Ischemic colitis

Ischemic colitis is a disorder in which part of your colon (large intestine) becomes inflamed and injured. Usually, the problem is caused by impaired blood flow to your colon. This can lead to areas of colon inflammation and, in some cases, permanent colon damage.

Ischemic colitis can affect any part of your colon, but most affected people develop pain on the left side of the abdomen. Urgent bowel movements and bloody diarrhea also are common to ischemic colitis.

Although it sounds scary, most cases of ischemic colitis are mild and resolve on their own in a couple of days. Still, because the condition can become severe, call your doctor right away if you develop symptoms of ischemic colitis.

schemic colitis involves inadequate blood supply reaching your colon. In acute cases, the most frequent cause is blood clots in the arteries leading to your colon. Chronic cases are usually associated with the buildup of fatty deposits (atherosclerosis) in the blood vessels leading to your colon.

In some people, ischemic colitis may be caused by or related to other medical conditions, including:

  • Inflammation of the blood vessels (vasculitis)
  • Protrusion of an organ or tissue into the surrounding tissue, interfering with the arterial as well as the venous blood supply to the intestine (hernia)
  • Elevated sugar, or glucose, levels in the blood (diabetes mellitus)
  • Easy blood clotting (hypercoagulable state)
  • Radiation treatment to the abdomen
  • Colon cancer

The role of medications
Certain medicines also rarely cause ischemic colitis as a side effect. These include:

  • Nonsteroidal anti-inflammatory drugs
  • Estrogen replacement medications
  • Migraine medications in the triptan or ergot class
  • Blood pressure pills
  • Certain antipsychotic drugs
  • The heart drug digoxin (Lanoxin)
  • Pseudoephedrine

Ischemic colitis

The prescription drug alosetron (Lotronex), used by women with severe irritable bowel syndrome (IBS), carries a Food and Drug Administration warning about its potential link to serious conditions, including ischemic colitis. Before you start Lotronex, your doctor will ask you to read a guide about this drug and sign an agreement that you understand its risks and possible benefits.

Other causes
Abdominal surgery, particularly when it involves repair of a bulging arterial wall (aneurysm) in the region, is occasionally followed by ischemic colitis. In some cases, ischemic colitis may be triggered by infections involving bacteria (such as Escherichia coli), viruses (cytomegalovirus) or parasites (Entamoeba histolytica).

Common signs and symptoms of ischemic colitis include:

  • Abdominal pain, tenderness or cramping, usually localized to the lower left side of your abdomen; the onset can be sudden or gradual
  • Low-grade fever
  • Bright red or maroon-colored blood in your stool or, at times, passage of blood without stool
  • A feeling of urgency to move your bowels
  • Diarrhea
  • Nausea
  • Vomiting

The risk of severe complications from ischemic colitis increases when signs and symptoms affect the right side of your abdomen.

The arteries that feed the right side of your colon also feed part of your small intestine. When blood flow is blocked on the right side of your colon, it’s likely that part of your small intestine also isn’t receiving adequate blood supply. Additional signs and symptoms of problems in the small intestine involve pain in the upper abdomen that comes on after eating and is severe enough to cause you to avoid food and lose weight.

Blocked blood flow to the small intestine may quickly lead to death of intestinal tissue (infarction or necrosis). If this life-threatening situation occurs, you’ll need surgery to clear the blockage and to remove the portion of the intestine that has died.

Risk factors for ischemic colitis include:

  • Age. The condition occurs with greatest frequency in older adults. If it occurs in a young adult, it may be a sign of a blood-clotting abnormality or an inflammation of the blood vessels (vasculitis).
  • Heart disease risk factors. The impaired blood flow responsible for ischemic colitis is more likely to occur in people who have traits or conditions commonly associated with heart disease. These include tobacco use, high blood pressure, and elevated cholesterol and triglyceride levels.
  • Certain medical conditions. Some disorders are considered predisposing factors that place you at greater risk of developing ischemic colitis, or they can aggravate it when it occurs. These include previous abdominal operations, heart failure, low blood pressure and shock.

