Ischemic Colitis
Severe case of Ischemic Colitis

Video Endoscopic Sequence 1 of 23.

Severe case of Ischemic Colitis

This 57-year-old male with history of diabetes mellitus hypertension and ischemic heart disease (including coronary artery bypass 3 years previously). He was taking 150 mg aspirin, verapamil 240 mg daily. Presents with abdominal pain and passage of maroonblood stools the white blood count was 18.000 with 90 neutrofils, a colonoscopy was performed finding this images displayedin this atlas.

This patient was successfully treated by surgery. A small amount of ascites was observed (bacterial culture: negative). The right colon is affected with large area of necrosis.

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Ischemic Colitis

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Discrepancy between subjective symptoms and objective findings is a hallmark of ischemic colitis. Thus, diagnosis requires a high index of suspicion in the appropriat clinical setting.

The diverse causes, variable clinical presentations, and severity makes the diagnosis and management of ischemic colitis a challenge.

Left-sided ischemic colitis is the most common form of ischemic injury to the gut. Although it is generally considered a condition of elderly persons, it can affect patients of any age. Ischemic colitis is the second or third most common cause of lower gastrointestinal bleeding. The most common medication inducing ischemic colitis is nonsteroidal anti-inflammatory agents. The endoscopic spectrum of ischemic colitis is broad, ranging from mild patchy subepithelial hemorrhage to extensive necrosis. Nevertheless, the ‘pathognomonic’ endoscopic appearance of ischemic colitis is a ‘segmental’ involvement of the left colon in the so-called ‘watershed area.

 

Ischemic colitis

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Some diverticulae are seen near of the necrosis.

Ischemic colitis is the most common form of intestinal ischemia. It manifests as a spectrum of injury from transient self-limited ischemia involving the mucosa and submucosa to acute fulminant ischemia with transmural infarction that may progress to necrosis and death. Although there are a variety of causes, the most common mechanism is an acute, self-limited compromise in intestinal blood flow. Patients typically have mild abdominal pain and tenderness over the involved segment of bowel. There is usually passage of blood mixed with stool, but hemodynamically significant bleeding is unusual. Although computed tomography may have suggestive findings, colonoscopy is the procedure of choice for diagnosis.

 

 

 

Ischemic colitis

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Although frequent in the elderly, younger patients may also be affected.

The colon is also predisposed to ischemia by its relatively low blood flow compared with the rest of the gastrointestinal tract

There are no endoscopic findings that are specific for ischemia, thus the clinical setting must be considered. Findings that favor ischemic colitis rather than inflammatory bowel disease are segmental area of injury, abrupt transition between normal and affected mucosa, rectal sparing, and a rapid resolution of mucosal changes on serial colonoscopy.

 

Ischemic colitis

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There are numerous conditions that predispose patients to ischemic colitis. The most common mechanism is hypotension from sepsis or impaired left ventricular function and hypovolemia from dehydration or hemorrhage producing a compromise in systemic perfusion and triggering a reflex mesenteric vasoconstriction.

Ischemic colitis

Video Endoscopic Sequence 6 of 23.

4 days after the first colonoscopy, a follow up colonoscopy was performed because the pathologist required more biopsies, the patient was under antibiotherapy.

Numerous medications may produce colonic ischemia by a similar mechanism.

The most common offenders are: antihypertensive agents, diuretics, nonsteroidal anti -inflammatory drugs, digoxin, oral contraceptives, pseudoephedrine, cocaine, Tegaserod and alosetron. Strenuous physical activities, such as long distance running or bicycling, have been reported to lead to colonic ischemia, presumably by physiologic shunting caused by mesenteric vasoconstriction and intravascular volume depletion from dehydration.

 

Ischemic colitis

Video Endoscopic Sequence 7 of 23.

Although our patient presented the ischemic colitis in the right colon ischemic colitis, it is reported that the most common sites of involvement are the splenic flexure and the sigmoid colon.

