Runny nose

Ischemic colitis - causes, signs, treatment. Treatment methods for ischemic intestinal colitis Ischemic colitis most often affects tests

Poor circulation (ischemia) of the intestinal vessels can cause a lack of blood in certain areas of the large intestine. Subsequently, an inflammatory process of the intestinal walls begins in this area, which leads to acute pain, stool disturbances, weight loss, and sometimes even to a stricture (narrowing of the intestine) in this area. In medicine, this disease is called ischemic intestinal colitis.

Causes

Scientists have proven that large intestine one of the least blood-supplied internal organs. And in case of injuries, imbalance of internal balance, internal damage to the intestinal walls, infection, blood flow decreases to critical levels. As a result, there is a risk of developing ischemia. Which in turn leads to ischemic colitis of the intestine.

Also to the reasons for development of this disease the following phenomena include:

Vascular spasms due to atherosclerosis. An increase in the amount of fat on the walls of blood vessels;
Reduced blood pressure;
Formation of blood clots ( blood clots) in vessels;
Aortic dissection or damage. As a rule, it is accompanied by anemia of internal organs and dehydration of the body;
DIC syndrome. Large-scale blood clotting in various vessels;
Liver transplant. The body does not accept the new organ;
Tumor formation in the intestine and its obstruction;
Sickle cell anemia. Violation of the structure of the hemoglobin protein. The protein takes on a sickle shape, resulting in an imbalance in oxygen balance. This disease is hereditary.

Varieties

There are several forms of this intestinal disease: acute and chronic colitis. When acute ischemic colitis is diagnosed in the human body, the organs of the intestinal mucosa die.

With the mild variety, cell death occurs only on the lining of the intestinal wall. In the worst case, tissue death may occur within the wall (intramural infarction), or all layers of the intestine may be damaged (transmural infarction).

In the chronic form of the disease, the patient experiences nausea, gag reflexes after eating, constipation alternating with loose stools, and constant sharp pain in the abdomen. As a rule, chronic colitis leads to intestinal stricture, and intestinal deformation (narrowing) occurs. And this has a beneficial effect on the further development of intestinal diseases, and can affect the development of intestinal gangrene and the appearance of ulcers.

Symptoms

Typically, patients experience constant pain in the stomach. Depending on the location of the damage to the colon, the source of pain may be in the left or right side of the abdomen. Sometimes the pain can be stabbing. Painful sensations can be in the form of short attacks of 10-15 minutes, or be constant. Specific sensations depend on the severity of the disease, and the pain can be aching, dull, pressing or intense, cutting, sharp. Usually the patient experiences pain in the intestinal area after eating. This happens almost immediately. The pain goes away after a few hours.

Foods such as sickly sweet, spicy, scalding foods, and dairy products can cause exacerbation of pain. Pain can also occur after physical activity. For example, long walking, heavy lifting, prolonged work in an uncomfortable bent position.

Another obvious symptom is loose stools with a lot of bloody or purulent discharge. Traces of blood, mucus and pus residues appear on the walls of the rectum. The amount of discharge depends on the shape and severity of intestinal damage. With the initial disease, they may not be present at all in the feces, but the smell of rot will already be present. Usually, at the first symptoms, diarrhea gives way to constipation and back.

Other symptoms characterizing ischemic colitis also include:

Nausea;
Vomiting;
Diarrhea;
Bloating;
Sleep disturbance;
Fatigue;
Weakness of the whole body as a whole;
Excessive sweating;
Dizziness and constant headaches.

Diagnostics

As a rule, ischemic colitis is an age-related disease. About 80% of patients with this diagnosis are over 50 years of age. To determine the disease, doctors conduct a general examination and pay attention to the patient’s complaints and lifestyle. They analyze what could lead to such an intestinal disease. For example, a patient has undergone surgery or has been diagnosed with a tumor. Constant intake of certain medicines, alcohol, spicy food, may contribute to the emergence of such deviations.

After the external examination, laboratory tests follow:

General blood test. Helps identify signs of anemia, lack of hemoglobin and red blood cells (erythrocytes). An increase in the number of leukocytes (white blood cells) is a clear sign of inflammation.
Urinalysis. Aimed at detection renal failure and infections of internal organs.
Stool analysis. If blood, mucous deposits, or purulent discharge are detected, we can accurately state that there is a disorder of the digestive system.
Biochemical blood test. Blood tests for cholesterol and its fractions, checking lipid ratio levels, protein and iron content in the blood, determining blood clotting parameters.

But the most effective method for determining ischemic colitis is instrumental study. These include:

Colonoscopy. One of the most effective methods. Typically performed in combination with a biopsy. The patient's large intestine is examined using a special device - an endoscope. This procedure allows you to see the inside of the intestinal wall and assess their condition. During a biopsy, an additional small piece of intestine is taken for subsequent more detailed analysis and accurate diagnosis.
Irrigoscopy. Examination of the intestine using X-rays. This method allows you to fairly accurately determine the degree of damage to the intestines. And also detect strictures and affected areas.
Ultrasound examination. Ultrasound is used to identify affected cells and vessels abdominal aorta. In this way, it is possible to detect the formation of fatty deposits on the walls of blood vessels.
Doppler study. Helps determine the condition of the arteries.
Laparoscopy. This method includes surgery. Several small holes are made in the patient's abdominal cavity. This is necessary to insert an endoscope - a device for examining internal organs. After examining and assessing the damage, an operating instrument can be inserted through these holes and treatment can be performed.
Electrocardiography. WITH using ECG fluctuations in electric fields are recorded, which makes it possible to identify abnormalities in the functioning of the intestines.

Treatment

In the initial stages of the disease, treatment mainly consists of eating certain foods and following a strict diet. It depends on the symptoms of the disease. For constipation, the patient is advised to eat food with high content fiber. Mild laxatives are prescribed. At loose stools use antidiarrheal drugs. Animal fats are replaced with fats plant origin. There is a downward trend and complete refusal from spicy, fatty and fried foods. To boost immunity and normalize the functioning of the body as a whole, vitamin complexes are prescribed.

If these methods do not help, doctors carry out antiplatelet therapy aimed at reducing blood viscosity. Vasodilators, enzymes, and phospholipids are prescribed. These medications are aimed at normalizing the water-alkaline balance and intestinal function in general. In some cases, a blood transfusion may be necessary.

