Difference between revisions of "Ischemic colitis"

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Ischemic colitis (view source)

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{{ Infobox diagnosis
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Name      = {{PAGENAME}}
| Image      = Ischemic_colitis_-_high_mag.jpg
| Image      = Ischemic_colitis_-_high_mag.jpg  
| Width      =
| Width      =
| Caption    = Ischemic colitis. [[H&E stain]].
| Caption    = Ischemic colitis. [[H&E stain]].
| Micro      = withering crypts (colonic epithelium has decreased cytoplasm - NC ratio increased, usually with decreased goblet cells), crypt loss/drop-out, lamina propria hyalinization, submucosa hyalinization, +/-pseudomembranes, +/-vascular thrombi
| Micro      = withering crypts (colonic epithelium has decreased cytoplasm - NC ratio increased, usually with decreased goblet cells), crypt loss/drop-out, lamina propria hyalinization, submucosa hyalinization, +/-pseudomembranes, +/-vascular thrombi, +/-cryptitis
| Subtypes  =
| Subtypes  =
| LMDDx      = [[inflammatory bowel disease]], [[radiation colitis]], toxins/drugs, [[infectious colitis]]
| LMDDx      = [[inflammatory bowel disease]], [[radiation colitis]], toxins/drugs, [[infectious colitis]]
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| Clinicalhx = +/-cardiovascular disease
| Clinicalhx = +/-cardiovascular disease
| Signs      = +/-blood per rectum, +/-diarrhea (may be non-bloody)  
| Signs      = +/-blood per rectum, +/-diarrhea (may be non-bloody)  
| Symptoms  =
| Symptoms  = abdominal pain, tenesmus
| Prevalence =
| Prevalence =
| Bloodwork  = +/-anemia
| Bloodwork  = +/-anemia
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*May occur together with ''[[ischemic enteritis]]'', in which case it is known as ''ischemic enterocolitis''.
*May occur together with ''[[ischemic enteritis]]'', in which case it is known as ''ischemic enterocolitis''.


Etiology - anything that leads to vascular occlusion:
===Etiology===
Anything that leads to vascular occlusion:
*[[Atherosclerosis]].
*[[Atherosclerosis]].
*[[Vasculitis]].
*[[Vasculitis]].
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*Ischemia = compromised blood supply.
*Ischemia = compromised blood supply.


Clinical - classic presentation:<ref name=pmid24070152>{{Cite journal  | last1 = Tadros | first1 = M. | last2 = Majumder | first2 = S. | last3 = Birk | first3 = JW. | title = A review of ischemic colitis: is our clinical recognition and management adequate? | journal = Expert Rev Gastroenterol Hepatol | volume = 7 | issue = 7 | pages = 605-13 | month = Sep | year = 2013 | doi = 10.1586/17474124.2013.832485 | PMID = 24070152 }}</ref>
===Clinical===
Classic presentation:<ref name=pmid24070152>{{Cite journal  | last1 = Tadros | first1 = M. | last2 = Majumder | first2 = S. | last3 = Birk | first3 = JW. | title = A review of ischemic colitis: is our clinical recognition and management adequate? | journal = Expert Rev Gastroenterol Hepatol | volume = 7 | issue = 7 | pages = 605-13 | month = Sep | year = 2013 | doi = 10.1586/17474124.2013.832485 | PMID = 24070152 }}</ref>
*Abdominal pain.
*Abdominal pain.
*Urgency to defecate.
*Urgency to defecate (tenesmus).
*Bloody diarrhea.  
*Bloody diarrhea.  


Note:
Note:
*Diarrhea may be non-bloody.
*Diarrhea may be non-bloody.
**This is a poor prognosticator<ref name=pmid20961178>{{Cite journal  | last1 = Montoro | first1 = MA. | last2 = Brandt | first2 = LJ. | last3 = Santolaria | first3 = S. | last4 = Gomollon | first4 = F. | last5 = Sánchez Puértolas | first5 = B. | last6 = Vera | first6 = J. | last7 = Bujanda | first7 = L. | last8 = Cosme | first8 = A. | last9 = Cabriada | first9 = JL. | title = Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study). | journal = Scand J Gastroenterol | volume = 46 | issue = 2 | pages = 236-46 | month = Feb | year = 2011 | doi = 10.3109/00365521.2010.525794 | PMID = 20961178 }}</ref> and possibly increases likelihood of not identifying it in time.
**This is a poor prognosticator<ref name=pmid20961178>{{Cite journal  | last1 = Montoro | first1 = MA. | last2 = Brandt | first2 = LJ. | last3 = Santolaria | first3 = S. | last4 = Gomollon | first4 = F. | last5 = Sánchez Puértolas | first5 = B. | last6 = Vera | first6 = J. | last7 = Bujanda | first7 = L. | last8 = Cosme | first8 = A. | last9 = Cabriada | first9 = JL. | title = Clinical patterns and outcomes of ischaemic colitis: results of the Working Group for the Study of Ischaemic Colitis in Spain (CIE study). | journal = Scand J Gastroenterol | volume = 46 | issue = 2 | pages = 236-46 | month = Feb | year = 2011 | doi = 10.3109/00365521.2010.525794 | PMID = 20961178 }}</ref> and possibly increases the likelihood of not identifying it in time.


