Ischemic bowel disease - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

Ischemic bowel disease can be classified into three types: acute mesenteric ischemia, chronic mesenteric ischemia, and colonic ischemia. Acute mesenteric ischemia may also be further subdivided into embolic mesenteric ischemia, thrombotic mesenteric ischemia, venous mesenteric ischemia, and nonocclusive mesenteric ischemia. Colonic ischemia is the most common type and has the most favorable prognosis.
Ischemic bowel disease may present clinically in a number of ways, including transient reversible ischemia, chronic irreversible ischemia, or acute fulminant ischemia.
Mesenteric venous thrombosis may lead to acute or subacute intestinal ischemia and may also present across a spectrum of severity.
Short-term complications include small bowel infarction, hemorrhagic shock, peritonitis, gangrenous colitis, fulminant universal colitis, colonic perforation, pneumoperitoneum, colon wall necrosis leading to the formation of pneumatosis linearis coli and portal venous gas seen on imaging.
Long-term complications of ischemic bowel disease depend on the location and nature of the underlying pathology. Possible complications include stricture formation, short bowel syndrome, and food fear leading to malnutrition.

Histopathology of intestinal ischemia

From the collection of Dr Jennifer Holder-Murray; used with permission

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History & Exam
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Definition

Epidemiology

Etiology

Pathophysiology

Images

Histopathology of intestinal ischemia
Distribution of blood flow to the colon originating from the inferior mesenteric artery, branches of which include the left colic, marginal, and sigmoid arteries and supply the left colon and superior portion of the rectum
Distribution of blood supply to the small intestine and colon from the superior mesenteric artery, branches of which include the middle, right, and ileocolic arteries as well as jejunal and ileal arteries and arterioles
Comparison of symptoms/signs and investigations for the three types of ischemic bowel disease
CT scan: colonic thickening with pneumatosis intestinalis
84-year-old man presenting with symptoms suggestive of ischemic bowel disease: (A) Abdominal CT revealing a massive circumferential and band-like air formation as intestinal pneumatosis (arrows) and pronounced edema of mesenteric fat (arrowhead) around necrotic bowel loops; (B) Another slice of abdominal CT showing long segmental pneumatosis of the small bowel
CT scan: circumferential wall thickening of the transverse colon; white arrow shows thumbprinting
CT angiogram: acute superior mesenteric artery thrombus
CT angiography: 3-dimensional reconstruction with superior mesenteric artery stenosis from severe atherosclerotic plaque in a patient on follow-up imaging for endovascular aneurysm repair
Plain abdominal x-ray: shows marked wall thickening of the transverse colon compatible with the finding of thumbprinting (white arrows)
Colonoscopy: demarcation between ischemic and normal colon
Colonoscopy: denudation of colonic mucosa
Colonoscopy: mucosal sloughing and likely nonviable colon

Citations

Key Articles

Brandt LJ, Feuerstadt P, Longstreth GF, et al. ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia (CI). Am J Gastroenterol. 2015 Jan;110(1):18-44.[Abstract][Full Text]
Bala M, Catena F, Kashuk J, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 2022 Oct 19;17(1):54.[Abstract][Full Text]
Björck M, Koelemay M, Acosta S, et al. Editor's choice - management of the diseases of mesenteric arteries and veins: clinical practice guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017 Apr;53(4):460-510.[Abstract][Full Text]
American College of Radiology. ACR appropriateness criteria: radiologic management of mesenteric ischemia. 2022 [internet publication].[Full Text]
Tilsed JV, Casamassima A, Kurihara H, et al. ESTES guidelines: acute mesenteric ischaemia. Eur J Trauma Emerg Surg. 2016 Apr;42(2):253-70.[Abstract][Full Text]

Referenced Articles

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