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Investigation and Management of Ischemic Colitis

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Investigation and Management of Ischemic Colitis REVIEW JORGE BAIXAULI, MD RAVI P. KIRAN, MS, FRCS (ENG), FRCS (GLAS) Department of Colorectal Surgery, The Cleveland Clinic Department of Colorectal Surgery, The Cleveland Clinic CONOR P. DELANEY, MB, MCh, PhD, FRCSI (GEN) Department of Colorectal Surgery, The Cleveland Clinic Investigation and management of ischemic colitis ■ ABSTRACT SCHEMIA OF THE COLON probably hap- I pens more often than we think, as the The colon is the most common site of gastrointestinal signs may be subtle and highly variable. ischemia. The condition resolves completely with Although most cases resolve spontaneously, conservative treatment in most cases, but late diagnosis or chronic colonic ischemia is increasingly being severe ischemia can be associated with high rates of recognized, and in a sizable minority of acute complications and death. Once ischemic colitis is cases it progresses to infarction and requires diagnosed, serial physical examinations and colonoscopies immediate surgery. are helpful to follow the condition. Prompt surgery is In this article we review the causes, signs, required for severe episodes, when conservative measures and management of ischemic colitis. fail, and for patients with chronic symptoms. ■ RECOGNITION INCREASING ■ KEY POINTS Colonic ischemia and infarction have long Colonic ischemia is associated with many precipitating been recognized. In 1953, Shaw and Green factors and may be due to single-vessel occlusion or global reported an episode of infarction after inferior mesenteric artery ligation for colon cancer.1 A hypoperfusion. decade later, Boley et al2 were the first to describe nongangrenous ischemia when they The clinical manifestations are varied and often subtle, and reported reversible vascular occlusion of the a high level of awareness is needed. Special consideration colon. Since then, the condition has been rec- should be given to the condition in patients who have ognized with increasing frequency. recently undergone cardiac or aortic surgery. ■ CAUSES ARE MANY Clinical patterns vary from transient colitis to fulminant ischemia with gangrene. Many medical conditions and medications can cause ischemia by reducing blood flow to the Routine biochemical tests are helpful but nonspecific. The colon (TABLE 1).3,4 The causes have been vari- diagnosis is usually made by history, examination, and ously classified as systemic or local, occlusive or nonocclusive, and iatrogenic or noniatro- endoscopy. genic. An idiopathic or “spontaneous” form is generally thought to be related to localized nonocclusive ischemia of the bowel. Some of the more common causes of ischemia in hospitalized patients include liga- tion of the inferior mesenteric artery during aortic surgery, low flow after cardiopulmonary bypass surgery, myocardial ischemia, and sep- sis. In these situations it is difficult for the patient to compensate because the collateral 920 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70 • NUMBER 11 NOVEMBER 2003 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. pathways to increase colonic blood flow have T ABLE 1 already been compromised. Ischemia is now known to be most com- Etiologic factors in colonic ischemia mon in the elderly, although it can occur at Idiopathic (spontaneous) almost any age. Approximately 90% of cases of colonic ischemia occur in patients over 60 Colonic obstruction years of age, who may be predisposed to Shock ischemia due to age-related lengthening of the colic vessels.5 Medications Digitalis, diuretics, nonsteroidal anti-inflammatory drugs, ■ ANATOMY AND AREAS catecholamines, estrogens, danazol, gold, neuroleptics OF THE COLON AT RISK Major vascular occlusion Mesenteric arterial thrombosis or embolization The colon is protected from ischemia to a Mesenteric venous thrombosis great extent by an abundant collateral blood Trauma supply (FIGURE 1). However, certain areas are Small vessel disease more vulnerable in some people. Diabetes mellitus, vasculitis, amyloidosis, rheumatoid arthritis, Two major arteries supply most of the radiation injury blood to the colon: the superior mesenteric Hematologic disorders artery (which supplies the ascending and Protein C deficiency, protein S deficiency, transverse colon) and the inferior mesenteric antithrombin III deficiency, sickle cell disease artery (which supplies the descending and sig- moid colon). Cocaine abuse The marginal artery of Drummond, which Long-distance running runs along the mesentery within 1 to 8 cm of the colon, is composed of the terminal por- tions of the branches from the major vascular arcades. This artery can keep the left colon ischemia.8 There is also a