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Ischemic colitis

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

Synonyms and keywords: Colon ischemia; colonic ischemia; colitis ischemic; ischaemic colitis;

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2], Mehrian Jafarizade, M.D [3]

Overview

Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply. Ischemic colitis may be classified on the degree of the histopathological damage in the colonic wall: reversible colopathy (submucosal or intramural bleeding), transient colitis, chronic segmental ischemia, gangrenous colitis, and universal fulminant colitis. Also, based on its clinical course into two types: acute ischemic colitis or chronic ischemic colitis. Ischemic colitis is the result of a sudden, temporary, reduction in blood flow that is insufficient to meet the metabolic demands of the region of colon. Ischemic change will subsequently extend from the mucosa to the serosa. Mucosalinjury will develop in 20 minutes to 1 hour, and transmural infarction occurs within 8 to 16 hours. Reperfusion injury can occur with the release of reactive oxygen species, which cause lipid peroxidation within cell membranes, causing cell necrosis. schemic colitis is characterized by abdominal pain which is out of proportion to physical findings. There is a sudden onset of crampy abdominal pain, diarrhea, and an urge to defecate. The pain is mild, located over the affected bowel, and usually to the left side of the lower abdomen. Mild rectal bleeding can be noticed within 24 hours. The blood may be bright red or maroon mixed with the stools. X-rays are mainly used to check for organ perforation and pneumoperitoneum in ischemic colitis. Other noticable signs on x-ray include colonic thumbprinting from mural thickening, pneumatosis coli, a sign of advanced disease, and dilation or air-fluid levels. Ischemic colitis is usually treated with supportive care. Treatment is determined by its severity and include intravenous fluids, bowel rest, nasogastric tube, and total parenteral nutrition.

Historical Perspective

In 1963, Boley et al first described ischemic colitis in animal studies as vascular occlusion of the colon. In 1966, Marston et al coined the term ischemic colitis.

Classification

Ischemic colitis may be classified on the degree of the histopathological damage in the colonic wall: reversible colopathy (submucosal or intramural bleeding), transient colitis, chronic segmental ischemia, gangrenous colitis, and universal fulminant colitis. Also, based on its clinical course into two types: acute ischemic colitis or chronic ischemic colitis.

Pathophysiology

Ischemic colitis is the result of a sudden, temporary, reduction in blood flow that is insufficient to meet the metabolic demands of the region of colon. Ischemic change will subsequently extend from the mucosa to the serosa. Mucosalinjury will develop in 20 minutes to 1 hour, and transmural infarction occurs within 8 to 16 hours. Reperfusion injury can occur with the release of reactive oxygen species, which cause lipid peroxidation within cell membranes, causing cell necrosis.

Causes

Ischemic colitis causes of reduced blood flow can include changes in the systemic circulation such as low blood pressure or local factors such as constriction of blood vessels, a blood clot, or drugs. In most cases, no specific cause can be identified.

Differentiating Ischemic Colitis from other Diseases

Ischemic colitis must be differentiated from the many other causes of abdominal pain, rectal bleeding, and diarrhea such as infection, inflammatory bowel disease, diverticulosis, or colon cancer. It is also important to differentiate ischemic colitis, which often resolves on its own, from the more immediately life-threatening condition of acute mesenteric ischemia of the small bowel.

Epidemiology and Demographics

Ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Ischemic colitis is responsible for about 50 out of 100,000 hospital admissions, and is seen on about 100 in 100,000 endoscopies.

Risk factors

Risk factors associated with ischemic colitis are cardiovascular and pulmonary diseases such as atherosclerosis and atrial fibrillation, gastrointestinal disease like diarrhea, surgical history and medications.

Screening

There is insufficient evidence to recommend routine screening for ischemic colitis.

Natural History, Complications and Prognosis

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 gasinto the bowel wall. Occasionally, after severe ischemia, patients may develop long-term complications such as a stricture or chronic colitis.

Diagnosis

History and Symptoms

Ischemic colitis is characterized by abdominal pain which is out of proportion to physical findings. There is a sudden onset of crampy abdominal pain, diarrhea, and an urge to defecate. The pain is mild, located over the affected bowel, and usually to the left side of the lower abdomen. Mild rectal bleeding can be noticed within 24 hours. The blood may be bright red or maroon mixed with the stools.

