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  • • 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

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Epidemiology

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  • • 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

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Symptoms and Signs

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  • • Abrupt onset of abdominal pain

    • Diarrhea (may be bloody)

    • Nausea

    • Vomiting

    • Tenesmus

    • Fever

    • Physical exam may be unremarkable

    • Pain out of proportion to exam findings

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Laboratory Findings

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  • • Nonspecific, no pathognomonic abnormalities

    • May have leukocytosis

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Imaging Findings

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  • 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

    Colonoscopy

    • -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

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  • • Colorectal cancer

    • Diverticulitis

    • Inflammatory bowel disease

    • Pseudomembranous colitis

    • Infectious colitis

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Rule Out

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  • • Neoplasm

    • Ulcerative colitis

    • Diverticulitis

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  • • Comprehensive history and physical exam

    • Is there recent history of low-flow state (AAA repair, cardiac event), pancreatitis

    • Colonoscopy

    • CT scan

    • Diagnosis requires high index of suspicion

    • Consider work-up for hypercoaguable state, embolic source (transesophageal echocardiography, aortography)

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When to Admit

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  • • 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

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  • • IV hydration

    • Broad-spectrum antibiotics

    • Inpatient hospitalization

    • Bowel rest

    • NG decompression

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Surgery

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Indications

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  • • 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)

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Medications

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  • • IV broad-spectrum antibiotics

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Treatment Monitoring

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  • • Serial abdominal exam

    • Serial WBC count

    • Follow-up endoscopy

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Complications

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  • • Severe ischemic disease often associated with other medical comorbidities

    • Overall mortality rate ~ 50%

    • Ischemic stricture

    • Peritonitis

    • Perforation

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Prognosis

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  • • In transient disease, 80-90% will completely heal

    • ...

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