Surgical treatment is provided in severe cases when the diagnosis is made too late and medications are not able to cope with the infection. The affected area is removed, an inspection is carried out and a special drainage is installed.

Consequences and complications

Unfortunately, complications after such operations are quite normal phenomenon. Since the patients are quite old, the body is not able to immediately rebuild and normalize all its basic processes. After surgery, the patient may experience intestinal obstruction. Food either passes through the intestines too slowly, with difficulty, or does not pass at all, causing flatulence, bloating, nausea and vomiting reflexes.

Sometimes the intestinal wall can rupture, leading to infection throughout the body. TO negative consequences intestinal colitis, also includes an increase in the size of the large intestine and profuse hemorrhage.

Prevention

In most cases, ischemic colitis occurs as a result of complications of atherosclerosis, during postoperative restoration of internal organs, or serious heart failure. Therefore, the basis of prevention is effective treatment of these diseases.

Periodic examinations by a gastroenterologist, proctologist and in the department general surgery are able to prevent intestinal diseases at the initial stage and get rid of them with the help of special diets and vitamins. People diagnosed with chronic ischemic colitis should completely change their diet. Add fresh fruits and vegetables, low-fat meat, and cereals to your daily diet. Avoid excess oily fish and meat products, mustard, pepper, sweet foods, coffee and alcoholic beverages. With this diet, the likelihood of necrosis and similar complications is reduced, and intestinal function is normalized without surgical intervention.

Studying the symptoms of the disease will also be useful. Knowing such information is never superfluous, because it is better to always remain on guard. The sooner the progression of the disease is revealed, the easier and faster the treatment will be.

Ischemic colitis is a transient circulatory disorder of the colon.

The blood supply to the large intestine is provided by the superior and inferior mesenteric arteries. The superior mesenteric artery supplies the entire small, cecum, ascending and partially transverse colon; inferior mesenteric artery - left half of the colon.

With ischemia of the large intestine, a significant number of microorganisms populating it contributes to the development of inflammation in the intestinal wall (even transient bacterial invasion is possible). The inflammatory process caused by ischemia of the colon wall further leads to the development of connective tissue in it and even the formation of a fibrous stricture.

The splenic flexure and left parts of the colon are most commonly affected by ischemic colitis.

What causes ischemic colitis?

Necrosis may develop, but usually the process is limited to the mucosa and submucosa and only sometimes affects the entire wall, which requires surgical intervention. It occurs primarily in older adults (over 60 years of age) and the etiology is unknown, although there is some association with the same risk factors as acute mesenteric ischemia.

Symptoms of ischemic colitis

Symptoms of ischemic colitis are less severe and develop more slowly than with acute mesenteric ischemia, and include pain in the left lower quadrant of the abdomen, accompanied by bleeding from the rectum.

Stomach ache. Pain in the abdomen appears 15-20 minutes after eating (especially a large meal) and lasts from 1 to 3 hours. The intensity of the pain varies, and is often quite severe. As the disease progresses and fibrous strictures of the colon develop, the pain becomes constant.

The most common localization of pain is the left iliac region, the projection of the splenic flexure of the transverse colon, and less commonly the epigastric or periumbilical region.

Dyspeptic disorders. Almost 50% of patients experience decreased appetite, nausea, bloating, and sometimes belching of air and food.
Stool disorders. They are observed almost constantly and are manifested by constipation or diarrhea, alternating with constipation. During an exacerbation, diarrhea is more common.
Weight loss for patients. A decrease in body weight in patients with ischemic colitis is observed quite naturally. This is explained by a limitation in the amount of food and the frequency of its intake (due to increased pain after eating) and a violation of the absorption function of the intestine (quite often, along with ischemia of the colon, there is a deterioration in blood circulation in the small intestine).
Intestinal bleeding. Observed in 80% of patients. The intensity of bleeding varies - from the admixture of blood in the stool to the release of significant amounts of blood from the rectum. Bleeding is caused by erosive and ulcerative changes in the mucous membrane of the colon.
Objective abdominal syndrome. Exacerbation of ischemic colitis is characterized by mild signs of irritation of the peritoneum, tension of the abdominal muscles. On palpation of the abdomen, diffuse sensitivity is noted, as well as pain mainly in the left iliac region or the left half of the abdomen.

Symptoms of severe irritation of the peritoneum, especially those that persist for several hours, make one think about transmural necrosis of the intestine.

Diagnosis of ischemic colitis

Diagnosis is made by colonoscopy; Angiography is not indicated.

Laboratory and instrumental data

Complete blood count: marked leukocytosis, shift leukocyte formula to the left, increase in ESR. With repeated intestinal bleeding, anemia develops.
Urinalysis: no significant changes.
Stool analysis: a large number of red blood cells, white blood cells, and intestinal epithelial cells are found in the stool.
Biochemical blood test: decreased content total protein, albumin (with a long course of the disease), iron, sometimes sodium, potassium, calcium.

Colonoscopy: performed strictly according to indications and only after reduction acute manifestations. The following changes are revealed: nodular areas of edematous mucous membrane of a blue-purple color, hemorrhagic lesions of the mucous membrane and submucosal layer, ulcerative defects (in the form of points, longitudinal, serpentine), strictures are often found, mainly in the area of the splenic flexure of the transverse colon.

Microscopic examination of colon biopsies reveals edema and thickening, fibrosis of the submucosal layer, infiltration of it with lymphocytes, plasma cells, granulation tissue in the area of the bottom of the ulcers. A characteristic microscopic sign of ischemic colitis is the presence of multiple hemosiderin-containing macrophages.

Survey radiography of the abdominal cavity: an increased amount of air is determined in the splenic angle of the colon or its other parts.
Irrigoscopy: performed only after relief of acute manifestations of the disease. At the level of the lesion, narrowing of the colon is determined, above and below - expansion of the intestine; haustra poorly expressed; sometimes nodular, polyp-like thickenings of the mucous membrane and ulcerations are visible. In marginal areas of the intestine, finger-like prints (the “thumbprint” symptom) are detected, caused by swelling of the mucous membrane; jaggedness and unevenness of the mucous membrane.
Angiography and Doppler ultrasonography: a decrease in the lumen of the mesenteric arteries is detected.
Parietal pH-metry of the colon using a catheter with a balloon: allows you to compare tissue pH before and after meals. A sign of tissue ischemia is intramural acidosis.

