstract quote Histological reaction patterns within the colon are not disease-specific but reflect mechanisms of injury and duration of disease. By correlating these patterns with known causes of colonic inflammation, we provide guidelines to enhance the diagnostic value of colonoscopic samples. Normal histological features are reviewed, and the sequence of inflammation and repair is used as the basis for appreciating pathological deviations. The common histological patterns of acute colitis with and without features of pseudomembranous or ischemic colitis and the morphological features of chronic colitis with and without crypt destruction are collated with clinical and endoscopic features to emphasize the importance of dialogue between the pathologist and gastroenterologist. Less common patterns, including eosinophilic colitis, graft-versus-host disease, chronic mucosal prolapse, portal hypertensive colopathy, and nonspecific or idiopathic ulcer, illustrate variations in the basic reaction patterns. Difficulties in differential diagnosis are underscored, and biopsy strategies are suggested.
FOCAL ACTIVE COLITIS
The clinical significance of a biopsy-based diagnosis of focal active colitis: a clinicopathologic study of 31 cases. Volk EE, Shapiro BD, Easley KA, Goldblum JR. Department of Anatomic Pathology, The Cleveland Clinic Foundation, Ohio, USA.	Mod Pathol 1998 Aug;11(8):789-94 Abstract quote Focal active colitis (FAC) is a common pattern of injury in colorectal biopsy specimens. Recently, FAC was found to be a marker of an infectious colitis-like diarrheal illness and ischemic colitis but not of Crohn's disease. We evaluated 31 cases of FAC at the Cleveland Clinic Foundation, Cleveland. Ohio, between 1982 and 1992, to assess the clinical significance of this histologic finding. We evaluated the degree of neutrophil-mediated crypt epithelial injury, the degree of neutrophil-mediated surface epithelial injury, and the lamina propria cellularity and cell type. In each biopsy specimen, all of the above features were scored as 1+ (involving < 10%), 2+ (10-25%), or 3+ (26-50%) of the specimen. Clinical follow-up for the 31 patients ranged from 1 to 51 months (mean, 26 mo). Clinical diagnoses included infectious-type colitis (15 cases, 48%); incidental FAC (9 cases, 29%), occurring in asymptomatic patients undergoing screening for colonic neoplasia; ischemic colitis (3 cases, 10%); and Crohn's disease (4 cases, 13%). Histologically, all of the cases had some degree of cryptitis, and 24 (77%) of the 31 had neutrophil-mediated surface epithelial injury. In 13 (42%) of the 31, there was an expansion of the lamina propria by neutrophils, in 12 (39%) by eosinophils, and in 11 (35%) by plasma cells. None of the histologic features correlated with specific clinical diagnostic categories (Fisher's exact test). In conclusion, FAC most commonly correlates clinically with an infectious-type of colitis. On occasion, FAC might be a harbinger of Crohn's disease. Histologic features are not useful in predicting specific clinical diagnoses as a correlate to FAC.
PSEUDOMEMBRANOUS COLITIS
Can ischemic colitis be differentiated from C difficile colitis in biopsy specimens? Dignan CR, Greenson JK. Department of Pathology, University of Michigan Hospitals, Ann Arbor 48109-0054, USA.	Am J Surg Pathol 1997 Jun;21(6):706-10 Abstract quote Pseudomembranous colitis is often caused by Clostridium difficile; however, it may also be due to ischemia. To determine if any histologic features could be used to differentiate C difficile from ischemia, 49 biopsies of pseudomembranous colitis (25 from patients with C difficile colitis and 24 from patients with ischemic colitis) were coded, randomized, and evaluated for the presence of numerous variables, including the amount and distribution of mucosal necrosis, lamina propria hyalinization, and atrophic "micro-crypts." Hyalinization of the lamina propria was seen in 19 cases of ischemia but not in C difficile colitis (p < 0.0001). Atrophic-appearing micro-crypts were seen in 18 ischemic cases and 6 C difficile cases (p < 0.0006). Lamina propria hemorrhage, full-thickness mucosal necrosis, and a diffuse microscopic distribution of pseudomembranes were significantly more common in ischemia than C difficile. Endoscopic examination identified pseudomembranes significantly more often with C difficile than ischemia, while the endoscopic appearance of masses or polyps was seen exclusively in cases of ischemia. The presence of a hyalinized lamina propria appeared to be a specific and sensitive marker for ischemia in colon biopsies with pseudomembranes. The presence of atrophic micro-crypts, lamina propria hemorrhage, full-thickness mucosal necrosis, diffuse involvement of all the surface of all biopsies by pseudomembranes, and the endoscopic impression of a localized process, polyp, or mass were also markers of ischemia, while the endoscopic identification of diffuse pseudomembranes favored the diagnosis of C difficile.

Epidemiology
Disease Associations
Pathogenesis
Laboratory/Radiologic/Other Diagnostic Testing
Gross Appearance and Clinical Variants
Histopathological Features and Variants
Differential Diagnosis
Prognosis and Treatment
Commonly Used Terms
Internet Links

EPIDEMIOLOGY	CHARACTERIZATION
AGE RANGE-MEDIAN	Usually over 5th decade
SEX (M:F)	Equal

PROGNOSIS AND TREATMENT	CHARACTERIZATION
PROGNOSTIC FACTORS
GENERAL
Prognosis of ischemic colitis: comparison of color doppler sonography with early clinical and laboratory findings. Danse EM, Van Beers BE, Jamart J, Hoang P, Laterre PF, Thys FC, Kartheuser A, Pringot J. Department of Radiology, Universite Catholique de Louvain, St-Luc University Hospital, Avenue Hippocrate 10, B-1200 Brussels, Belgium.	AJR Am J Roentgenol 2000 Oct;175(4):1151-4 Abstract quote OBJECTIVE. The objective of this study was to compare the value of color Doppler sonography with early clinical and laboratory findings in determining the prognosis of patients with ischemic colitis. SUBJECTS AND METHODS. We reviewed the early clinical, laboratory, and color Doppler sonographic data of 24 patients with ischemic colitis. The patients were divided into two groups on the basis of their outcome. The first group comprised the patients with transient ischemia who recovered uneventfully, and the second group included the patients who needed surgery because of symptomatic transmural colic gangrene or colic stricture. Clinical data and laboratory values were compared with color Doppler sonographic findings including colic wall thickness, presence of stratification, and arterial flow in the bowel wall. RESULTS. At univariate analysis, increased age (p = 0.007), leukocyte count (p = 0.030), lactate dehydrogenase level (p = 0.030), blood lactate level (p = 0.041), and absence of vascular flow in the colic wall (p<0.001) were significantly related to complicated ischemic colitis. At multivariate analysis, absence of arterial flow was the only significant predictor of complicated ischemic colitis (p = 0.002), with a sensitivity of 82%, a specificity of 92%, a positive predictive value of 90%, and a negative predictive value of 86%. CONCLUSION. Absence of arterial flow in the wall of the ischemic colon on initial color Doppler sonography is suggestive of an unfavorable outcome and is more closely associated with outcome than early clinical and laboratory findings.
TREATMENT