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Questions
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Evidence
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Snapshot
  • A 73-year-old woman presents with severe abdominal pain and a recent history of passing bloody stools. The pain began about 3 days ago and is more concentrated at the left side of the abdomen. Physical examination shows decreased-to-absent bowel sounds, abdominal distention, and diffuse tenderness to palpation over her abdomen. A barium-enema study is performed which shows "thumb-printing" of the colon. 
Introduction
  • Clinical definition
    • medical condition characterized by inadequate blood supply to the large intestine leading to inflammation and injury of the colon
  • Epidemiology
    • demographics
      • more common in the elderly population
      • most common form of bowel ischemia
    • risk factors 
      • aortoiliac surgery/instrumentation
      • myocardial infarction
      • hemodialysis
      • hypercoagulable states (e.g., hereditary thrombophilia)
  • Pathogenesis
    • ischemic colitis is the result of blood flow reduction to the colon and is particularly prominent at the “watershed” areas of the colon where collateral blood flow is limited
      • the splenic flexure and rectosigmoid junction are particularly at risk for ischemia 
    • nonocclusive colonic ischemia
      • accounts for the mass majority of cases (95%)
      • typically transient hypoperfusion
      • examples include shock, systemic hypotension or atherosclerosis of SMA  
    • occlusive colonic ischemia
      • can be embolic (e.g., spontaneous or iatrogenic) or thrombotic secondary to atherosclerotic disease
    • mesenteric vein thrombosis
      • extremely rare and usually involves the small intestine
Presentation
  • Symptoms 
    • mild cramping abdominal pain commonly involving the left side  
      • less severe compared to mesenteric ischemia
    • hematochezia
      • usually follows within 24 hours after abdominal pain
    • diarrhea
    • vomiting
  • Physical exam
    • fever
    • abdominal tenderness
    • weight loss
Imaging
  • Abdominal radiograph
    • usually normal but may be useful in excluding other causes of abdominal pain
    • may also identify complications of mesenteric ischemia (e.g., necrosis)
  • Computed tomography (CT) without oral contrast
    • best initial test  
    • may see bowel wall thickening in a segmental pattern (thumbprinting), bowel dilation, mesenteric stranding, or intestinal pneumatosis 
  • Endoscopic evaluation
    • can be done via colonoscopy for flexible sigmoidoscopy
    • allows for biopsy of suspicious areas
    • positive findings include edematous, friable mucosa, erythema, and interspersed pale areas 
Studies
  • Laboratory studies
    • leukocytosis
    • elevated lactate
    • metabolic acidosis
Differential
  • Mesenteric ischemia 
    • differentiating factors
      • commonly presents with severe abdominal pain and does not accompany hematochezia
  • Colonic malignancy 
    • differentiating factors
      • will appear differently on endoscopy and abdominal CT
Treatment 
  • Management approach
    • treatment is dependent on its etiology, severity, and the clinical setting  
  • Mild colonic ischemia
    • supportive care
      • bowel rest and observation
      • nasogastric tube if ileus is present
      • monitor for persistent fever, leukocytosis, peritonitis, or other signs of clinical deterioration
    • most patients will recover within days
  • Moderate colonic ischemia
    • antibiotics
    • antithrombotic therapy
      • indicated for patients with mesenteric venous thrombosis or thromboembolism
  • Severe colonic ischemia
    • signs of peritonitis, pneumatosis on imaging, or gangrene on colonoscopy
    • exploratory laparotomy
      • inidicated in patients with signs of bowel ischemia
      • resected of necrotic bowel if applicable
Complications
  • Bowel necrosis
  • Perforation
  • Sepsis
  • Death
  • Stricture/obstruction
 

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Questions (2)

(M1.GI.13.91) A 71-year-old Caucasian male presents to your office with bloody diarrhea and epigastric pain that occurs 30 minutes after eating. He has lost 15 pounds in 1 month, which he attributes to fear that the pain will return following a meal. He has a history of hyperlipidemia and myocardial infarction. Physical exam and esophagogastroduodenoscopy are unremarkable. What is the most likely cause of this patient's pain? Tested Concept

QID: 101148
1

Atherosclerosis

49%

(57/117)

2

Peptic ulcer disease

26%

(31/117)

3

Crohn's disease

3%

(4/117)

4

Amyloid deposition

5%

(6/117)

5

Diverticulosis

15%

(17/117)

M 1 E

Select Answer to see Preferred Response

(M1.GI.13.107) A 75-year-old male is hospitalized for bloody diarrhea and abdominal pain after meals. Endoscopic work-up and CT scan lead the attending physician to diagnose ischemic colitis at the splenic flexure. Which of the following would most likely predispose this patient to ischemic colitis: Tested Concept

QID: 101164
1

Increased splanchnic blood flow following a large meal

17%

(39/234)

2

Essential hypertension

21%

(49/234)

3

Obstruction of the abdominal aorta following surgery

50%

(118/234)

4

Hyperreninemic hyperaldosteronism secondary to type II diabetes mellitus

6%

(14/234)

5

Juxtaglomerular cell tumor

5%

(11/234)

M 2 D

Select Answer to see Preferred Response

Evidence (3)
Topic COMMENTS (7)
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