The following circumstances help in diagnosing ischemic colitis:

age over 60-65 years;
presence of coronary artery disease, arterial hypertension, diabetes mellitus, obliterating atherosclerosis peripheral arteries (these diseases significantly increase the risk of developing ischemic colitis);
episodes of acute abdominal pain followed by intestinal bleeding;
the corresponding endoscopic picture of the condition of the colon mucosa and the results histological examination colon biopsies;

– is it acute or chronic? inflammatory disease of the large intestine, which occurs due to disruption of the blood supply to its walls. Manifested by abdominal pain of varying intensity, unstable stools, bleeding, flatulence, nausea, vomiting and weight loss (with chronic course). In severe cases, body temperature rises and symptoms of general intoxication appear. For diagnostic purposes, sigmoidoscopy, irrigoscopy, colonoscopy and angiography of the inferior mesenteric artery are performed. Treatment at the initial stages is conservative, if ineffective - surgical.

ICD-10

K55.0 K55.1

General information

Irrigoscopy is one of the most informative diagnostic studies for ischemic colitis. With reversible changes in the areas of ischemia, defects in the form of finger indentations can be seen. Through short time they may disappear, so the study should be carried out immediately at the first suspicion of ischemic colitis. Necrotic changes are visible in the form of persistent ulcerative defects. When performing irrigoscopy, strictures can also be diagnosed. Colonoscopy allows you to more clearly see morphological changes in the walls of the entire large intestine and take a biopsy from areas with ischemia or strictures of the colon, especially if there is a suspicion of their malignant degeneration.

To determine the cause and level of vascular obstruction, angiography of the inferior mesenteric artery is performed. For complications of ischemic colitis, general and biochemical blood tests are performed to assess the patient's condition. To correct antibiotic therapy, stool and blood cultures are performed to determine drug sensitivity.

Differential diagnosis in ischemic colitis, it is carried out with infectious diseases (dysentery, amoebiasis, helminthiasis), nonspecific ulcerative colitis, Crohn's disease, malignant neoplasms. In infectious diseases, symptoms of general intoxication come to the fore; there is a corresponding epidemiological history. Ulcerative colitis and Crohn's disease develop gradually at a younger age. Development cancerous tumors colon cancer occurs over a long period of time, often over several years.

Treatment of ischemic colitis

At the first stage of the disease, conservative therapy is carried out. A gentle diet, mild laxatives, and drugs that improve blood flow (vasodilators) and blood rheology (antiplatelet agents) are prescribed. The results of complex treatment of ischemic colitis are improved by drugs such as dipyridamole, pentoxifylline, and vitamin complexes. At in serious condition The patient undergoes detoxification therapy, correction of water and electrolyte balance, and sometimes a blood transfusion is performed. Parenteral nutrition is of great importance for unloading the intestines. For bacterial complications of ischemic colitis, antibiotics and sulfonamide drugs are prescribed.

Surgical treatment of ischemic colitis is indicated for extensive necrosis, gangrene of the large intestine, perforation and peritonitis. The affected area of the intestine is removed within healthy tissue, then an inspection is carried out and postoperative drainage is left. Since patients with ischemic colitis are mostly elderly, complications after such operations are quite common. For strictures that block or narrow the intestinal lumen, elective surgeries are performed.

Prognosis and prevention

The prognosis of ischemic colitis depends on the form of the disease, course and presence of complications. If blood flow has resumed and necrosis has not developed, the prognosis is quite favorable. With necrosis, everything depends on the extent of the process, timely diagnosis and correctly performed surgical intervention. Also, the course of the pathology depends on the age, general condition of the patient and concomitant diseases.

Since ischemic colitis occurs in most cases as a complication of atherosclerosis, heart failure, postoperative period during interventions on the intestines, stomach, and pelvic organs, the basis of prevention is adequate treatment of primary diseases. It is also of great importance proper nutrition, regular preventive medical examinations.

Development coronary disease of the colon with thrombosis and embolism, vascular trauma, allergic reactions is associated with vascular occlusion and, as a rule, is accompanied by the development of gangrene, although a transition to a chronic form with the gradual formation of a stricture or long course ulcerative colitis. The development of one or another form of the disease in this situation is determined by the condition collateral circulation, the diameter of the damaged vessel, the completeness and duration of occlusion, the rate of revascularization, etc.

Along with this, there are non-occlusive lesions, the possibility of development of which is associated with the anatomical and functional characteristics of the colon. In addition to the fact that the blood flow in the colon, compared to other organs, is the lowest, there are also the most vulnerable places - anastomoses between the branches of the main vessels of the colon. It is also necessary to take into account that the functional activity of this organ is normally accompanied by a decrease in blood flow in it. In this regard, it becomes clear that any pathological processes accompanied by hypovolemia, such as chronic diseases hearts with congestive heart failure, abdominal aortic aneurysms, shock, strokes, massive bleeding occurring with hypotension syndrome are important predisposing factors in the development of chronic forms of coronary artery disease of the colon.

Restriction of blood flow due to atherosclerosis of the aorta and colon arteries can lead to ischemia, especially in the left flexure and the proximal part of the sigmoid colon. Therefore, chronic forms of ischemic colitis often manifest as segmental lesions.

Disorders of the mesenteric blood supply under the influence of vasopressor drugs such as ephedrine, adrenaline, vasopressin, and estrogen-containing contraceptives have been described.

In ischemic colitis, the mucous membrane is primarily affected, since it is especially sensitive to hypoxic conditions. Apparently, this is due to the high activity of the metabolic processes occurring in it.

For mild to moderate severe forms In ischemic colitis, not only the serous and muscular membranes remain viable, but also changes in the mucous membrane, if they do not represent necrosis, can almost completely undergo reverse development. Only in severe forms do deep injuries occur, often resulting in perforation or stricture formation.

Clinic and diagnostics

The clinical picture of ischemic colitis is not particularly specific and is characterized by pain, repeated intestinal bleeding and unstable stool with pathological impurities. The severity of certain symptoms is largely determined by the nature of the course and form of the disease.