Physical Examination

Ischemic colitis is characterized by abdominal pain which is out of proportion to physical findings, specifically excruciating abdominal pain despite limited focal tenderness.

Laboratory Findings

There are no specific blood tests for ischemic colitis, but an elevated white blood cell count may be present. Other laboratory findings in ischemic colitis include electrolyte and renal abnormalities secondary to dehydration, metabolic acidosis, and lactate level may be elevated due to any tissue hypoxia.

Abdominal X Ray

Among patients with ischemic colitis, the plain X-rays are often normal or show non-specific findings. X-rays are mainly used to check for organ perforation and pneumoperitoneum in ischemic colitis. Other noticable signs on x-ray include colonic thumbprinting from mural thickening, pneumatosis coli, a sign of advanced disease, and dilation or air-fluid levels.

CT

Among patients with ischemic colitis, the CT scan shows mild to moderate diffuse bowel wall thickening and marked hyperenhancement of the mucosa.

MRI

Magnetic resonance imaging (MRI) findings in ischemic colitis of colonic pneumatosis and portomesenteric venous gas can be used to predict the presence of transmural colonic infarction.

Ultrasound

In ischemic colitis ultrasound has limited use because of bowel gas, but may show luminal thickening over the affected segment and hypoechoic wall due to edema. Limited use due to overlying bowel gas, operator-dependent quality, and poor sensitivity for low flow vessel disease.

Other imaging finding

Fluoroscopy barium studies rarely used in diagnosis of ischemic colitis. Contrast enema is abnormal in 90% of patients but is rarely used for diagnostic purposes. Barium enema should be avoided in cases where there is a suspicion of gangrene or perforation. Also, barium enema makes the later use of angiography or endoscopy more difficult because of residual contrast agent. 

Other Diagnostic studies

Among patients with a suspicion of ischemic colitis, endoscopic evaluation, via colonoscopy or flexible sigmoidoscopy, is the diagnostic procedure of choice if the diagnosis remains unclear after other imaging studies. Colonoscopy is sensitive and allows visualization of colonic mucosa and histological analysis of biopsies. Colonoscopy requires to be performed within 48 hours for diagnosis of ischemic colitis.

Treatment

Medical Therapy

Ischemic colitis is usually treated with supportive care. Treatment is determined by its severity and include intravenous fluids, bowel rest, nasogastric tube, and total parenteral nutrition. Patients with colonic dilatation are managed with insertion of a rectal tube or endoscopic decompression. There is no evidence about the role of anticoagulation or antiplatelet therapy. Steroids have not been shown to improve outcomes.

Surgery

The mainstay of treatment for ischemic colitis is medical therapy. Surgery is usually reserved for patients with either sepsis, persistent fever and leukocytosis, peritoneal irritation, protracted pain, diarrhea or bleeding, protein-losing colopathy for more than 14 days, free intra-abdominal air, or endoscopically-proved extensive gangrene. Laparotomy confirms the diagnosis and all affected bowel is resected. 20% of patients with acute ischemic colitis will require surgery with an associated mortality rate of up to 60%. Ileocolostomy is performed in patients with right-sided ischemic colitis with viable ileum and transverse colon.

Primary prevention

There are no established measures for the primary prevention of ischemic colitis, but one can prevent the risk factors leading to ischemic colitis by not smoking, exercising regularly, and maintaining a healthy diet.

References

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Pathophysiology

Pathophysiology

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

Overview

Ischemic colitis is the result of a sudden reduction in blood flow that is insufficient to meet the metabolic demands of the region of the colon. Ischemic changes will subsequently extend from the mucosa to the serosa. Mucosal injury will develop in 20 minutes to 1 hour and transmural infarction occurs within 8 to 16 hours. Reperfusion injury can occur with the release of reactive oxygen species, which cause lipid peroxidation within cell membranes, causing cell necrosis.