The classic site of involvement is the splenic flexure. Usually, there is involvement of the sigmoid colon with notable sparing of the rectum. However, because there is considerable variation in the collateral blood supply, ischemic colitis may occur anywhere in the colon.

 

Ischemic colitis

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Ischemic colitis was first described in relation to vascular surgeries and continues to be a potential complication of aortic or cardiac bypass surgery. Aortic surgery is associated with a 1% to 7% incidence of ischemic colitis, often caused by iatrogenic IMA ligation or intraoperative hypoperfusion in patients with chronic IMA occlusion, and usually affects the distal left colon.

 

Ischemic colitis

Video Endoscopic Sequence 9 of 23.

Most patients will present with the acute onset of a mild, crampy abdominal pain and tenderness over the affected bowel. An urge to defecate is common. Within 24 hours, there is usually passage of bright red or maroon blood, often mixed with stool. Blood loss is usually minimal, without hemodynamic compromise or the need for transfusion.

 

 

 

 

 

Ischemic colitis

Video Endoscopic Sequence 10 of 23.

Complications of ischemic colitis include chronic ischemic colitis, gangrene of the bowel with resulting perforation and peritonitis, and stricture, which usually develops 3 to 4 weeks after the acute insult. Rare complications include inflammatory polyposis, pyocolon.

 

Ischemic colitis

Video Endoscopic Sequence 11 of 23.

Ischemic colitis occurs as the result of a compromise in intestinal blood flow that can produce a spectrum of injury from transient self-limited ischemia to fulminant ischemia or transmural infarction. Its diagnosis requires a high index of suspicion, and the clinician should consider the diagnosis in patients with acute abdominal pain and bloody stools. Although most patients improve within several days with supportive care, others will require laparotomy with bowel resection.

 

Ischemic colitis Cecal appendix and the Cecum

Video Endoscopic Sequence 12 of 23.

Cecal appendix and the Cecum

 

Ischemic colitis

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Ischemic colitis

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Open Surgical Specimen that shows extensive necrosis

 

 

 

 

 

Ischemic colitis

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Hallmarks of ischemic bowel are necrotizing phlebitis and thrombi formation Thrombophlebitis morphology differs in viable bowel (lymphocytic) and ischemic bowel (necrotizing lesions) Necrosis, ulceration and granulation tissue extend into submucosa and surrounding smooth muscle fibers of muscularis mucosa Hemosiderin / hemorrhage and edema in lamina propria; hyaline thrombi in small vessels May see crypt abscesses; deep portion of colonic crypt is often spared Usually few inflammatory cells Suggestive features are surface exudate of neutrophils, fibrin or mucosal necrosis (early) or transmural fibrosis (late) Endoscopically normal mucosa has no microscopic abnormalities.

Ischemic colitis
 

Video Endoscopic Sequence 17 of 23.

Ischemic colitis encompasses a number of clinical entities, all with an end result of insufficient blood supply to a segment or the entire colon. This disease results in ischemic necrosis of varying severities that can range from superficial mucosal involvement to full-thickness transmural necrosis.

 

Ischemic colitis

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Ischemic colitis

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Ischemic colitis

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Ischemic colitis

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Ischemic colitis

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Ischemic colitis

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Ischemic Colitis.

Ischemic Colitis.

Later endoscopic finding in a mild case of colonic ischemia. Note the more pronounced submucosal hemorrhage as well as the presence of pseudomembranes.

Ischemic colitis (IC) is the most common manifestation of gastrointestinal ischemia. IC has been considered to have relatively high prevalence in the elderly population with underlying vascular disorder. Most of the cases occur in patients over 50 years of age, and the usual associations are arteriosclerosis, diabetes melitus, hypertension and vascular surgery.

Arteriosclerosis, may lead to IC by intrinsic obstruction of colonic vessels. However, this disease has recently to be on reported the increase in the young population, in association with collagen-vascular diseases (i.e., scleroderma), Wegener’s granulomatosis,
Idiopathic Lymphocytic Phlebitis, Amyloidosis, and as a complication of the birth control pill.