watershed area at Colonic viable when the inferior mesenteric artery is Sudek’s point between the sigmoid colon and ischemia is ligated during rectosigmoidectomy. the rectum where the lowest sigmoid branch- But the anatomy is highly variable. For es usually join branches of the superior rectal most common example, the marginal artery of Drummond is artery. A third potential watershed area is the in patients occasionally tenuous at the splenic flexure, as right colon, where the marginal vessel is poor- described by Griffiths, and indeed is absent at ly developed in up to 50% of people. over age 60 this point in up to 5% of patients.6 It is poor- Therefore, any portion of the bowel may ly developed in the right colon in 50% of the be affected, but the sites most often affected population, explaining the occurrence of are the sigmoid colon, ascending colon, and right-sided colitis.7 One or more of the three splenic flexure. In systemic low-flow states the branches of the superior mesenteric artery may right colon is most often involved, while be absent in up to 20% of people. Branches of localized nonocclusive ischemia involves the inferior mesenteric artery may similarly be watershed areas such as the splenic flexure and absent. the junction of the sigmoid and rectum. On the other hand, 60% of people have Ligation or occlusion of the inferior an additional vessel, called the arch of Riolan mesenteric artery produces changes in the sig- or meandering mesenteric vessel, which com- moid colon, although changes may be more municates between the left colic and superior widespread if other vessels are previously mesenteric arteries. occluded. The splenic flexure is a “watershed” area Colonic ischemia isolated to the right between the areas supplied by the two main colon is often a manifestation of acute arteries. Sierocinski found that a 1.2-cm to ischemia, which may have a more fulminant 2.8-cm area of the splenic flexure was devoid course. Right-sided ischemic colitis accounts of vasa recta, thereby predisposing this area to for 8% to 46% of cases.9–11 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70 • NUMBER 11 NOVEMBER 2003 921 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. ■ Why some areas of the colon are prone to ischemia The colon is protected from ischemia by a collateral blood supply via the marginal artery of Drummond, a system of arcades connecting the major arteries. The anatomy is highly variable, however, and certain areas are more vulnerable in some people. Vasa recta The splenic flexure (Griffith’s point) is vulnerable to ischemia because the marginal artery of Drummond is occasionally tenu- ous here and is absent in up to 5% of patients; a 1.2–2.8 cm2 area may be devoid of vasa recta Marginal artery Middle Superior colic of Drummond mesenteric artery artery Vasa recta Right colic artery The right colon may be vulnerable in Left colic Ileocolic systemic low-flow artery artery states, as the marginal Marginal artery artery of Drummond is of Drummond poorly developed here in 50% of the population The rectosigmoid junction (Sudek’s point) is also vulnerable because it is Inferior distal to the last collateral connection mesenteric with proximal arteries artery CCF ©2003 FIGURE 1 ■ CLINICAL PRESENTATION are transient and reversible, or that progress to chronic and irreversible strictures (10%–15%) Once blood flow drops below a critical thresh- or chronic segmental colitis (20%–25%).4 old, ischemia occurs, with consequences The pattern of clinical presentation (TABLE dependent on the individual’s ability to 2) depends on the cause, the extent of vascu- respond by increasing flow. Ischemia is then lar obstruction, the speed of ischemic insult, manifested as a spectrum of findings varying the degree of collateralization, and comorbid from transient intramural and submucosal conditions. In most cases there is no identifi- hemorrhage and edema to gangrene. able initiating factor, but a recent history of Ischemic colitis may present in two major cardiac or vascular surgery, major systemic ill- clinical patterns: gangrenous (15%–20% of ness, or myocardial event may be present.12–16 cases) and nongangrenous (80%–85%). In the Up to 20% of patients may have associated nongangrenous form, lesions may develop that colonic pathology such as cancer. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70 • NUMBER 11 NOVEMBER 2003 925 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. ISCHEMIC COLITIS BAIXAULI AND COLLEAGUES T ABLE 2 Colonic ischemia: Classification based on clinical course Nongangrenous form Reversible (50%) Transient Persistent/recurrent Irreversible Chronic segmental colitis Strictures Gangrenous form ■ DIAGNOSTIC TESTS FOR COLONIC ISCHEMIA The diagnosis of colonic ischemia depends on early
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