Physiology

Colonic Blood Supply

Pathophysiology

The pathophysiology of ischemic colitis is as follows:[2][3][4]

Development of Ischemia

Microscopic Pathology

Images

By Nephron Micrograph of a colonic pseudomembrane, a finding that may be associated with ischemic colitis. H&E stain.Source: Own work, CC BY-SA 3.0

Videos

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References

  1. ↑ Rosenblum JD, Boyle CM, Schwartz LB (1997). “The mesenteric circulation. Anatomy and physiology”. Surg Clin North Am. 77 (2): 289–306. PMID 9146713.
  2. ↑ Granger DN, Rutili G, McCord JM (1981). “Superoxide radicals in feline intestinal ischemia”. Gastroenterology. 81 (1): 22–9. PMID 6263743.
  3. ↑ Brandt LJ, Boley SJ, Goldberg L, et al: Colitis in the elderly. Am J Gastroenterol 76:239, 1981.
  4. ↑ Washington, Christopher; Carmichael, Joseph (2012). “Management of Ischemic Colitis”. Clinics in Colon and Rectal Surgery. 25 (04): 228–235. doi:10.1055/s-0032-1329534. ISSN 1531-0043.

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Causes

Causes

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

Overview

Causes of reduced blood flow leading to ischemic colitis include changes in the systemic circulation such as low blood pressure (hypotension) or local factors such as constriction of blood vessels, a blood clot, or drugs. In most cases, no specific cause can be identified.

Causes

The causes of ischemic colitis are as follows:[1][2][3]

Non-occlusive Ischemia

Occlusive Ischemia

Drugs

The following drugs cause vasoconstriction which may compromise blood supply to the colon.

References

  1. ↑ Hass, David J.; Kozuch, Patricia; Brandt, Lawrence J. (2007). “Pharmacologically Mediated Colon Ischemia”. The American Journal of Gastroenterology. 102 (8): 1765–1780. doi:10.1111/j.1572-0241.2007.01260.x. ISSN 0002-9270.
  2. ↑ Theodoropoulou, Αngeliki; Κoutroubakis, Ioannis E (2008). “Ischemic colitis: Clinical practice in diagnosis and treatment”. World Journal of Gastroenterology. 14 (48): 7302. doi:10.3748/wjg.14.7302. ISSN 1007-9327.
  3. ↑ Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 7th ed., 2002 Saunders, p. 2332.

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Differentiating Ischemic colitis from other Diseases

Differentiating Ischemic colitis from other Diseases

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

Overview

Ischemic colitis must be differentiated from the many other causes of abdominal pain, rectal bleeding, and diarrhea such as infection, inflammatory bowel disease, diverticulosis, or colon cancer. It is also important to differentiate ischemic colitis, which often resolves on its own, from the more immediately life-threatening condition of acute mesenteric ischemia of the small bowel.

Differentiating ischemic colitis from other Diseases

The differential of ischemic colitis is as follows:[1][2]

Diseases History and Symptoms Physical Examination Laboratory findings
Diarrhea Rectal bleeding Abdominal pain Atopy Dehydration Fever Hypotension Malnutrition Blood in stool (frank or occult) Microorganism in stool Pseudomembranes on endoscopy
Allergic Colitis + ++ + ++ ++
Chemical colitis + ++ ++ + + ++ +
Infectious colitis ++ ++ ++ +++ +++ ++ + ++ ++ +
Radiation colitis + ++ + + + ++
Ischemic colitis + + ++ + + + + ++
Drug-induced colitis + + ++ + ++ +

The differential diagnosis of abdominal pain are:

Classification of acute abdomen based

on etiology

Presentation Clinical findings Diagnosis Comments
Fever Rigors and Chills Abdominal Pain Jaundice Hypotension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Common causes of

Peritonitis

Spontaneous bacterial peritonitis + Diffuse − − − − Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
 Ultrasound for evaluation of liver cirrhosis –
Perforated gastric and duodenal ulcer + Diffuse − + + + N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
 Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis
Acute suppurative cholangitis + + RUQ + + + + ±
Acute cholangitis + − RUQ + − − − N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis + RUQ + − − Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis + Epigastric ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back
Acute appendicitis + RLQ − + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Acute diverticulitis + LLQ ± + − Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation
Hollow Viscous Obstruction Small intestine obstruction − Diffuse − + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Gall stone disease/Cholelithiasis ± −
Volvulus – Diffuse – + – Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Biliary colic – RUQ + – – N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting
Renal colic – Flank pain – – – N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical – – – Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination
Acute ischemic colitis ± Diffuse – + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting
Hemorrhagic causes Ruptured abdominal aortic aneurysm – Diffuse – – – N Normal CT scan Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage – Diffuse – – – N Anemia CT scan History of trauma
Gynaecological Causes Fallopian tube Acute salpingitis + LLQ/ RLQ − ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge
Ovarian cyst complications and endometrial disease Torsion of the cyst – RLQ / LLQ – ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Endometriosis – RLQ/LLQ – +/- +/- N Normal Laproscopy Menstrual-associated symptoms, pelvic

