• Most common form of GI ischemia
• May occur following low-flow states: shock, myocardial infarction, abdominal aortic aneurysm (AAA) repair
• Reversible or irreversible
• Vascular compromise by occlusive or nonocclusive mechanisms
• May affect any portion of colon
• Watershed areas (splenic flexure, rectosigmoid junction) especially vulnerable
• No pathognomonic findings or signs; requires high index of suspicion
• Ischemia of the right colon seen in patients with coronary artery disease (CAD), aortic stenosis
• Affects elderly most often (> 60 years)
• May occur in association with diabetes, lupus, sickle cell crisis, pancreatitis
• Left-sided ischemic colitis 1-2% following aortic reconstruction, higher incidence with ruptured AAA
• Abrupt onset of abdominal pain
• Diarrhea (may be bloody)
• Physical exam may be unremarkable
• Pain out of proportion to exam findings
• Abdominal x-rays: Nonspecific Abdominal catastrophe: free air, pneumatosis intestinalis, portal vein air
•Barium enema: May feature thumbprints
• CT: May show thicken bowel wall
• Angiography: May reveal major mesenteric vascular occlusion, stenosis, spasm
-May reveal edematous, hemorrhagic mucosa with or without ulcerations
-Advanced ischemia appears as blue-black discoloration, patchy areas of black, nonviable mucosa
• Grayish membrane resembles pseudomembranous colitis
• Ulcerative colitis
• Comprehensive history and physical exam
• Is there recent history of low-flow state (AAA repair, cardiac event), pancreatitis
• CT scan
• Diagnosis requires high index of suspicion
• Consider work-up for hypercoaguable state, embolic source (transesophageal echocardiography, aortography)
• Patients with suspicion of ischemic colitis should be admitted for work-up, hydration, IV antibiotics, and observation to be certain that the problem is reversible
• Irreversible disease, failure of conservative measures (hydration, antibiotics, bowel rest) with persistence of symptoms
• Full thickness necrosis (gangrenous ischemic colitis)
• Development of stricture/obstruction
• Worsening clinical course (fever, tachycardia, leukocytosis, acidosis, hypotension)
• Serial abdominal exam
• Serial WBC count
• Follow-up endoscopy
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