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Cited by 377Abdominal vascular conditions and treatmentsGastrointestinal disorders and treatmentsDiverticular Disease and Complications

ACG Clinical Guideline: Epidemiology, Risk Factors, Patterns of Presentation, Diagnosis, and Management of Colon Ischemia (CI)

Brandt, Lawrence J, Feuerstadt, Paul, Longstreth, George F, Boley, Scott J·2015·American Journal of Gastroenterology
DOI 10.1038/ajg.2014.395
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Abstract

INTRODUCTION This clinical guideline was designed to address colon ischemia (CI) including its definition, epidemiology, risk factors, presentations, methods of diagnosis, and therapeutic interventions. Each section of the document will present key recommendations or summary statements followed by a comprehensive summary of supporting evidence. An overall summary of all recommendations is listed in Table 1.Table 1: Recommendations and summary statementsTable 1: Continued.A search of MEDLINE (1946 to present) and EMBASE (1980 to present) with language restriction to English was conducted using the search terms ischemic colitis, ischaemic colitis, colon ischemia, colonic ischemia, colon ischaemia, colonic ischaemia, colon gangrene, colonic gangrene, colon infarction, colonic infarction, rectal ischemia, rectal ischaemia, ischemic proctitis, ischaemic proctitis, cecal ischemia, cecal ischaemia, ischemic colon stricture, ischaemic colon stricture, ischemic colonic stricture, ischaemic colonic stricture, ischemic megacolon, ischaemic megacolon, colon cast, and colonic cast. The references obtained were reviewed and the best studies were included as evidence for guideline statements or in the absence of quality evidence, expert opinion was offered. The GRADE system (Grading of Recommendations Assessment, Development, and Evaluation) was used to evaluate the quality of evidence and strength of recommendations (1, 2). The level of evidence ranged from “high” (implying that further research was unlikely to change the authors’ confidence in the estimate of the effect) to “moderate” (further research would be likely to have an impact on the authors’ confidence in the estimate of effect) to “low” (further research would be expected to have an important impact on the authors’ confidence in the estimate of the effect and would be likely to change the estimate) to “very low” (any estimate of effect is very uncertain). The strength of a recommendation was graded as “strong” when the desirable effects of an intervention clearly outweighed the undesirable effects and as “conditional” when there was uncertainty about the tradeoffs between the desirable and undesirable effects of an intervention. Of note, in this clinical guideline there are several sections focusing on factors associated with prognosis in CI. Because the GRADE system currently is not designed to rate the quality of the literature for these topics, we have preceded each of these sections with “summary statements” that detail the most important concepts regarding each area, but without a GRADE rating. DEFINITION CI is the condition that results when blood flow to the colon is reduced to a level insufficient to maintain cellular metabolic function. The end result of this process is that colonocytes become acidotic, dysfunctional, lose their integrity and, ultimately, die. Although the etymologic root of the word ischemia is from the Greek iskhaimos, meaning a “stopping of the blood,” we now know that blood flow need not stop but only diminish significantly to cause ischemic damage. Moreover, ischemia may be followed by reperfusion injury and, for relatively brief periods of ischemia, this combined injury may produce more damage than just reduction of blood flow without reperfusion. The degree to which colonic blood flow must diminish before ischemia results varies with the acuteness of the event, the degree of preexisting vascular collateralization, and the length of time the low flow state persists. CI may manifest with reversible or irreversible damage. Reversible damage includes colopathy, i.e., subepithelial hemorrhage or edema, and colitis; colitis reflects an evolutionary stage in which the overlying mucosa ulcerates as the subepithelial edema and blood are resorbed. In reversible disease, such resorption occurs rather promptly, usually within 3 days. Ulcerations may persist for several months before resolving, although during this time, the patient usually is asymptomatic. Irreversible manifestations of CI include gangrene, fulminant colitis, stricture formation, and, rarely, chronic ischemic colitis. Recurrent sepsis due to bacterial translocation is another rare manifestation of irreversibly damaged bowel. EPIDEMIOLOGY The absence of a unique diagnosis code for acute large bowel ischemia in the ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) challenges case finding for research. This system, which is commonly used in the United States, assigns the hospital discharge code 557.0 (acute vascular insufficiency of intestine) and 557.9 (unspecified vascular insufficiency of intestine) to ischemic colitis as well as many other small and large bowel entities. This limitation persists in the newer ICD-10-CM classification system. Therefore, either medical records must be reviewed carefully or clear stipulations must be applied to databases to reliably identify with CI the we to ischemic colitis not have a of disease, is t

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  • In 95% of cases, CI occurs due to sudden but transient reduction in blood flow to the colon due to non-occlusive causes and as a result, the watershed zones are affected.

    “In 95% of cases, CI occurs due to sudden but transient reduction in blood flow to the colon due to non-occlusive causes and as a result, the watershed zones are affected[30].”

    From Ischemic bowel disease in 2021. (2021) · cites this paper as [30]

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Authors
Brandt, L. J., Feuerstadt, P., Longstreth, G. F., & Boley, S. J.
Affiliations
  • Albert Einstein College of Medicine (US)
  • Yale University (US)
  • Kaiser Permanente (US)
Corresponding author
Brandt, Lawrence J
ORCID
Venue
American Journal of Gastroenterology
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2015-01
Volume
110
Issue
1
Pages
18-44
ISSN
0002-9270 (ISSN-L)
DOI
10.1038/ajg.2014.395
OpenAlex
W2089383900
Cited by
377
References
195
Citations by year
2026: 44 · 2025: 42 · 2024: 31 · 2023: 35 · 2022: 27 · 2021: 48 · 2020: 32 · 2019: 44 · 2018: 22 · 2017: 17 · 2016: 25 · 2015: 8
FWCI
24.16
Type
journal article
Language
en
Open access
closed
Licence
www.springer.com/tdm (unspecified)
Locations
  • The American Journal of Gastroenterology (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Abdominal vascular conditions and treatments
  • Health Sciences › Medicine › Surgery › Gastrointestinal disorders and treatments
  • Health Sciences › Medicine › Surgery › Diverticular Disease and Complications
Keywords
ischemic colitis, colonic gangrene, colonic infarction, epidemiology, risk factors, presentations, diagnosis, management, prognosis, treatment outcomes, mortality, quality of evidence, GRADE, clinical guidelines
MeSH terms
Humans, Risk Factors, Colitis, Ischemic, Disease Management

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