In most cases, ischemic colitis resolves on its own within one to two days. In more advanced cases of ischemic colitis, complications may include:

  • Gangrene. Untreated ischemic colitis could lead to tissue death (gangrene) in your colon. Gangrene may develop three to four weeks after the initial impairment of blood flow to your colon and can result in death if you don’t receive timely treatment.
  • Bleeding. Ischemic colitis can also cause a hole (perforation) in your intestine or persistent bleeding.
  • Pain and blockage. Even as healing occurs, ischemic colitis can lead to colon scarring and narrowing. This can cause chronic abdominal pain and blockage.
  • Colon cancer. In rare cases, ischemic colitis is the first sign of colon cancer.
  • Other rare complications. These may include the accumulation of pus in the colon (abscess) and an inflammation of the membrane of the abdominal wall (peritonitis).

You’re likely to start by first seeing your family doctor or a general practitioner. However, in some cases when you call to set up an appointment, you may be referred immediately to a digestive disorders specialist called a gastroenterologist or to an emergency department if your symptoms are severe.

Because appointments can be brief, and because there’s often a lot of ground to cover, it’s a good idea to be well prepared for your appointment. Here’s some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

  • Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance. For example, you may need to avoid solid foods and certain medications in the day leading up to your appointment.
  • Write down any symptoms you’re experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
  • Write down key personal information, including any major stresses or recent life changes. Also include your diet and exercise habits.
  • Make a list of your key medical information, including other conditions you’re being treated for and the names of the medications that you’re taking. Include on your list every prescription and over-the-counter drug you use, as well as any vitamins and supplements.
  • Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out.

For ischemic colitis, some basic questions to ask your doctor include:

  • What is likely causing my symptoms or condition?
  • Are there any other possible causes for my symptoms or condition?
  • Do you think my condition is temporary or chronic?
  • What kinds of tests do I need?
  • What is the best course of action?
  • I have these other health conditions. How can I best manage them together?
  • Are there any restrictions that I need to follow?
  • Is there anything I can do to prevent a recurrence of this problem?
  • Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist?
  • Is there a generic alternative to the medicine you’re prescribing me?
  • Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask questions during your appointment at any time that you don’t understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to talk about in-depth. Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • Have your symptoms stayed the same or gotten worse?
  • How severe are your symptoms?
  • Have you had any change in your bowel habits or has there been blood in your stools?
  • Where is your pain located?
  • Do you have any personal history of blood clots in your legs, lungs or anywhere else?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?
  • Have you had any recent medical procedures?
  • What medications are you currently taking?
  • Do you or did you smoke? How much?

What you can do in the meantime
While you’re waiting for your appointment, make a conscious effort to drink more fluid. Good hydration may help improve your symptoms. Ask your doctor if you should switch to a liquid diet before your appointment.

Ischemic colitis diagnosis

Your doctor begins by taking a medical history and conducting a thorough physical examination. During the exam, he or she will check your abdomen for areas of tenderness. You also may undergo the following diagnostic procedures:

  • Colonoscopy. A colonoscopy is considered the definitive test for diagnosing ischemic colitis. In this procedure, a flexible lighted tube is inserted into your rectum and guided into the colon. A tiny camera at the tip of the scope sends images of your colon to a video screen. Your doctor can then view the interior lining of your colon and detect any inflammatory tissue and ulcers.
  • Biopsy. Sometimes, as part of a colonoscopy, your doctor may remove a small tissue sample (biopsy) from your colon for laboratory analysis. In ischemic colitis, swelling and bleeding may be present under the colon’s lining (mucosal layers), and can be detected in the laboratory.

A colonoscopy can rule out other causes of inflammation in your colon, including certain infections, inflammatory bowel disease, inflammation of the walls of the intestines (diverticulitis) and colon cancer. If the inflammation is severe, your doctor may not be able to see your entire colon well or obtain adequate biopsies.

