Endoscopic Spectrum of “Left”-Sided Ischemic Colitis

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Clinical Pearls

Ischemic colitis classically presents with segmental involvement (patchy erythema, edema, and subepithelial hemorrhages) in the left colon, specifically at watershed areas like Griffith’s point.
The rectum is characteristically spared in ischemic colitis due to its robust dual blood supply, a key endoscopic feature distinguishing it from ulcerative colitis.
The 'colon single stripe sign' (CSSS or Zuckerman’s sign)—a linear ulcer located on the mesenteric border of the colon—is a highly specific endoscopic marker for moderate ischemic colitis.
Progression to deep, confluent ulcerations, luminal narrowing, and frank mucosal necrosis indicates severe, transmural ischemic colitis that may require surgical intervention.

The endoscopic spectrum of ischemic colitis is broad. Key elements though are sparing of the rectum and segmental distribution, mainly in the left colon (at the watershed area, arc of Riolan).
Colonic ischemia occurs due to changes in systemic circulation and/or alterations in local mesenteric vasculature.
The most frequent areas affected are left colon (Griffith’s point), and superior rectum (Sudeck’s point), the lower rectum usually being spared because of its dual blood supply.
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. In severe colitis there are deep ulcers, luminal narrowing and strictures and frank necrosis.

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