In its course, ischemic colitis can be acute or chronic, and depending on the degree of blood supply disturbance and tissue damage, two forms are distinguished - reversible (transient ischemia) and irreversible with the formation of either a stricture or gangrene of the intestinal wall.

Reversible (transitory) form. With this form of the disease, pathological changes in the colon are observed only for a short time and quickly undergo complete reversal. The main symptom of the disease is pain in the left half of the abdomen, which occurs suddenly and just as quickly disappears spontaneously. Attacks of pain can be repeated throughout the day, and their intensity varies. More often it is not pronounced or is so insignificant that patients forget about it and only with careful questioning can it be identified. It sometimes resembles coronary pain or pain from intermittent claudication and is associated with the functional activity of the intestines caused by digestive processes. The fact that pain often occurs 15-20 minutes after eating, subsides after a few hours and is localized along the colon is important. diagnostic value, indicating a possible ischemic nature. The pain is often accompanied by tenesmus and blood in the stool. In some cases, bleeding occurs several days or even weeks after the onset of the disease. The blood is mixed and can be either dark or bright red. Its amount is usually insignificant, and massive bleeding usually indicates ischemic damage to the intestine. Along with the admixture of blood, ischemic colitis is characterized by frequent secretion of mucus from anus, especially after a painful attack.

Fever, tachycardia, leukocytosis are signs of progression of ischemic colitis.

Palpation of the abdomen determines moderate pain along the colon. Signs of peritoneal irritation may also be detected. In this case, increased peritoneal phenomena indicate impending irreversible ischemic changes in the colon.

Sigmoidoscopy during an acute episode of ischemia only in rare cases reveals typical submucosal hemorrhages; A rectal biopsy has a certain diagnostic value, in which changes characteristic of ischemia are determined.

Colonoscopy reveals submucosal hemorrhages and an erosive process against the background of an unchanged or pale (consequence of impaired blood supply) mucous membrane. The changes are focal in nature and are most pronounced at the apices of the haustra.

Of great importance in the diagnosis of reversible ischemic disease of the colon is X-ray examination colon with barium enema. Important radiological sign ischemic colitis is a symptom of so-called “finger impressions”. It consists of oval or round filling defects, which are projected by submucosal hemorrhages in the intestinal wall. However, a reliable sign of vascular lesions is their appearance only when the colon is tightly filled with barium. Hemorrhages usually resolve within a few days, and the fingering symptom disappears. With a more pronounced degree of ischemia, the mucous membrane over the site of hemorrhage is rejected, forming an ulcerative defect.

Delaying the implementation of these research methods, especially irrigoscopy, may interfere with establishing the correct diagnosis, since lesions with a reversible form often disappear without treatment.

There are two possible outcomes of reversible (transient) ischemic colitis - resolution or progression of the process with the transition to an irreversible form with the development of ischemic stricture.

With the further development of ischemic colitis, ulcers form at the site of defects in the mucous membrane and an admixture of pus appears in the stool. Due to exudation into the intestinal lumen, feces become liquid. When digitally examining the rectum, there may be dark blood and pus in its lumen. In such cases, sigmoidoscopy can reveal ulcerative defects of irregular shape with a sharp border, covered with fibrinous plaque. These changes are visible against the background of an unchanged or pale mucous membrane.

During irrigoscopy, there is significant variability in the areas of damage to the colon - from short to long areas. In the altered segments, the phenomena of spasm, irritability, loss of haustration, smooth or uneven, jagged contour of the intestine are determined. Spasm and swelling are much more pronounced than with transient ischemia. With a sharp spasm localized in a short segment, radiological changes are similar to a tumor process. If there is a persistent narrowing that is detected during repeated studies, colonoscopy or laparotomy is indicated to exclude a diagnostic error.

Colonoscopy reveals an erosive and ulcerative process, most often localized in the left half of the colon, especially in its proximal part. The ulcers have a variety of shapes, are often tortuous and covered with a purulent grayish film. With more severe damage, necrosis and rejection of the mucous membrane are determined. In this case, the inner surface of the intestine is represented by extensive ulcerative defects with clear boundaries.

An irreversible form of ischemic colitis. This form is more common in middle-aged and elderly people with heart disease or atherosclerosis and is diagnosed in the absence of a history of indications of chronic intestinal disorders. Its most characteristic manifestation is the formation of colon stricture.

IN clinical picture When a stricture forms, the symptoms of increasing intestinal obstruction: cramping pain, pronounced rumbling and periodic bloating, alternating constipation and diarrhea.

Radiological manifestations of an irreversible form, along with the symptom of “finger indentations”, are irregularity of the contours of the mucous membrane, caused by the subsidence of edema and the appearance of ulcers, tubular narrowings and saccular protrusions on the intestinal wall opposite the mesentery, which can be mistaken for diverticula. Ischemic stricture rarely takes the form of a tumor lesion with clearly defined boundaries, however, in the presence of persistent narrowing of the colon, it is necessary to exclude a malignant disease.

Colonoscopy reveals a narrowing of the intestinal lumen, usually of irregular shape, with cicatricial bridges; the mucous membrane before the stricture is usually unchanged or with minor inflammatory manifestations, which distinguishes it from the stricture of Crohn's disease.

Histological changes are often limited to the mucosa only, but may involve the entire thickness of the intestinal wall. Along with typical hemorrhages, there are phenomena of membranous and pseudomembranous colitis, in which pathological areas are located in the form of spots. The most characteristic microscopic sign of ischemic colitis, in addition to hemorrhages and ulcerations, is the presence of many hemosiderin-containing macrophages.

Angiography of the inferior mesenteric artery has the greatest diagnostic value, although if indicated, it is possible to study blood flow in the right parts of the colon by catheterizing the superior mesenteric artery. Angiographic examination of intestinal vessels is carried out according to generally accepted methods.

Differential diagnosis

Differential diagnosis of ischemic colitis includes ulcerative colitis, Crohn's disease, cancer, diverticulitis and intestinal obstruction.

The vascular nature of the disease should first of all be suspected in elderly people suffering from cardiovascular diseases, with the manifestation of atypical ulcerative colitis and a short history. In cases where an elderly patient complains of intestinal bleeding that appeared shortly after a collaptoid state, hypertensive crisis, etc., the diagnosis of ischemic colitis does not present any particular difficulties. It should be considered that ulcerative colitis almost invariably occurs with damage to the rectum and in the active stage of the process, rectal biopsy reveals characteristic changes.

