Epidemiology, Risk Factors, Patterns of Presentation, Diagnosis, and Management of Colon Ischemia

Publication Date: January 1, 2015

Recommendations

CLINICAL PRESENTATION

The diagnosis of CI is usually established because of symptoms including sudden cramping, mild, abdominal pain; an urgent desire to defecate; and passage within 24 h of bright red or maroon blood per rectum or bloody diarrhea. (Strong  “We recommend”Very low)
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A diagnosis of non-IRCI should be considered when patients present with hematochezia. (Strong  “We recommend”Very low)
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IMAGING OF CI

CT with intravenous and oral contrast should be ordered as the imaging modality of choice for patients with suspected CI, to assess the distribution and phase of colitis. (Strong  “We recommend”Moderate)
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The diagnosis of CI can be suggested based on CT findings (e.g., bowel wall thickening, edema, and thumbprinting). (Strong  “We recommend”Moderate)
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Multiphasic CT angiography (CTA) should be performed on any patient with suspected IRCI or in any patient in whom the possibility of AMI cannot be excluded. (Strong  “We recommend”Moderate)
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CT or magnetic resonance imaging (MRI) findings of colonic pneumatosis and portomesenteric venous gas can be used to predict the presence of transmural colonic infarction. (Strong  “We recommend”Moderate)
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In a patient in whom the presentation of CI may be a heralding sign of acute mesenteric ischemia (AMI; e.g., IRCI, severe pain without bleeding, and atrial fibrillation), and the multiphasic CT is negative for vascular occlusive disease, traditional splanchnic angiography should be considered for further assessment. (Conditional (weak)  “We suggest”Low)
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COLONOSCOPY

Early colonoscopy (within 48 h of presentation) should be performed in suspected CI cases to confirm the diagnosis. (Strong  “We recommend”Low)
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When performing colonoscopy on a patient with suspected CI, the colon should be insufflated minimally. (Conditional (weak)  “We suggest”Very low)
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In patients with severe CI, CT should be used to evaluate the distribution of disease. Limited colonoscopy is appropriate to confirm the nature of the CT abnormality. The endoscopic procedure should be stopped at the distal-most extent of the disease. (Strong  “We recommend”Low)
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Biopsies of the colonic mucosa should be obtained except in cases of gangrene. (Strong  “We recommend”Very low)
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Colonoscopy should not be performed in patients who have signs of acute peritonitis or evidence of irreversible ischemic damage (i.e., gangrene and pneumatosis). (Strong  “We recommend”Very low)
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SEVERITY AND TREATMENT OF CI

Most cases of CI resolve spontaneously and do not require specific therapy. (Strong  “We recommend”Low)
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Surgical intervention should be considered in the presence of CI accompanied by hypotension, tachycardia, and abdominal pain without rectal bleeding; for IRCI and pancolonic CI; and in the presence of gangrene. (Strong  “We recommend”Moderate)
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Antimicrobial therapy should be considered for patients with moderate or severe disease. (Strong  “We recommend”Very low)
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Recommendation Grading

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Overview

Title

Epidemiology, Risk Factors, Patterns of Presentation, Diagnosis, and Management of Colon Ischemia

Authoring Organization

Publication Month/Year

January 1, 2015

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This clinical guideline was designed to address colon ischemia (CI) including its definition, epidemiology, risk factors, presentations, methods of diagnosis, and therapeutic interventions.

Target Patient Population

Patients with colon ischemia

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D003107 - Colorectal Surgery, D007511 - Ischemia, D003106 - Colon

Keywords

ischemia, colon surgery, Colorectal Surgery, colon ischemia, colon

Source Citation

Brandt, Lawrence J MD, MACG, AGAF, FASGE; Feuerstadt, Paul MD, FACG; Longstreth, George F MD, FACG, AGAF; Boley, Scott J MD, FACS4 ACG Clinical Guideline: Epidemiology, Risk Factors, Patterns of Presentation, Diagnosis, and Management of Colon Ischemia (CI), American Journal of Gastroenterology: January 2015 - Volume 110 - Issue 1 - p 18-44 doi: 10.1038/ajg.2014.395

Supplemental Methodology Resources

Methodology Supplement