Ischaemic colitis is a common condition in the elderly and can range from transient inflammation to severe gangrene, with its true incidence often underestimated. Predisposing factors include vascular occlusions, low blood flow states, and hypercoagulable conditions, while symptoms typically present as left-sided cramping, rectal bleeding, and diarrhea. Management may involve supportive care and regular assessments, with surgery indicated for severe cases showing signs of peritonitis or infarction.

1. ISCHAEMIC
COLITIS
Dr Dhaval Mangukiya
SIDS Hospital

2. ISCHAEMIC COLITIS
 Relatively common in the elderly
 Commonest form of ischaemic injury to the GI tract
 Spectrum of disease from transient mucosal inflammation to
gangrene
 Real incidence is uncertain:
(1.7 cases per 1000 autopsies in Sweden)
Scand J Gastro 2006

3. COLONIC CIRCULATION
Contributions from
superior & inferior
mesenteric arteries,
iliac arteries
Less blood per area of
large bowel compared
with small bowel

4. COLONIC CIRCULATION
Marginal artery of
Drummond
Arc of Riolan
Griffith’s & Sudeck’s
points

5. PATHOPHYSIOLOGY OF COLONIC
ISCHAEMIA
 Occlusion of main vessels is rare
 Transient low flow state with degenerative narrowing of small
vessels in the elderly
 Vasoconstriction & increased metabolic requirements in some
cases

6. SPECIFIC CAUSES OF COLONIC
ISCHAEMIA
 After AAA repair
 AMI & shock, cardiopulmonary bypass (high mortality)
 Hypercoagulable states
 Vasculitis
 Marathon running
 Cocaine

7. COLONIC ISCHAEMIA AFTER
AORTIC ANEURYSM REPAIR
 Occurs in 5% of cases
 High index of suspicion & early colonoscopy
 Trial of implantation of IMA after repair: 128 patients with patent
IMA randomised - ischaemia in 6 patients after implantation & 10
patients without implantation (NS)
 Austria, J Vasc Surg, 2006

8. HYPERCOAGULABLE STATES
 Coagulation abnormalities in 28% of patients with colonic
ischaemia compared with 8.4% of general population
 Coagulation abnormalities included factor V & activated protein C
resistance, protein S deficiency, anticardiolipin antibody
 Canton Ohio, Southern Medical Journal 2004

9. ISCHAEMIA DUE TO COCAINE

10. DISTRIBUTION OF ISCHAEMIC
CHANGES
 Most commonly splenic flexure & descending colon
 After AAA repair & IMA ligation usually involves sigmoid colon
 Embolic disease causes right colon ischaemia

11. DISTRIBUTION OF ISCHAEMIC
CHANGES

12. PATHOLOGY OF COLONIC ISCHAEMIA
Oedema, submucosal haemorrhage &
haemosiderin laden macrophages
Mucosal sloughing & ulceration
Full thickness infarction, ghost cells
Chronic colitis with ulceration
Ischaemic stricture

13. PATHOLOGY OF COLONIC ISCHAEMIA

14. ISCHAEMIC STRICTURE
3 months 18 months
2 years

15. SYMPTOMS & SIGNS OF COLONIC
ISCHAEMIA
 Left sided cramping pain with or without faecal urgency
 Rectal bleeding
 Diarrhoea
 Signs of peritonitis
 Clinical context – post AAA repair

16. DIAGNOSIS OF COLONIC
ISCHAEMIA
 CT scan
 Colonoscopy
 Angiography is rarely helpful

17. CT DIAGNOSIS OF COLONIC
ISCHEMIA

18. MANAGEMENT OF COLONIC
ISCHAEMIA
 Suspect & confirm diagnosis
 Supportive treatment – IV fluids, IV antibiotics, bowel rest
 Regular clinical & colonoscopic assessment

19. COLOURS OF ISCHAEMIA
Red Yellow
Green Grey

20. COLOURS OF ISCHAEMIA
Black

21. COLONOSCOPIC MANAGEMENT BASED
ON COLOUR
(CLEVELAND CLINIC GUIDELINES):
 Red mucosa – repeat 4-5 days
 Yellow mucosa – repeat 2-3 days
 Green mucosa – repeat next day
 Grey mucosa – repeat in 12 hours
 Black mucosa - laparotomy

22. INDICATIONS FOR SURGERY IN
COLONIC ISCHAEMIA
Peritonitis – at presentation or after
observation
Free gas, intramural gas,
intraportal gas on X-ray
Infarction at colonoscopy – lack of bleeding
Colonic stricture

23. SURGERY FOR COLONIC
ISCHAEMIA
 Resect ischaemic bowel – normal mucosa at resection margins
 Hartmann’s procedure or anterior resection/left hemicolectomy &
loop ileostomy for left sided ischaemia
 Right hemi-colectomy for right sided ischaemia
 Low Hartmann’s for rectal ischaemia

24. SURGERY FOR COLONIC
ISCHAEMIA

25. OUTCOME OF ISCHAEMIC COLITIS
 129 patients studied 1992-2002, mean age 66 (29-98), 47% male
 54 in hospital at presentation
 43 patients (33 percent) had peritonitis & required immediate
surgery (51% mortality)
 70 patients treated non operatively – 17 required subsequent
surgery (24%)
 Longo et al, St. Louis, Surgery 2003