Education Blog for Healthcare Professionals

Ischemic Colitis and Thrombophilia

Stephan Moll, MD writes… 

Ischemic colitis is an uncommon and typically benign disorder.  For mostly unclear reasons, multiple small vessels in the colonic wall have decreased perfusion or become occluded, resulting in patchy, superficially ulcerated areas.  Typically, no surgical intervention is needed and the patient recovers spontaneously within 1-2 weeks.  Often patients have only one episode. Few people have recurrences.

Symptoms

Colicky abdominal pain, vomiting, and rectal bleeding.

Who gets it?

Ischemic colitis can occur in the elderly, but also in apparently healthy younger people.  It is overall poorly understood why some people develop it.  Predisposing factors may be thrombophilias.  Case reports have been published of ischemic colitis occurring in patients with various thrombophilias (factor V Leiden, antithrombin deficiency and others), but it is not known whether that association is coincidental or causative.  There have also been case reports of ischemic colitis associated with cocaine abuse, diabetes, sickle cell disease, dehydration, drugs that lead to spasm of blood vessels, herbal products (such as bitter orange, ma huang, and guarana), oral contraceptives and air travel.  Again, it is not known whether that association is coincidental or causative.  It has also been postulated that the problem may be due to low blood pressure in these intestinal vascular beds, such as during hemodialysis.

Diagnosis

A diagnosis is made by colonoscopy with colon biopsy.  Classic histological findings: mucosal and submuscosal hemorrhage with edema and capillary fibrin thrombi, with neutrophilic colonic wall infiltration. Vascular radiological studies, such as arteriograms, are not useful or recommended in this disorder.

Treatment

Watchful waiting is mostly all that is needed.  Surgery is usually not needed.  Anticoagulants or anti-platelet agents are typically not  indicated. However, if the patient has recurrent episodes and a thrombophilia is detected, anticoagulants could be considered, in an attempt to decrease recurrences.  However, it is not known whether they are effective.

Should  thrombophilia testing be done?

No, not in the patient with only one episode of ischemic colitis.  Finding a thrombophilia would not make a treatment difference, as most episodes of ischemic colitis heal by themselves and do not recur.  However, if a person has recurrent episodes, I would consider embarking on a thrombophilia work-up, as I would consider an anticoagulant trial if a thrombophilia were found.  It is not clear whether aspirin has any beneficial effect in preventing further episodes of ischemic colitis.

A completely different disease: “Ischemic colon”

Ischemic colitis is very different to acute mesenteric ischemia ( ischemic colon), which is typically due to a larger vessel occlusion – the superior mesenteric artery, inferior mesenteric artery thrombosis, or their branches, and leads to ischemia, necrosis and the need for urgent surgical intervention. Underlying causes are typically arteriosclerosis and cardio-embolic causes. For work-up of unexplained large vessel occlusion see discussion here.

Reference

O’Neill S et al. “Systematic Review of the Management of Ischaemic Colitis”. Colorectal Dis.  2012 (Jul 7);14(11):e751-63.

 

Disclosures:  I have no financial disclosures relevant to this post.

Last updated:  Jan 11th, 2013

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