symptoms

Cyst rupture – RLQ / LLQ – +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Pregnancy Ruptured ectopic pregnancy – RLQ / LLQ – – – N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding
Functional Irritable Bowel Syndrome – Diffuse – – – – N

Clinical diagnosis

–

References

  1. ↑ Thielman NM, Guerrant RL (2004). “Clinical practice. Acute infectious diarrhea”. N Engl J Med. 350 (1): 38–47. doi:10.1056/NEJMcp031534. PMID 14702426.
  2. ↑ Khan AM, Faruque AS, Hossain MS, Sattar S, Fuchs GJ, Salam MA (2004). “Plesiomonas shigelloides-associated diarrhoea in Bangladeshi children: a hospital-based surveillance study”. J Trop Pediatr. 50 (6): 354–6. doi:10.1093/tropej/50.6.354. PMID 15537721.

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Epidemiology and Demographics

Epidemiology and Demographics

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

Overview

Ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Ischemic colitis is responsible for about 50 out of 100,000 hospital admissions, and is seen on about 100 in 100,000 endoscopies.

Epidemiology and Demographics

The epidemiology and demographics of ischemic colitis are as follows:[1][2][3][4][5][6]

Prevalence

  • The exact incidence of ischemic colitis is difficult to estimate, as many patients with mild ischemia may not seek medical attention.
  • Ischemic colitis is responsible for about 50 out of 100,000 hospital admissions, and is seen on about 100 in 100,000 endoscopies.

Age

  • Ischemic colitis is a disease of the elderly, with greater than 90% of cases occurring in people over the age of 60.

Sex

  • Females are more likely to suffer from ischemic colitis than are males.

References

  1. ↑ Higgins P, Davis K, Laine L (2004). “Systematic review: the epidemiology of ischaemic colitis”. Aliment Pharmacol Ther. 19 (7): 729–38. doi:10.1111/j.1365-2036.2004.01903.x. PMID 15043513.
  2. ↑ Brandt LJ, Boley SJ (2000). “AGA technical review on intestinal ischemia. American Gastrointestinal Association”. Gastroenterology. 118 (5): 954–68. doi:10.1016/S0016-5085(00)70183-1. PMID 10784596.
  3. ↑ American Gastroenterological Association (2000). “American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia”. Gastroenterology. 118 (5): 951–3. doi:10.1016/S0016-5085(00)70182-X. PMID 10784595. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3069&nbr=2295
  4. ↑ Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 7th ed., 2002 Saunders, p. 2332.
  5. ↑ Higgins, P. D. R.; Davis, K. J.; Laine, L. (2004). “The epidemiology of ischaemic colitis”. Alimentary Pharmacology and Therapeutics. 19 (7): 729–738. doi:10.1111/j.1365-2036.2004.01903.x. ISSN 0269-2813.
  6. ↑ chang, l.; kahler, k. h.; sarawate, c.; quimbo, r.; kralstein, j. (2007). “Assessment of potential risk factors associated with ischaemic colitis”. Neurogastroenterology & Motility. 0 (0): 070927130501002–???. doi:10.1111/j.1365-2982.2007.01015.x. ISSN 1350-1925.

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Natural History, Complications and Prognosis

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]

Overview

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.

