Black Friday Deal Is Live!
Lifetime membership to EndoCollab is 50% off → just $249 one-time (regular $499). Includes full video library, atlas, community, WhatsApp group, everything. Offer ends Cyber Monday. https://link.endocollab.com/bfcm25
By Klaus Mönkemüller, MD, PhD, FASGE, FJGES, Troy Pleasant, MD, and Anand Dwivedi, MD
Virginia Tech Carilion School of Medicine, Virginia, USA
Transient or left-sided ischemic colitis is the most common type of ischemia of the gastrointestinal tract. Indeed, ischemic colitis is the second or third most common cause of lower GI bleeding. Herein we present two cases with classic features of transient ischemic colitis and focus on its endoscopic diagnosis.
Case Presentations:
Case 1: Elderly patient developed abdominal pain followed by bloody diarrhea. Colonoscopy showed patchy colitis of the left colon (Figure 1), the rectum was spared. Notice the patchy characteristic of this colitis. Panel A shows small ulcers with erythematous halo. In Panels C to E the classic Zuckerman sign can be appreciated.
Figure 1. Endoscopic images from case 1.
A diagnosis of ischemic colitis was confirmed histologically. There were no significant risk factors for vascular occlusive disease or vasculitis. The patient improved with supportive measures, and she was discharged home two days later.
Case 2:
60-year-old female patient without significant past medical history presented with hematochezia that started after acute onset left sided abdominal pain. Only the bleeding continued, the pain disappeared after about 12-18 hours. CT of the abdomen revealed left sided colon stenosis and inflammation. Colonoscopy images are shown (Figure 2).
Figure 2. Endoscopic images from case 2.
Colonic ischemia occurs due to changes in systemic circulation and/or alterations in local mesenteric vasculature. Left-sided ischemic colitis, also called transient ischemic colitis, is characterized by acute onset abdominal pain and bloody diarrhea or hematochezia. This condition can occur in any age group, but it is seen most in the elderly. Risk factors for transient ischemic colitis are atherosclerosis, heart failure, cardiac arrhythmias, shock, vasculopathies, abdominal aortic surgery, and hypercoagulability states. Indeed, the abrupt blood flow to the colon, which can occur after a marathon, exertion, or transient vessel occlusion from constriction (cocaine), thrombosis or low flow state can also result in transient ischemic colitis. Classic medications associated with ischemic colitis are estrogens, NSAIDs and alosetron (1).
The most frequently affected areas are the left colon and superior rectum, the lower rectum usually being spared because of its dual blood supply.
The main differential diagnoses of ischemic colitis are infectious colitis, diverticulitis, and inflammatory bowel disease. Therefore, stool cultures and histology are an important part of the work-up of patients presenting with abdominal pain and bloody stools. Regular stool cultures do not detect Klebsiella oxytoca or enterohaemorrhagic Escherichia coli, and this should be specifically stated in the microbiology request form. The diagnosis is established by endoscopy and histology (1).
The endoscopic spectrum of ischemic colitis is broad (Figure 3).
Figure 3. Endoscopic spectrum of ischemic colitis
Key elements though are sparing of the rectum and segmental distribution, mainly in the left colon (at the watershed area, arc of Riolan). These are called Sudeck’s and Griffith’s points or areas (Figure 4).
Figure 4. Watershed areas in transient left sided ischemic colitis (2).
In mild ischemic colitis there are usually segmentally distributed patchy erythema, edema and subepithelial hemorrhages. In moderate colitis, in addition to changes seen in mild disease, there are localized erosions and ulcers, which may be confluent. Often, a linear ulcer in the mesenteric border of the colon is seen. This is known as colon single strip sign (CSSS) or Zuckerman’s sign (1).
Figure 5. Colon single strip sign (CSSS) or Zuckerman’s sign.
In severe colitis there are deep ulcers, luminal narrowing and strictures and frank necrosis.
Most cases of ischemic colitis are self-limited and do not require any specific medical or surgical therapy. However, in clinically unstable patients with signs of peritonitis colon resection should be considered.
The Practicing Endoscopist is Brought to You by EndoCollab
Happy Black Friday — the 50% off deal is now open to everyone.
One payment of $249 (normally $499) → everything forever.
You get:
-
Instant invite to our members-only WhatsApp group (real-time case consultation 24/7 — this alone is worth more than the price). Currently 439/1,024 spots filled (Meta’s hard technical limit – once full, new members will be waitlisted)
-
Full video course library (new courses added monthly)
-
Complete Endoscopy Atlas
-
Private community platform + all future content
References:
-
Monkemuller K, Wilcox. Video GIE: https://www.videogie.org/article/S2212-0971(13)70152-3/fulltext
For more tips and tricks on diagnostic and therapeutic endoscopy visit endocollab.com
https://community.endocollab.com/posts/9686997?utm_source=manual
https://community.endocollab.com/posts/9619598?utm_source=manual
https://community.endocollab.com/posts/18198906
No COI by KM, TP or AD with any of the companies/utensils or products mentioned in this article.