Ischemic colitis differs from Crohn's disease by the constancy of the localization of the process in the splenic flexure and the absence of anal and perianal lesions. Histological examination data with the detection of typical granulomas also help.

Differential diagnosis of ischemic colon disease, ulcerative colitis and Crohn's disease is shown in the table.

Sign	Ischemic colon disease guts	Ulcerative colitis	Crohn's disease
Start	acute	often gradual	gradual
Age 50 and older	80%	less than 10%	less than 5%
Bleeding from the rectum	single	regular	uncharacteristic
Formation of strictures	typical	uncharacteristic	typical
Concomitant diseases of the cardiovascular system	characteristic	rare	rare
Course of the disease	fast changing	chronic, less often acute	Chronic
Segmentation of the lesion	characteristic	uncharacteristic	characteristic
Characteristic localization	splenic flexure, descending, sigmoid, transverse colon	rectum, in some cases, damage to more proximal segments of the colon	terminal ileitis, right half of the colon, total colitis
“Finger indentations” on radiographs	characteristic	very rare	uncharacteristic
Histological picture	macrophages containing hemosiderin	crypt abscesses	sarcoid granulomas

Treatment

Correct treatment of reversible ischemic colon disease requires early diagnosis and continuous monitoring of the patient with careful repeated x-ray monitoring. Therapy for reversible ischemia consists of prescribing diet, mild laxatives, vasodilators and antiplatelet agents. In the future, for preventive purposes, patients are recommended to take prodectin 0.6 g 4 times a day, trental 0.48 g 3 times a day, chimes 200-400 mg/day to improve rheological properties as an antiplatelet agent or other means that improve blood circulation. In some cases, this can be facilitated by the administration of gammalon 25-50 mg 3 times a day in combination with stugeron 0.25 mg 3 times a day.

Vitamin therapy is important: ascorbic acid, ascorutin, B vitamins, multivitamin preparations (undevit, gendevit, ferroplex), etc.

With a more pronounced clinical picture, not accompanied by shock and a picture of peritonitis, transfusion therapy is added to the treatment, aimed at correcting the water-electrolyte balance, blood transfusions, and parenteral nutrition. It should be noted that parenteral nutrition creates physiological rest in the colon and is therefore an important point of treatment. Analgesics should be prescribed with caution so as not to miss possible development peritonitis due to disease progression. In case of joining secondary infection it is necessary to use antibiotics and sulfonamides taking into account the sensitivity of the flora.

When dilatation of the colon is performed, it is decompressed using a colonoscope, vent pipe. Corticosteroids, in contrast to ulcerative colitis and Crohn's disease, for which they are effective, are contraindicated in ischemic colon disease.

In the complex treatment of ischemic disease of the colon, hyperbaric oxygenation occupies a special place, since it allows dosed increases in the degree of oxygen perfusion due to physically dissolved oxygen and thereby correct tissue hypoxia. Experience with the use of hyperbaric oxygenation in the treatment of ischemic colitis shows that after 2-4 sessions, patients note improved sleep and mood, and a surge of vigor. In comparatively short terms is being liquidated pain syndrome, reparative processes in the colon are accelerated. Hyperbaric oxygen therapy potentiates the effects of anti-inflammatory drugs.

Usually, 1 course of treatment of 10-15 sessions is sufficient, carried out daily with a 40-60-minute exposure at an optimal level of oxygen compression, individually selected titration, i.e. by gradually increasing oxygen pressure from session to session in the range of 1.3- 2 atm. under the control of blood pressure, heart rate, acid-base status, clinical, electrocardiographic and rheo-encephalographic data.

Long-term results indicate that the positive clinical effect is maintained for 3-5 months, after which it is advisable to repeat the course of hyperbaric oxygenation.

It must be emphasized that if ischemic damage lasts for 7-10 days, despite treatment, or if symptoms increase, surgical treatment should be used.

After the symptoms of coronary artery disease of the colon have subsided, a double X-ray examination with a barium enema is performed for a year, which facilitates the diagnosis of developing strictures or shows the reverse development of changes in the colon.

In the presence of a stricture, the indication for surgery is signs of intestinal obstruction or suspicion of malignant degeneration in the area of narrowing. It is better to perform the operation in in a planned manner, which creates the conditions for resection of the colon with simultaneous restoration of its patency.

For the gangrenous form of ischemic disease of the colon, the only treatment method is emergency surgery, which consists of resection of necrotic colon according to Mikulicz or Hartmann. Simultaneous restoration of colonic patency is undesirable, since it is very difficult to determine the true extent of ischemic damage. Incorrect determination of the boundaries of resection leads to repeated surgical interventions due to ongoing necrosis and dehiscence of the anastomotic sutures. Quite understandable, considering old age patients, the importance of thorough preoperative preparation and post-operative care, as well as the prevention of hypovolemia, sepsis, and renal dysfunction.

Forecast for ischemic disease of the colon, in cases of adequate therapeutic or surgical treatment, favorable.

Caused by inadequate blood supply, is the most frequent manifestation intestinal ischemia (60%). The severity depends on the location and extent, the severity of the onset of the disease, the presence of collaterals and the level of vascular occlusion: the most vulnerable are the splenic flexure, rectosigmoid junction and the right colon. Many different etiological factors lead to common pathological changes:

Vascular occlusion:
- Occlusion large vessels: infrarenal aortic shunt, SMA thrombosis/embolism, portal vein/SMV thrombosis, trauma, acute pancreatitis, aortic dissection.
- Occlusion of peripheral vessels: diabetic angiopathy, thrombosis, embolism, vasculitis, amyloidosis, rheumatoid arthritis, radiation damage, trauma, embolization during interventional radiological procedures (with bleeding from lower sections Gastrointestinal tract), hypercoagulable state (deficiency of proteins C and S, antithrombin III, sickle cell anemia).

Non-occlusive diseases:
- Shock, sepsis, decreased perfusion (eg, atrial fibrillation, myocardial infarction, heart-lung machine), steal phenomenon, increased intra-abdominal pressure syndrome.
- Obstruction of the colon, intussusception, hernia.
- Intoxication: cocaine, drugs (NSAIDs, vasopressors, digoxin, diuretics, chemotherapy drugs, gold compounds).

