GI Endoscopy · 3 min read
Transient or “Left”-Sided Ischemic Colitis: Case Reports With Focus on its Endoscopic Spectrum
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.
References:
Monkemuller K, Wilcox. Video GIE: https://www.videogie.org/article/S2212-0971(13)70152-3/fulltext
No COI by KM, TP or AD with any of the companies/utensils or products mentioned in this article.
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