==Gross==
==Gross==
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Features:
Features:
*Withering crypts - '''important'''.
*Withering crypts - '''important'''.
**Colonic epithelium has decreased cytoplasm - NC ratio increased.
**Colonic epithelium has decreased cytoplasm - [[NC ratio]] increased.
**Usually with decreased goblet cells.
**Usually with decreased goblet cells.
*Crypt loss/drop-out.
*Crypt loss/drop-out.
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**Dense pink material replaces loose connective tissue.
**Dense pink material replaces loose connective tissue.
*Submucosa hyalinization.
*Submucosa hyalinization.
*+/-[[Cryptitis]].<ref name=pmid11175639>{{Cite journal  | last1 = Zhang | first1 = S. | last2 = Ashraf | first2 = M. | last3 = Schinella | first3 = R. | title = Ischemic colitis with atypical reactive changes that mimic dysplasia (pseudodysplasia). | journal = Arch Pathol Lab Med | volume = 125 | issue = 2 | pages = 224-7 | month = Feb | year = 2001 | doi = 10.1043/0003-9985(2001)1250224:ICWARC2.0.CO;2 | PMID = 11175639 }}</ref>
*+/-Pseudomembranes (microscopic):<ref name=Ref_PBoD837-8>{{Ref PBoD|837-8}}</ref>
*+/-Pseudomembranes (microscopic):<ref name=Ref_PBoD837-8>{{Ref PBoD|837-8}}</ref>
**Loss of surface epithelium.  
**Loss of surface epithelium.  
**[[PMN]]s in lamina propria.  
**[[PMN]]s in lamina propria.  
**+/-Capillary fibrin thrombi.  
**+/-Capillary fibrin thrombi.  
*+/-Reactive epithelial changes - may mimic dysplasia.<ref name=pmid11175639/>


Note:  
Notes:  
*Pseudomembranes arise from the crypts - considered ''acute''.
*Pseudomembranes arise from the crypts - considered ''acute''.


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**[[NSAID]] overdose.<ref name=pmid11736840>{{Cite journal  | last1 = Appu | first1 = S. | last2 = Thompson | first2 = G. | title = Gangrenous ischaemic colitis following non-steroidal anti-inflammatory drug overdose. | journal = ANZ J Surg | volume = 71 | issue = 11 | pages = 694-5 | month = Nov | year = 2001 | doi =  | PMID = 11736840 }}</ref>
**[[NSAID]] overdose.<ref name=pmid11736840>{{Cite journal  | last1 = Appu | first1 = S. | last2 = Thompson | first2 = G. | title = Gangrenous ischaemic colitis following non-steroidal anti-inflammatory drug overdose. | journal = ANZ J Surg | volume = 71 | issue = 11 | pages = 694-5 | month = Nov | year = 2001 | doi =  | PMID = 11736840 }}</ref>
*[[Infectious colitis]].
*[[Infectious colitis]].
===Ischemia versus infection on biopsy===
Dignan and Greenson<ref name=pmid9199649>{{Cite journal  | last1 = Dignan | first1 = CR. | last2 = Greenson | first2 = JK. | title = Can ischemic colitis be differentiated from C difficile colitis in biopsy specimens? | journal = Am J Surg Pathol | volume = 21 | issue = 6 | pages = 706-10 | month = Jun | year = 1997 | doi =  | PMID = 9199649 }}</ref> created a tabular comparison between ischemia and (''C. difficile'') infection.
A modified version of the Dignan-Greenson table (below) shows that the two etiologies generally cannot be separated; however, hyalinization appears to be useful if it is present:
{| class="wikitable sortable"
! Histologic feature
!Ischemia (24 cases)
!Infection (25 cases)
|-
| Atrophic crypts
| 75%
| 24%
|-
| Lamina propria - haemorrhage
| 75%
| 36%
|-
| Lamina propria - hyalinization
| 67%
| 0%
|-
| Diffuse (histologic) pseudomembranes
| 25%
| 4%
|-
| Mucosal necrosis (full thickness)
| 58%
| 28%
|}


===Images===
===Images===
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www:
www:
*[http://www.flickr.com/photos/euthman/3385570758/ Ischemic colitis (flickr.com/euthman)].
*[http://www.flickr.com/photos/euthman/3385570758/ Ischemic colitis (flickr.com/euthman)].
*[http://esynopsis.uchc.edu/eAtlas/GI/1018b.htm Ischemic colitis (uchc.edu)].


==Sign out==
==Sign out==
===Biopsy===
===Biopsy===
<pre>
Left Colon, Biopsy:
- Compatible with ischemic colitis (attenuated epithelium, hyalinized
  lamina propria, cryptitis).
Comment:
The differential diagnosis includes: drug reaction, infectious etiologies and, less likely, inflammatory bowel disease. Clinical correlation is required.
</pre>
====Block letters====
<pre>
<pre>
TRANSVERSE COLON, BIOPSY:
TRANSVERSE COLON, BIOPSY:
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etiologies and, less likely, inflammatory bowel disease. Clinical
etiologies and, less likely, inflammatory bowel disease. Clinical
correlation is required.
correlation is required.
</pre>
===Biopsy with nonspecific findings/compatible===
<pre>
Colon, Random Biopsies:     
    - Mild acute colitis with mild eosinophilia, see comment.
    - NEGATIVE for significant architectural distortion.
Comment:
The colitis could be due to ischemia, drug reaction, infection or inflammatory
bowel disease. Clinical correlation is required.
</pre>
</pre>


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*[[Infarction]].
*[[Infarction]].
*[[Colon]].
*[[Colon]].
*[[Ischemic enteritis]].
*[[Colonic cast]].


==References==
==References==
Engy
1

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