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    Epidemiology, Risk Factors, Patterns of Presentation, Diagnosis, and Management of Colon Ischemia (CI) (beta)

    Official guideline from the American College of Gastroenterology.

    Strong recommendation
    Conditional recommendation
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence

    Recommendations and Best Practices

    Clinical Presentation
    1. The diagnosis of CI is usually established in the presence of symptoms including sudden cramping, mild, abdominal pain; an urgent desire to defecate; and passage within 24 h of bright red or maroon blood or bloody diarrhea.
    2. A diagnosis of non-isolated right colon ischemia (non-IRCI) should be considered when patients present with hematochezia.
    Imaging of CI
    1. CT with intravenous and oral contrast should be the first imaging modality of choice for patients with suspected CI to assess the distribution and phase of colitis.
    2. The diagnosis of CI can be suggested based on CT findings (e.g., bowel wall thickening, edema, thumbprinting).
    3. Multiphasic CTA should be performed on any patient with suspected IRCI or in any patient in whom the possibility of AMI cannot be excluded.
    4. CT or MRI findings of colonic pneumatosis and porto-mesenteric venous gas can be used to predict the presence of transmural colonic infarction.
    5. In a patient in whom the presentation of CI may be a heralding sign of AMI (e.g., IRCI, severe pain without bleeding, atrial fibrillation), and the multiphasic CT is negative for vascular occlusive disease, traditional splanchnic angiography should be considered for further assessment.
    Colonoscopy in the Diagnosis of CI
    1. Early colonoscopy (within 48 h of presentation) should be performed in suspected CI to confirm the diagnosis.
    2. When performing colonoscopy on a patient with suspected CI, the colon should be insufflated minimally.
    3. In patients with severe CI, CT should be used to evaluate the distribution of disease. Limited colonoscopy is appropriate to confirm the nature of the CT abnormality. Colonoscopy should be halted at the distalmost extent of the disease.
    4. Biopsies of the colonic mucosa should be obtained except in cases of gangrene.
    5. Colonoscopy should not be performed in patients who have signs of acute peritonitis or evidence of irreversible ischemic damage (i.e., gangrene and pneumatosis).
    Severity and Treatment of CI
    1. Most cases of CI resolve spontaneously and do not require specific therapy.
    2. Surgical intervention should be considered in the presence of CI accompanied by hypotension, tachycardia, and abdominal pain without rectal bleeding; for IRCI and pan-colonic CI; and in the presence of gangrene.
    3. Antimicrobial therapy should be considered for patients with moderate or severe disease.
    What do the icons mean?  
    Research PaperBrandt LJ, Feuerstadt P, Longstreth GF, Boley SJ. Acg clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia(Ci). American Journal of Gastroenterology. 2015;110(1):18-44.