Natural History

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

Complications

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

Prognosis

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

References

  1. ↑ Hunter GC, Guernsey JM (1988). “Mesenteric ischemia”. Med. Clin. North Am. 72 (5): 1091–115. PMID 3045452.
  2. ↑ Nikolic, Amanda L.; Keck, James O. (2017). “Ischaemic colitis: uncertainty in diagnosis, pathophysiology and management”. ANZ Journal of Surgery. doi:10.1111/ans.14237. ISSN 1445-1433.
  3. ↑ Montoro, Miguel A.; Brandt, Lawrence J.; Santolaria, Santos; Gomollon, Fernando; Puértolas, Belén Sánchez; Vera, Jesús; Bujanda, Luis.; Cosme, Angel; Cabriada, José Luis; Durán, Margarita; Mata, Laura; Santamaría, Ana; Ceña, Gloria; Blas, Jose Manuel; Ponce, Julio; Ponce, Marta; Rodrigo, Luis; Ortiz, Jacobo; Muñoz, Carmen; Arozena, Gloria; Ginard, Daniel; López-Serrano, Antonio; Castro, Manuel; Sans, Miquel; Campo, Rafael; Casalots, Alex; Orive, Víctor; Loizate, Alberto; Titó, Lluçia; Portabella, Eva; Otazua, Pedro; Calvo, M.; Botella, Maria Teresa; Thomson, Concepción; Mundi, Jose Luis; Quintero, Enrique; Nicolás, David; Borda, Fernando; Martinez, Benito; Gisbert, Javier P.; Chaparro, María; Bernadó, Alfredo Jimenez; Gómez-Camacho, Federico; Cerezo, Antonio; Nuñez, Enrique Casal (2010). “Clinical patterns and outcomes of ischaemic colitis: Results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study)”. Scandinavian Journal of Gastroenterology. 46 (2): 236–246. doi:10.3109/00365521.2010.525794. ISSN 0036-5521.
  4. ↑ . doi:10.3109/10.3748/wjg.14.7302. Missing or empty |title= (help)
  5. ↑ O’Neill, Stephen; Elder, Kenny; Harrison, Sarah J.; Yalamarthi, Satheesh (2011). “Predictors of severity in ischaemic colitis”. International Journal of Colorectal Disease. 27 (2): 187–191. doi:10.1007/s00384-011-1301-x. ISSN 0179-1958.
  6. ↑ Medina C, Vilaseca J, Videla S, Fabra R, Armengol-Miro J, Malagelada J (2004). “Outcome of patients with ischemic colitis: review of fifty-three cases”. Dis Colon Rectum. 47 (2): 180–4. PMID 15043287.
  7. ↑ Simi M, Pietroletti R, Navarra L, Leardi S (1995). “Bowel stricture due to ischemic colitis: report of three cases requiring surgery”. Hepatogastroenterology. 42 (3): 279–81. PMID 7590579.
  8. ↑ Boley, SJ, Brandt, LJ, Veith, FJ. Ischemic disorders of the intestines. Curr Probl Surg 1978; 15:1.
  9. ↑ Hunter G, Guernsey J (1988). “Mesenteric ischemia”. Med Clin North Am. 72 (5): 1091–115. PMID 3045452.
  10. ↑ Cappell M (1998). “Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia”. Gastroenterol Clin North Am. 27 (4): 827–60, vi. PMID 9890115.
  11. ↑ Cappell M (1998). “Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia”. Gastroenterol Clin North Am. 27 (4): 827–60, vi. PMID 9890115.
  12. ↑ Simi M, Pietroletti R, Navarra L, Leardi S (1995). “Bowel stricture due to ischemic colitis: report of three cases requiring surgery”. Hepatogastroenterology. 42 (3): 279–81. PMID 7590579.
  13. ↑ Oz M, Forde K (1990). “Endoscopic alternatives in the management of colonic strictures”. Surgery. 108 (3): 513–9. PMID 2396196.
  14. ↑ Profili S, Bifulco V, Meloni G, Demelas L, Niolu P, Manzoni M (1996). “self-expandable uncoated metallic prosthesis“. Radiol Med (Torino). 91 (5): 665–7. PMID 8693144.
  15. ↑ Longo W, Ballantyne G, Gusberg R (1992). “Ischemic colitis: patterns and prognosis”. Dis Colon Rectum. 35 (8): 726–30. PMID 1643995.
  16. ↑ Parish K, Chapman W, Williams L (1991). “Ischemic colitis. An ever-changing spectrum?”. Am Surg. 57 (2): 118–21. PMID 1992867.

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Diagnosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | Abdominal X Ray | CT | Endoscopy

Treatment

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case Studies

Case #1

Related Chapters

This article concerns ischemia of the large bowel. See mesenteric ischemia for ischemia of small bowel

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