It’s often necessary to have a repeat colonoscopy once the inflammation has subsided. This allows your doctor to be sure that nothing of concern is present, such as persistent inflammation, scarring or colon cancer.

Other diagnostic tests
Your doctor may also suggest these other procedures to make a diagnosis:

  • X-rays of the abdomen and pelvis. These are often conducted in combination with a barium enema. In this process, a contrast material (liquid barium) is introduced into your colon through your rectum. Once your colon is coated with barium, a radiologist takes X-ray pictures of your intestines. These images, which can be viewed on a video monitor, can detect abnormalities within your colon and help distinguish ischemic colitis from other inflammatory conditions. Images that indicate ischemic colitis may show thickening (thumbprinting) of the wall of your colon.
  • Abdominal arteriogram. This is an X-ray of the arteries in your abdomen. It can show narrowing or blockages in these vessels, which may indicate ischemic colitis. A contrast dye is injected into your arteries before the X-rays are taken to help produce clear images. This procedure is usually not necessary for the diagnosis of ischemic colitis.
  • Abdominal magnetic resonance imaging (MRI). This imaging test can provide excellent views of the blood vessels and show blockages that may indicate ischemic colitis. Abdominal MRI is infrequently used in the diagnosis of ischemic colitis.
  • Abdominal computerized tomography (CT) scans. Doctors sometimes use these scans to rule out other conditions that can cause symptoms similar to ischemic colitis. This radiological test uses sophisticated X-ray technology to produce detailed cross-sectional images of your colon. Your doctor may be able to detect thickening of the colon wall on the scans.
  • Blood tests. People with ischemic colitis may have an elevated white blood cell count (WBC) that occurs when the body is fighting an infection. If your doctor suspects you have a blood-clotting problem, you may be referred to a blood specialist (hematologist) for more-specific blood tests.
  • Stool sample. Analysis of a sample of your stool in the laboratory may reveal bacteria and other infectious microorganisms associated or confused with ischemic colitis.

Treatment for ischemic colitis

The choice of treatment for ischemic colitis depends on the severity of your condition.

When ischemic colitis is mild, your doctor may prescribe medications to keep your blood pressure at normal levels, which will help facilitate blood flow to your colon. You may also need to take antibiotics to prevent infections from developing. Your doctor will treat any underlying health problems, such as heart failure, and may prescribe an aspirin a day.

With such conservative measures, symptoms often diminish in 24 to 48 hours in mild cases, without the need for hospitalization.

However, if you’re dehydrated, you may need hospitalization to provide fluids and nutrients through your veins (intravenously). You may also need restrictions on food intake for a few days to let your intestines rest.

Your doctor will continue to monitor you regularly with follow-up colonoscopies to determine whether the disease has healed or progressed, and whether complications have developed. In mild cases, healing may occur in two weeks or less. In more severe cases, recovery can take longer, and relapses can occur.

If you develop ischemic colitis before the age of 50 or have a history of blood clots, you could have a disorder increasing the tendency of your blood to clot. Your doctor may treat this with a blood thinner such as warfarin, which could help prevent the likelihood of future ischemic colitis episodes.

Surgery
Some people with severe or prolonged ischemic colitis need surgical treatment to remove (resect) the affected part of the colon or bowel.

You may need surgery for ischemic colitis if your condition is associated with:

  • Abdominal tenderness and fever that are severe and persistent, even after initial treatment with fluids and medications.
  • Bleeding ulcers.
  • A hole (perforation) in your colon.
  • Gangrene and blood infection (sepsis). Treatment for this severe complication also includes broad-spectrum antibiotics and blood replacement.

There’s no proven way to prevent ischemic colitis. But the good news is that the majority of those who have it recover quickly and never have another episode.

Still, it makes sense to avoid a drug that may have caused ischemic colitis in the past. And if you have underlying conditions associated with a risk of ischemic colitis — including heart disease and high blood pressure — make sure you’re receiving ongoing treatment. Your doctor may recommend that you:

  • Stop smoking
  • Take cholesterol-lowering medication
  • Treat high blood pressure
  • Exercise regularly