Ischemic colitis

Ischemic colitis is a transitory violation of the circulation of the large intestine.

The blood supply of the large intestine is provided by the upper and lower mesenteric arteries. The upper mesenteric artery blood supply to the entire thin, blind, ascending and partially transverse colon; the lower mesenteric artery is the left half of the large intestine.

With ischemia of the large intestine, a significant number of microorganisms inhabiting it contribute to the development of inflammation in the intestinal wall (even transient bacterial invasion is possible). Inflammatory process, caused by ischemia of the wall of the colon, further leads to the development of connective tissue in it and even the formation of fibrous stricture.

The most permanently with ischemic colitis affects the splenic flexure and the left parts of the colon.

[1], [2], [3], [4], [5]

What causes ischemic colitis?

Necrosis may develop, but usually the process is limited to the mucosa and submucosa and only occasionally affects the entire wall, which requires surgical intervention. This occurs mainly in the elderly (over 60 years of age), and the etiology is unknown, although there is a definite association with the same risk factors that are associated with acute mesenteric ischemia.

Symptoms of ischemic colitis

Symptoms of ischemic colitis are less pronounced and develop more slowly than in acute mesenteric ischemia, and include pain in the left lower quadrant of the abdomen, accompanied by rectal bleeding.

1. Stomach ache. Pain sensations in the abdomen appear 15-20 minutes after eating (especially abundant) and last from 1 to 3 hours. The intensity of pain is different, often they are quite strong. With the progression of the disease and the development of fibrotic strictures of the colon, the pain becomes permanent.

The most frequent pain localization is the left iliac region, the projection of the splenic flexure of the transverse colon, and, rarely, the substrate or the peripodal region.

2. Dyspeptic disorders. Almost 50% of patients have decreased appetite, nausea, bloating, sometimes belching with air, food.
3. Violations of the stool. Observed almost continuously and manifested by constipation or diarrhea, alternating with constipation. During an exacerbation diarrhea is more typical.
4. Losing weight of patients. The drop in body weight in patients with ischemic colitis is fairly regular. This is due to the restriction of the amount of food and the frequency of its intake (due to increased pain after eating) and a violation of the absorption function of the intestine (quite often, along with ischemia of the colon, there is a worsening of blood circulation in the small intestine).
5. Intestinal bleeding. 80% of patients are observed. The intensity of bleeding is different - from the admixture of blood in the feces until the allocation of significant amounts of blood from the rectum. Bleeding is caused by erosive-ulcerative changes in the mucous membrane of the large intestine.
6. Objective abdominal syndrome. Exacerbation of ischemic colitis is characterized by indistinctly expressed signs of irritation of the peritoneum, the tension of the abdominal muscles. When palpation of the abdomen, diffuse sensation is noted, as well as soreness predominantly in the left iliac region or the left side of the abdomen.

Symptoms of pronounced irritation of the peritoneum, especially those persisting for several hours, make one think of transmural necrosis of the intestine.

Diagnosis of ischemic colitis

The diagnosis is made with a colonoscopy; angiography is not indicated.

Laboratory and instrumental data

1. General blood test : characterized by pronounced leukocytosis, a shift of the leukocyte formula to the left, an increase in ESR. With repeated intestinal bleeding anemia develops.
2. Urinalysis : without significant changes.
3. Stool analysis : a large number of erythrocytes, leukocytes, intestinal epithelium cells are found in the feces.
4. Biochemical blood test: reduction in the total protein, albumin (with a long course of the disease), iron, sometimes sodium, potassium, calcium.

Colonoscopy: performed strictly according to indications and only after the reduction of acute manifestations. The following changes are revealed: knotty areas of swollen mucous membrane of blue-purple color, hemorrhagic lesions of mucous membrane and submucosa, ulcerous defects (in the form of dots, longitudinal, serpentine), strictures are often found, mainly in the area of splenic flexure of the transverse colon.

Microscopic examination of colon biopsy specimens reveals edema and thickening, submucosal fibrosis, infiltration by its lymphocytes, plasma cells, granulation tissue in the area of the bottom of ulcers. A characteristic microscopic sign of ischemic colitis is the presence of multiple hemosiderin-containing macrophages.

6. Obstetric radiography of the abdominal cavity: an increased amount of air in the splenic corner of the colon or other parts of the colon is determined.
7. Irrigoscopy : performed only after relief of acute manifestations of the disease. At the level of lesion, narrowing of the colon is determined, above and below is the expansion of the intestine; Hausters are poorly expressed; sometimes nodular, polypoid thickening of the mucous membrane, ulceration. In the marginal areas of the intestine, finger-like prints are identified (a symptom of the "thumbprint"), caused by swelling of the mucous membrane; dentition and irregularity of the mucosa.
8. Angiography and Doppler ultrasonography: a decrease in the lumen of the mesenteric arteries is revealed.
9. Pristenochnaya pH-metry of the large intestine using a catheter with a balloon: allows you to compare the pH of tissues before and after eating. An indication of tissue ischemia is intramural acidosis.

In the diagnosis of ischemic colitis, the following circumstances help:

• age over 60-65 years;
• presence of IHD, arterial hypertension, diabetes mellitus, obliterating atherosclerosis of peripheral arteries (these diseases significantly increase the risk of development of ischemic colitis);
• episodes of acute abdominal pain followed by intestinal bleeding;
• the corresponding endoscopic picture of the condition of the colon mucosa and the results of a histological examination of colon biopsy specimens;

[6], [7], [8], [9], [10],

Differential diagnosis of ischemic colitis

Ischemic colitis has many common clinical manifestations with Crohn's disease and ulcerative colitis: abdominal pain, dyspeptic syndrome, stool disorders, intestinal bleeding, ulceration of the mucous membrane.

[11], [12], [13], [14], [15], [16],

Treatment of ischemic colitis

Treatment of ischemic colitis is symptomatic and includes intravenous fluids, hunger and antibiotic therapy. The need for surgical treatment is rarely required.

What is the prognosis of ischemic colitis?

Approximately 5% of patients experience a relapse. Sometimes a stricture develops on the ischemia site, which requires a gut resection.