Attention: Patients may have other significant pathological changes (eg, cancer) in affected or unaffected areas.

Treatment varies from conservative management (mild and moderate forms) to segmental resections and even colectomy (severe or life-threatening forms).

A) Epidemiology of ischemic colitis:
The peak incidence is observed between 60 and 90 years of age. Women are affected more often than men. The reason for emergency hospitalization is in one case out of 2000.
The true incidence is unknown due to misdiagnosis. Previously, up to 10% of ischemic colitis was caused by replacement of the infrarenal aorta, less often by interventional manipulations under X-ray control.
Localization: 80% - in the left sections (between the splenic flexure and the sigmoid colon), 10-20% - in the descending or transverse colon,

b) Symptoms of ischemic colitis

Acute ischemia:
Initial stage: acute ischemia => acute onset of abdominal pain, possibly cramping, hyperperistalsis, may be accompanied by diarrhea and the urge to defecate.
Second stage: beginning tissue necrosis (after 12-24 hours) => paresis, paradoxical reduction of pain, bleeding (unchanged blood in the stool), mild peritoneal symptoms.
Third stage: peritonitis, sepsis - increased peritoneal symptoms, signs of intoxication (fever, leukocytosis with a shift to the left, tachycardia); complete paresis, nausea, vomiting, unstable hemodynamics, septic shock.
Complications:
- Colon dilatation and wall changes => perforation, sepsis, oliguria, multiple organ failure, death.
- Sepsis -> bacterial colonization of implants placed due to ischemia (e.g. artificial valves, aortic prostheses, etc.)

Chronic ischemia:
Angina abdominalis (“abdominal toad”): pain after eating as a result of insufficient blood flow to the intestines.
Strictures due to ischemic colitis => symptoms of obstruction.

V) Differential diagnosis of ischemic colitis:
- IBD: ulcerative colitis, .
- Infectious colitis: Shigella, enterohemorrhagic E.coli, Salmonella, Campylobacter, etc.
- Colorectal cancer.
- Diverticulosis, diverticulitis.
- Radiation proctitis.
- Other causes of acute abdominal pain and/or bleeding from the lower gastrointestinal tract.

a, b - Pneumatosis of the colon and gas in the portal veins in a patient with ischemic colitis. Pneumatosis of the colon (a) is manifested by a curved contour of gas (shown by arrows) along the contour of the fluid-filled luminescent colon.
On the periphery of the left lobe of the liver (b), many gas-filled tubes are visible (shown by arrows). Computed tomography.
c - Symmetrical thickening (shown by arrow) of the lower part of the descending colon (barely noticeable thickening of the wall) corresponds to the area shown by the white arrow on the radiograph.
Computed tomography through the superior aperture of the pelvis.
d - Ischemic colitis in a patient with pain in the left lower quadrant of the abdomen.
Thickening of the wall of the descending colon (shown by an arrow) with dissection in the wall area was detected. Computed tomography.

G) Pathomorphology
Macroscopic examination:
Acute ischemia: swelling of the entire wall or just the intestinal mucosa => area of ulceration and necrosis, segmental full-wall necrosis => segmental gangrene.
Chronic ischemia: fibrous stricture, the mucosal surface is intact.

Microscopic examination:
Acute ischemia: superficial necrosis of the mucosa (crypts are initially intact) => hemorrhages and pseudomembranes => transmural necrosis (loss of nuclei, cell shadows, inflammatory reaction, disruption of cellular architecture); There may be visible blood clots, emboli, or cholesterol emboli.
Chronic ischemia: the mucosa is mostly intact, but there is crypt atrophy and focal erosions, thickening/hyalinosis of the lamina propria, diffuse fibrosis.

a - Macroscopic picture of severe acute ischemic colitis with total infarction of the intestinal wall.
b - Macroscopic picture of the colon in ischemic colitis. Areas of necrosis and peritonitis are visible.
c - Onset of ischemic colitis. Thickening of the submucosal layer due to edema (on a radiopaque barium image shows a “thumbprint” pattern), hemorrhagic necrosis of the mucous membrane is noticeable.
The muscular plate of the mucous membrane is still viable. Total microscopic section of the intestinal wall.
d - Secondary ischemia with thrombosis of the mesenteric veins.
Microscopic picture: a characteristic massive accumulation of blood is visible in the intestinal wall with necrosis of the mucous membrane and muscular layer of the lamina propria of the mucous membrane and thrombosis of the veins of the submucosal layer.
e - Ischemic colitis with atheromatous embolism.
Microscopic picture: massive swelling of the submucosal layer, hemorrhages and foci of necrosis of the mucous membrane, a large cholesterol embolus in the lumen of the muscular artery deep in the submucosal layer (main center) were detected.

d) Examination for ischemic colitis

Minimum Standard Required:
Anamnesis:
- Recent vascular surgery, embolism, abdominal pain, history of vasculitis, taking medications (including warfarin, acetylsalicylic acid).
- Triad of symptoms: acute abdominal pain, bleeding from the rectum, diarrhea.

Clinical examination:
- Basic indicators of the body’s condition: arrhythmia (atrial fibrillation), stability of hemodynamic parameters?
- Abdominal bloating, abdominal pain inconsistent with clinical examination, hyperperistalsis or paresis, peritoneal symptoms?
- Preservation of pulse femoral arteries and distal vessels of the extremities? Signs of widespread atherosclerosis?

Laboratory tests: blood => leukocytosis, anemia, thrombocytopenia (?), lactic acidosis, creatine kinase-BB, hypophosphatemia, coagulopathy, hypoproteinemia?

Radiation imaging methods:
- X-ray of the abdominal cavity/chest: free gas, “finger indentation” symptom, loss of haustration, widened loops.
- CT with oral/intravenous contrast if possible (renal function!): the most practical test if pain is primary symptom=> free gas in the abdominal cavity, segmental thickening of the intestinal wall, fingerprint sign, pneumatosis, loss of haustration, dilated loops, double halo sign, gas in the portal vein? Other causes of abdominal pain? Status of main paths vascular outflow: blood clots?

