Ischemic colitis. That’s clearly a medical term, the kind that can confuse some lay people, but actually it’s fairly simple. Most of us know that anything medical ending in “itis” means an inflammation, so this is partly an inflammation of the colon. Ischemia means impaired blood flow to an organ or tissue. So in simple terms, ischemic colitis means that your colon is inflamed, or irritated, because it, or some part of it, is not receiving enough blood.
So who should be concerned about ischemic colitis? It mainly occurs in older people, over 50. (I’m not quite there yet, and this is one “-itis” I haven’t had…yet.) There are certain risk factors that can increase your chance of getting ischemic colitis. The most obvious is a heart condition, or some of the other conditions involved with coronary heart disease, like high blood pressure and a high cholesterol level. Smoking also increases the chance that you will get ischemic colitis. There are also some other illnesses or conditions that can increase your risk; if you’ve had an abdominal surgery, or low blood pressure and/or shock, or if you’ve suffered heart failure, you’re more likely than the average person to get ischemic colitis at some point in your life.
Ischemic colitis occurs when not enough blood is getting to your colon, which is pretty much the last large portion of your intestinal tract, about six feet or so of the thirty that make up the intestinal tract, before the “exit.” If you think of your colon as another organ, such as your heart, you could think of this as a “colon attack,” according to the doctors at the Three Rivers Endoscopy Center (www.gihealth.com/html/education). It can be caused by blood clots in the vessels that bring blood to the colon (arteries, not veins); this usually results in acute ischemic colitis, that comes on suddenly and is usually severe, but with treatment, short-lived. If you have atherosclerosis, or fatty deposits in your veins, you may end up with chronic colitis; if it is chronic, it is generally less severe, but will probably last much longer. Some other conditions can also cause ischemic colitis; they include high glucose or sugar levels in the blood, or diabetes; easy blood clotting, a blood condition called hyper-coagulable state (clotting is also called coagulation); vasculitis, or an inflammation (‘itis”) of the blood vessels; prior radiation treatment in the abdominal area; and the bulging of one of your other organs, interfering with the blood flow in both veins and arteries.
Some medicines can also cause ischemic colitis, although it is pretty rare. The use or over-use of over the counter NSAIDs (non-steroidal anti-inflammatories, such as ibuprofen or naproxen) can play a role; some blood pressure medicines; digoxin (another heart drug); pseudoephedrine (usually an anti-histamine); heparin (an anticoagulant that may have the rare side effect of clots in the blood vessels); a prescription drug for IBS called Lotronex TM that is usually taken by women; and sometimes estrogen (hormone) replacements.
One other major factor that can cause ischemic colitis is abdominal surgery, especially when it is to repair an aneurysm; in that case the ischemic colitis usually is in the same area as the repair. Bacterial infections such as E. Coli (Escherichia coli), viral infections like cytomegalovirus, and parasitic infections like amoebic dysentery (Entamoeba histolytica) can all trigger ischemic colitis, although that too is not common.
The symptoms of ischemic colitis are similar to those of ulcerative colitis in many ways; both illnesses can cause abdominal pain and cramping, with tenderness, although with ulcerative colitis and Crohn’s the pain is usually in the lower right quadrant of the abdomen, and the pain of ischemic colitis usually manifests in the lower left quadrant. The pain can come on suddenly, or can sneak up on you gradually. A low grade fever is usually present. You may notice red or maroon colored blood in your stool (called hematochezia), or you may pass blood without producing a stool. Diarrhea is another symptom, especially with urgency; nausea and/or vomiting may also be present. If you have these symptoms, especially if you are passing blood, either in a stool or by itself, you should see a doctor as soon as possible.