IC is classified into the non-gangrenous type
(transient and stricture), and gangrenous type.

The nongangrenous type is the most common form of IC, on presentation, affecting elderly patients (74 +/-10 years).

IC appears to have two patterns of severity. Anatomical distribution is more variable than a developmental explanation of the vascular supply. It is possible to predict the severity of the disease to some extent as represented by objective markers of inflammation (presence of ulcerative lesion in endoscopic findings in acute stage) by finding the time from onset of abdominal pain to detection of bloody stool.

Non-gangrenous IC usually requires only conservative therapy, including repeated careful assessment, pain control, and fluid replacement, and is associated with a good prognosis.16 Surgical management may be necessary if there are signs of deterioration, perforation, hemorrhage, or sepsis.

Urgent surgery and high morbidity and mortality rates are hallmarks of the gangrenous type. Special consideration must be given to those patients in whom IC develops in the context of colon cancer or obstructive colonic lesions. Absence of arterial flow in the wall of the ischemic colon on initial colour Doppler sonography is suggestive of an unfavourable outcome and is more closely associated with outcome than early clinical and laboratory findings.

Ischemic Colitis

Video Endoscopic Sequence 1 of 2.

Ischemic Colitis

This a 81 year old female, due to a weight loss and anemia she was hospitalized in abdominal ultrasound radiologist detected in the right iliac fossa a kidney-shaped pelvic mass, and was suspected to be a neoplasia of the cecum, colonoscopy is performed, no malignancy was found. but in the descending colon and splenic flexure, an area of ulceration, this continuous and up there is no vascularization in this area, this endoscopic image is compatible with ischemic colitis.

Ischemic colitis is the most common type of intestinal ischemia and has a clinical spectrum of injury that ranges from mild and transient ischemia to acute fulminant colitis.

 

 

 

Ischemic Colitis

Video Endoscopic Sequence 2 of 2.

Ischemic Colitis

The image reflect mucosal changes of ischemia (inadequate blood supply) in increasing severity, from patchy erythema to frank ulceration.

Colonoscopy is safe and helpful in the early diagnosis of ischemic colitis. Nongangrenous colonic ischemia usually requires only medical management and is associated with a good prognosis.

Ischemic changes may be mucosal, mural (due to hypoperfusion) or transmural (major vessels involved) Chronic ischemia may produce similar changes as acute ischemia, may be segmental and patchy.

Splenic flexure and descending colon are "watershed" areas, at borders of territory supplied by inferior and superior mesenteric arteries.

Endoscopy: petechial hemorrhages, edematous and fragile mucosa, segmental erythema, scattered erosion, longitudinal ulcerations, sharply defined segment of involvement. Symptoms: sudden onset of abdominal pain and bleeding Complications: intestinal gangrene in 1-4 days, bacterial superinfection, enterotoxin formation (pseudomembranes), stricture; perforation may be fatal. Severe disease associated with tachycardia and peritonism signs.

 

Video Endoscopic Sequence 1 of 3.

Ischemic Colitis

This is a 71 year-old, female, who suffers from Alzheimer's disease and using cardiovascular drugs, who had had several episodes of intermittentLower GI Bleeding. Colonoscopy displays extensive ulceration of the cecum.

 

Colitis Isquemica

Video Endoscopic Sequence 2 of 3.

Ischemic Colitis

The video clip displays the terminal ileum, the distorted and ulcerated anatomy is observed In the cecum and in wich appears to be the hole of the the appendix, a small hole is seen, thus fistula is discarded.

 

 

 

 

 

 

Colitis Isquemica

Video Endoscopic Sequence 3 of 3.

Ischemic Colitis

ileocecal valve which is affected by ischemia is observed. the video clip displays the terminal ileum

 

 

 

 

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