Colonoscopy- “gold” standard: the most sensitive method, contraindicated in the presence of peritoneal symptoms: normal rectum (in the absence of complete occlusion of the aorta); segmental changes in the mucosa => hemorrhages, necrosis, ulcers, vulnerability? Strictures?

Additional research (optional):
Radiocontrast studies are usually not indicated in acute situation (usual signs: symptom of “finger indentations”, swelling of the intestinal wall, loss of haustration, ulcers); chronic ischemia => bowel shape, stricture?
Visceral angiography (interventional, e.g. thrombolysis): role is relatively limited in the acute setting unless thrombolysis may be successful; assessment of symptoms of chronic ischemia - vascular architectonics.

a - Ischemic colitis with pneumatosis of the colon. Tiny bubbles are visible overlying the shadow of the colon. Air bubbles in the intestinal wall, side view (shown by arrows).
The intestinal lumen is crossed by a thick fold (shown by a white arrow). X-ray of the descending colon.
b - Picture of a “thumb print” on a single image of a patient with acute ischemic colitis. Barium contrast enema.
c - Ischemic colitis with pneumatosis of the colon. A curved band of air (shown by arrows) surrounds the contrast-filled intestinal lumen.
Computed tomography at the level of the descending colon.

e) Classification of ischemic colitis
- Based on etiological factors: occlusive/non-occlusive ischemia.

Based on pathological changes:
Gangrenous ischemic colitis (15-20%).
Non-gangrenous ischemic colitis (80-85%):
- Transient, reversible (60-70%).
- Chronic irreversible => chronic segmental colitis(20-25%) => stricture (10-15%).

and) Treatment without surgery for ischemic colitis:
Restoration of hemodynamic parameters: volume replacement is more important than the use of vasopressors.
Broad spectrum antibiotics, series clinical trials with periods of “rest” for the colon.
Heparinization if tolerated.
Perhaps interventional radiology.
Repeat colonoscopies: monitoring the effectiveness of treatment, repeat examination of the colon in optimal conditions to identify other pathological changes.

a - area of acute focal ischemia. Colonoscopy.
b - ischemic colitis of the splenic flexure.
Almost pathognomonic internal bleeding. Colonoscopy.

h) Surgery for ischemic colitis:

Indications:
Acute ischemia: peritonitis, pain inconsistent with clinical examination data, signs of gangrene, sepsis refractory to treatment, pneumoperitoneum; no improvement, persistent protein loss due to pathological changes in the intestine (duration > 14 days).
Chronic ischemia: recurrent sepsis, symptomatic colonic stricture, any stricture in which the presence of a tumor cannot be excluded.

Surgical approach:
1. Acute ischemia:
Resection of the affected segment => intraoperative assessment of the viability of the colon: bleeding from the edges of the mucosa, venous thrombi, presence of a palpable pulse?
- Primary anastomosis or stoma (for example, double-barreled).
- Controversial viability: planned relaparotomy or more extended resection.
Exploratory laparotomy if the area of necrosis is too large and incomparable to life.

2. Chronic ischemia:
Resection of the affected segment with the formation of a primary anastomosis.
Vascular interventions and subsequent reconstruction are possible.

And) Results of treatment of ischemic colitis:
Transient ischemia: relatively good prognosis, largely depends on the prognosis for other organs; 50% of cases are reversible, clinical resolution within 48-72 hours, endoscopic resolution within 2 weeks; in more severe forms, healing is prolonged (up to 6 months) => stricture?
Gangrenous ischemia: mortality in 50-60% of cases - a population of patients with concomitant diseases and with the most severe course of the disease!
Chronic ischemia: Complication rates and mortality are similar to those with colon resection for other diseases, but the risk of cardiovascular complications is higher.

To) Observation and further treatment:
Complete bowel examination after 6 weeks (if condition allows).
Emergency surgery: planning further interventions, e.g. restoration of intestinal continuity as planned, after complete restoration of physical condition and nutrition.
Determination of the option and duration of anticoagulant therapy.

is an inflammatory process in the large intestine that occurs during a transient disruption of the blood supply to its wall. Usually develops after the age of 60 years. The diagnosis is confirmed by computed tomography, irrigoscopy and colonoscopy. It is treated predominantly conservatively. Surgical intervention is indicated for significant spread of the process and necrosis of a large area of the intestinal wall.

Variants of the course of the disease:

Acute colitis. It appears suddenly against the background of complete well-being. Accompanied by vivid clinical symptoms and rapid deterioration of the condition.
Chronic colitis. Symptoms are moderate or erased. The patient's condition worsens gradually.

Gastrointestinal symptoms

Local symptoms come to the fore in chronic colitis:

The intensity of symptoms depends on the extent of the process. If the pathological focus is limited to a small segment of the intestine, the manifestations of the disease will be weak and erased. With significant circulatory impairment, signs of colitis increase.

Manifestations of the disease also depend on the stage of its development:

With a reversible disruption of blood flow in the intestines, pain occurs periodically and almost always subside on its own. Blood in the stool and bleeding occur a few days after the onset of the disease. Reversible ischemic colitis is possible with short-term violation blood flow or against the background of the development of collaterals (bypass blood vessels).
With irreversible disruption of the blood supply, symptoms progressively increase. The pain intensifies, the stool becomes liquid with an admixture of blood. The general condition worsens, signs of intoxication of the body appear. This option is possible with significant disruption of blood flow, intestinal necrosis and the absence of collaterals.

Extraintestinal (general) symptoms

Changes in general condition are characteristic of acute colitis with irreversible damage blood flow The following symptoms occur:

Signs of general intoxication increase along with an increase in the area of necrosis (tissue death) of the intestine.

With chronic ischemic colitis, other symptoms may appear:

general weakness, weakness;
decreased performance, memory impairment;
anemia - a decrease in hemoglobin and red blood cells in the blood, leading to oxygen starvation fabrics;
signs of a lack of certain vitamins when their absorption is impaired (dry skin, brittle nails and hair, muscle weakness, muscle cramps, etc.).

Causes of the disease

The main cause of ischemic colitis is a decrease in blood flow to a certain area of the colon. The following conditions can cause ischemia:

Variants of the course of the disease:

Occlusive ischemia. When the lumen of the vessel is completely blocked (occluded), acute ischemic colitis develops. The area of damage to the colon will depend on the diameter of the vessel and the duration of occlusion, the possibility of development collateral blood flow. With incomplete overlap, chronic colitis is formed.
Nonocclusive ischemia. Occurs when blood pressure decreases in the vessels supplying the intestines. A chronic form of pathology usually develops.

