Stephan Moll, MD writes…
Ischemic colitis is an uncommon disorder. It is typically not dangerous and resolves without treatment. For mostly unclear reasons multiple small or tiny blood vessels in the wall of the intestine (the large intestine = colon) have decreased blood flow or become blocked by small blood clots. This results in a lack of blood flow and oxygen delivery (ischemia = Latin for impaired oxygen supply) to a number of small areas of the intestinal wall. This leads patchy, superficial damage of the colon wall results. The damage areas often heal by themselves and no surgery is needed. The patient recovers spontaneously within a week or two. Often people have only one episode. Few people have two or more bouts.
What are the Symptoms?
Symptoms typically include colicky (cramping) abdominal pain, vomiting, and rectal bleeding. Symptoms often resolve in 1-2 weeks.
Who gets it?
It can occur in the elderly, but also in apparently healthy younger people. It is overall poorly understood why some people develop this problem. Predisposing factors may be clotting disorders (thrombophilias). While there have been several case reports of ischemic colitis occurring in patients with various clotting disorder (factor V Leiden, antithrombin deficiency and others) it is not known whether that is a coincidental and unrelated occurrence, or whether the thrombophilia causes the ischemic colitis. There have also been case reports of patients with ischemic colitis associated with cocaine abuse, diabetes, sickle cell disease, dehydration, drugs that lead to spasm of blood vessels (including herbal products, such as bitter orange, ma huang, and guarana) and oral contraceptives and air travel. Again, it is not known whether that is a coincidental or causative association. It has also been postulated that some people develop the problem due to low blood pressure in these areas of the intestine, such as kidney failure patients during dialysis.
How is it diagnosed?
A diagnosis is made by colonoscopy with colon biopsy. Vascular Xray studies, such as arteriograms, are not useful or recommended in this disorder.
How is it treated?
Watchful waiting is mostly all that is needed. Surgery is not often needed. Blood thinners (such as warfarin) or aspirin are not typically indicated. However, if the patient has recurrent episodes and a clotting disorder is detected, blood thinners could be tried to decrease the rate of future events. However, it is not known whether they help.
Is it worth to test for thrombophilia?
No, not in the patient with only one episode of ischemic colitis. However, if a person has recurrent episodes, then I would embark on a thrombophilia (clotting disorder) work-up, as I would consider blood thinners if a thrombophilia were found.
A completely different disease: “Ischemic Colon”
This disorder is very different to a more serious disorder called ischemic colon, in which large areas of the intestine get damage or die due to occlusion of large vessels. Other medical terms for these potentially dangerous conditions are “mesenteric ischemia”, “acute mesenteric ischemia” or “superior mesenteric artery thrombosis” or “inferior mesenteric artery thrombosis” . In this emergency, patients typically need surgery and partial colon resection for “dead bowel”. This type of obstruction is most commonly caused by: (a) arteriosclerosis (= hardening of the arteries in patients with other arterial risk factors, such as diabetes, smoking, high blood pressure, high cholesterol); (b) blood clots that travel from the heart (= emboli), for example in patients with irregular heart beat (= atrial fibrillation); (c) blood clots that form in the large intestinal arteries in patients with strong clotting abnormalities (=thrombophilias). Vascular Xray studies, such as arteriograms, are typically needed in this disorder to find out where the vessel occlusion is. Patients often need surgical bowel resection and then either aspirin (for arteriosclerosis) or blood thinners like warfarin (in the case of a clot having been sent from the heart to the intestine, such as in atrial fibrillation).
- Ischemic colitis epsisodes typically resolved by themselves without specific treatment.
- We don’t know who gets it or why.
- It may or may not be related to thrombophilia.
- Thrombophilia work-up is not indicated.
- Blood thinners are typically not given.
O’Neill S et al. “Systematic Review of the Management of Ischaemic Colitis”. Colorectal Dis. 2012 Jul 7.
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Disclosures: I have no financial disclosures relevant to this post.
Last updated: Jan 15th, 2013