Colonic ischemia: When to be aggressive. Don't miss the diagnosis

The incidence of colonic ischemia (CI) is difficult to determine precisely because many patients with mild symptoms do not seek medical help and because CI may be confused with other colonic disorders (infectious colitis and inflammatory bowel disease). Rough estimates are that 1% of colonoscopies performed at a tertiary care center endoscopy suite and 1 of every 2000 hospitalizations are for CI. Six patterns of CI are recognized today: reversible colopathy, transient colitis, chronic ulcerating colitis, gangrene, stricture, and fulminant universal colitis. In the absence of an acute abdomen and pathologic confirmation of advanced disease, physical findings alone usually are insufficient to make a diagnosis. Abdominal radiography, CT scan, barium enema, and colonoscopy are the studies of choice, unless gangrene or perforation is present, in which case immediate surgery is warranted. Angiography or, alternatively, air enema is useful when there is difficulty in differentiating CI from acute mesenteric ischemia. Even though the milder, self-limited forms of CI occur more frequently than the more severe types, clinicians need to know when to be aggressive in the management of CI, and when a "watch and wait" approach is inappropriate.