For 2 days, a 79-year-old man with a history of congestive heart failure experienced abdominal pain, diarrhea, and dark red rectal bleeding. The pain was localized to the left lower quadrant.
Tenderness and moderate guarding were noted on examination. Blood test results showed moderate leukocytosis. A flexible sigmoidoscopy revealed normal rectal mucosa; black-blue patchy discoloration that indicated necrosis and submucosal hemorrhage was seen on the mucosa of the sigmoid colon. An emergency laparotomy demonstrated full-thickness necrosis of the sigmoid and part of the descending colon; there was no perforation of the colon.
Dr Virendra Parikh of Fort Wayne, Ind, writes that ischemic colitis can occur spontaneously in patients with a normal arterial system in a low-flow state as well as in those who have atherosclerotic disease. Precipitating factors include embolic events, abdominal aortic reconstruction, pancreatitis, and severe shock.
Signs and symptoms of ischemic colitis are subtle, nonspecific, and unreliable; thus, diagnosis can be delayed, which may lead to full-thickness gangrene—an often fatal condition. Maintain a high degree of clinical suspicion, particularly in high-risk patients, such as those with advanced diabetes, renal failure, congestive heart failure, and collagen vascular disease.
Plain abdominal films may show colonic wall thickening or thumbprinting. A barium enema examination of the colon is contraindicated because of the risk of perforation; moreover, the study may interfere with the interpretation of the results of a subsequent angiogram. Unless the patient has massive GI bleeding, angiography generally is not done in the acute setting. The preferred initial diagnostic procedure is an endoscopic examination with minimal air insufflation.
Black to bluish discoloration of the mucosa signals advanced necrosis and severe disease that warrants emergency surgical treatment. This patient underwent segmental resection of the nonviable colon with a temporary colostomy.