When you get to the doctor, your history will be taken, and you should be sure to tell the nurse (usually the first to take it) every symptom you have, even if you think it may not be important. Make a list to take with you; it can help you remember in the often-disconcerting atmosphere of a clinic or emergency room. The doctor will palpate, or feel thoroughly, your abdomen to look for tender or painful area. He or she may recommend a diagnostic test like a colonoscopy, which is the best possible test for diagnosing ischemic colitis. If, during the course of the colonoscopy, the doctor sees something suspicious, he may biopsy it (take a small tissue sample) to see what it is. Bleeding and swelling in the colon’s lining are common in ischemic colitis, and the lab can find that in a tissue sample. The colonoscopy is also important to rule out other possible causes of your symptoms, like infections, inflammatory bowel disease (IBD), diverticulitis, or colon cancer.
Other possible tests that may be done in the process of diagnosing or ruling out ischemic colitis are x-rays of your lower abdomen (generally with the dreaded barium enema); another kind of X-ray called an abdominal arteriogram, that looks at the arteries in your colon, which can show if your blood vessels are narrowed or blocked; an MRI (magnetic resonance imaging) of your abdominal area; CT, or computerized tomography scans, that can produce cross-section views of your colon and can often rule out other conditions; blood tests to see if your white blood cell count is elevated, indicating you have an infection; and an analysis of a stool sample, with could detect bacteria or other types of infections in your colon.
The treatment for ischemic colitis depends on how severe your condition is, and how advanced it is. If it is mild, you may be able to just take a medication to keep your blood pressure normal, which will ensure the steady flow of blood to the colon, and usually an antibiotic to prevent the development of an infection. If you have any other health problems, frequently heart failure, your doctor may also prescribe a daily aspirin regimen. In a case like this, your ischemic colitis can be treated at home, without having to be hospitalized, and you may have relief in as little as 24 hours. If you’re dehydrated, however, you may need to get intravenous fluid and nutrition, which would mean a short stay at the hospital. You may also be restricted on what foods you eat, and how much, for a few days, to let your colon have a rest. Your doctor will want you to come back regularly for a while, so that he can be sure that the ischemic colitis is healed and there are no complications. How long you will have to continue return visits, and how often you may need additional colonoscopies, depends on your doctor and your condition. In some more severe cases, the treatment will be similar, but healing and recovery may take six months or more, and there is a possibility of a relapse.
Some patients with ischemic colitis will need surgery. If your pain and fever are severe and and don’t go away even after the first treatment, you may be one of them. Surgery for ischemic colitis may also be necessary if you have a small area of your arteries that is very constricted, if you have bleeding ulcers accompanying the ischemic colitis, or if you have a hole in the colon wall. Any diseased or gangrenous tissue will be removed, and you’ll probably be given a broad-spectrum antibiotic, and blood transfusion if necessary.
If left untreated, ischemic colitis can have serious complications. One is gangrene, or tissue death; your tissue “eats” from blood cells, and if the tissue of the colon isn’t getting fed, it will die. This can result in death if you don’t receive early treatment (usually removing the dead portion of the colon). Another possible complication of ischemic colitis is the development of a hole, or perforation, in your intestine, which can bleed, sometimes excessively. Pain and blockage are actually possible side effects of the healing of ischemic colitis: the colon can develop scar tissue and become narrower. Sometimes ischemic colitis is the first sign that you may have colon cancer. Rare complications of ischemic colitis are abscesses in the colon (pus), and peritonitis, an inflammation of the peritoneum, or lining, of the abdominal wall.
At this time, there is no way to prevent ischemic colitis. The best thing to do is remove any risk factors that you can, including quitting smoking, lowering your cholesterol through a combination of medication and diet change, exercise regularly, and take any blood pressure medicine that your doctor prescribes, just as he prescribes it. That’s not a guarantee that you will never have ischemic colitis, but it will make it less likely. And again, if you have severe pain and tenderness in the lower left quadrant of your abdomen, accompanied by a fever, and you see blood in your stool or just pass blood without a stool, see your doctor as soon as possible.
(Some of the information in the above article, particularly in the sections on diagnosis and treatment, is from personal communication with Yaser M. Rayyan, M.D., board certified by the American Board of Internal Medicine and the American Board of Gastroenterology. He has my profound gratitude for the information, and for his caring treatment of my own illness. Any errors are my own.)
