Ischemic colitis natural history, complications and prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2]

Ischemic colitis can span a wide spectrum of severity. Majority of patients are treated supportively and recover fully, while a minority with very severe ischemia may develop sepsis and become critically ill. Most patients make a full recovery. As the disease progresses, submucosal hemorrhage or edema may result in focal mucosal thickening, known as “thumbprinting.” Pneumatosis intestinalis may occur if mucosal damage has taken place with passage of gas into the bowel wall. Occasionally, after severe ischemia, patients may develop long-term complications such as a stricture or chronic colitis.

The natural history of ischemic colitis is as follows:^{[1][2][3][4][5][6][7][8][9][10]}

• As the disease progresses, submucosal hemorrhage or edema may result in focal mucosal thickening, known as “thumbprinting” 
• Pneumatosis intestinalis may occur if mucosal damage has taken place with passage of gas into the bowel wall
• The symptoms of ischemic colitis usually develop in the sixth decade of life and start with symptoms such as abdominal pain, bloody diarrhea, and vomiting
• Ischemic colitis can progress to different stages depending on the elapsed time:
  • Reversible ischemic colopathy
    • Characterized by submucosal hemorrhage at endoscopy, with involvement of superficial mucosa.
    • Self-limiting
  • Transient: the most common form
    • Present with abdominal pain, rectal bleeding and full-thickness involvement of the mucosa.
  • Chronic segmental or chronic ulcerative
    • Persistent symptoms or recurrent episodes of pain, rectal bleeding, diarrhea, and segmental colitis on imaging
    • Resection is usually curative
  • Ischemic colonic stricture
    • Found at follow-up endoscopy
  • Gangrenous colitis
    • Suspected when there is increasing abdominal pain, signs of local or generalized peritonitis, fevers or ileus
  • Universal fulminant pancolitis
    • Presents acutely with severe symptoms, progressive transmural infarction and necrosis of the entire colon, resultant sepsis and perforation
    • 75% mortality rate
    • Symptoms include sepsis, severe abdominal pain, peritonitis and rectal bleeding

The complications of ischemic colitis are as follows:^{[11][12][13][14]}

• About 20% of patients with acute ischemic colitis may develop a long-term complication known as chronic ischemic colitis
  • Symptoms can include recurrent infections, bloody diarrhea, weight loss, and chronic abdominal pain
  • Chronic ischemic colitis is often treated with surgical removal of the chronically diseased portion of the bowel

• A colonic stricture is a band of scar tissue which forms as a result of the ischemic injury and narrows the lumen of the colon
  • Strictures are often treated observantly; they may heal spontaneously over 12-24 months
  • If a bowel obstruction develops as a result of the stricture, surgical resection is the usual treatment although endoscopic dilatation and stenting have also been employed

The prognosis of ischemic colitis is as follows:^[15][16]

• Majority of patients with ischemic colitis recover fully, although the prognosis depends on the severity of the ischemia
• Patients with pre-existing peripheral vascular disease or ischemia of the ascending (right) colon may be at increased risk for complications or death

• Non-gangrenous ischemic colitis, which comprises the majority of cases, is associated with a mortality rate of approximately 6%
  • Minority of patients who develop gangrene as a result of colonic ischemia have a mortality rate of 50-75% with surgical treatment
  • Mortality rate is almost 100% without surgical intervention

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