Diagnostics

Differential diagnosis is carried out with the following conditions:

The final diagnosis is made after colonoscopy with biopsy, irrigography, and computed tomography.

Principles of treatment

Therapy for ischemic colitis begins with diet and medication. The operation is rarely performed and is indicated only in the presence of conditions that threaten the patient’s life.

Diet

General principles of nutrition for ischemic colitis:

Frequent and small meals. 5-6 meals with decreasing portion sizes are recommended. Dinner should be 2-3 hours before bedtime.
Steamed and boiled food. Fried foods are not recommended until complete recovery or stable remission.
Drinking regime. You should drink up to 1.5-2 liters of clean water per day, unless there are contraindications ( serious illnesses heart and kidneys).

The list of products is presented in the table.

Recommended Products	Not Recommended Products
lean varieties of poultry, fish, meat; bread made from rye flour; unhealthy baked goods (in moderation); cereals (oatmeal, buckwheat, millet); vegetable broth soups; low-fat fermented milk products; hard cheese; vegetables (except prohibited ones); green; non-acidic fruits and berries; homemade jam, honey	fatty meats, fish, poultry; white bread; baked goods; semolina; soups with meat and fish broth; fermented milk products with high fat content; processed cheese; vegetables that cause gas (cabbage, legumes); sour berries and fruits; seasonings and sauces; smoked products, sausages, canned food; confectionery; milk chocolate; tea, coffee, cocoa; alcohol

With a widespread process, the patient is transferred to parenteral nutrition.

Drug therapy

Depending on the specific clinical situation, the following medications are prescribed:

Surgical therapy

Indications for surgery:

An intestinal resection is performed - excision of a part of an organ affected by necrosis. The volume of the operation depends on the extent of the process. The ends of the intestinal tube are compared and sutured. The abdominal cavity is inspected and the pus is removed. At extensive damage When it is not possible to match the ends of the intestine, a stoma is formed - an opening on the front wall of the abdomen for the removal of feces.

Complications and prognosis for life

Without treatment, ischemic colitis leads to the development of complications:

If complications develop, surgical treatment is indicated.

The prognosis is favorable with timely diagnosis of the pathology. After prescribed therapy, stable remission of the disease can be achieved. Relapse occurs in 5% of cases. In advanced situations, the development of peritonitis and sepsis can lead to death.

Prevention

Since the exact cause of ischemic colitis cannot always be determined, it is difficult to talk about its prevention. You can reduce the risk of developing the disease if you follow the recommendations:

give up bad habits: smoking, drinking alcohol;
promptly treat diseases of the large intestine and cardiovascular system;
monitor your weight, blood pressure, and blood cholesterol levels.

When the first signs of the disease appear, you need to consult a doctor - therapist, gastroenterologist, or surgeon. It is important to remember that pain and bleeding occur with various pathologies, and only after the examination can you set accurate diagnosis. Delay is dangerous to health and life.

Ischemic colitis is inflammatory changes in the colon caused by impaired blood supply to the intestinal wall. The term “ischemic colitis” was proposed by Magtson in 1966. Ischemic colitis accounts for at least a third of all diagnosed inflammatory changes colon in elderly people, but the true frequency of ischemic changes has not been established.

The development of ischemic disease of the colon with thrombosis and embolism, vascular trauma, allergic reactions is associated with vascular occlusion and, as a rule, is accompanied by the development of gangrene, although a transition to a chronic form with the gradual formation of a stricture or a long course of ulcerative colitis is not excluded. The development of one or another form of the disease in this situation is determined by the state of collateral circulation, the diameter of the damaged vessel, the completeness and duration of occlusion, the rate of revascularization, etc.

Along with this, there are non-occlusive lesions, the possibility of development of which is associated with the anatomical and functional characteristics of the colon. In addition to the fact that the blood flow in the colon, compared to other organs, is the lowest, there are also the most vulnerable places - anastomoses between the branches of the main vessels of the colon. It is also necessary to take into account that the functional activity of this organ is normally accompanied by a decrease in blood flow in it. In this regard, it becomes clear that any pathological processes accompanied by hypovolemia, such as chronic heart diseases with congestive heart failure, abdominal aortic aneurysms, shock, strokes, massive bleeding occurring with hypotension syndrome, are important predisposing factors in the development of chronic forms ischemic disease of the colon.

Disorders of the mesenteric blood supply under the influence of vasopressor drugs such as ephedrine, adrenaline, vasopressin, and estrogen-containing contraceptives have been described.

In mild and moderate forms of ischemic colitis, not only the serous and muscular membranes remain viable, but also changes in the mucous membrane, if they do not represent necrosis, can almost completely undergo reverse development. Only in severe forms do deep injuries occur, often resulting in perforation or stricture formation.

Clinic and diagnostics

Reversible (transitory) form. With this form of the disease, pathological changes in the colon are observed only for a short time and quickly undergo complete reversal. The main symptom of the disease is pain in the left half of the abdomen, which occurs suddenly and just as quickly disappears spontaneously. Attacks of pain can be repeated throughout the day, and their intensity varies. More often it is not pronounced or is so insignificant that patients forget about it and only with careful questioning can it be identified. It sometimes resembles coronary pain or pain from intermittent claudication and is associated with the functional activity of the intestines caused by digestive processes. The fact that pain often occurs 15-20 minutes after eating, subsides after a few hours and is localized along the colon has important diagnostic significance, indicating a possible ischemic nature. The pain is often accompanied by tenesmus and blood in the stool. In some cases, bleeding occurs several days or even weeks after the onset of the disease. The blood is mixed and can be either dark or bright red. Its amount is usually insignificant, and massive bleeding usually indicates ischemic damage to the intestine. Along with the admixture of blood, ischemic colitis is characterized by frequent secretion of mucus from the anus, especially after a painful attack.

Fever, tachycardia, leukocytosis are signs of progression of ischemic colitis.

Of great importance in the diagnosis of reversible ischemic disease of the colon is an X-ray examination of the colon with a barium enema. An important radiological sign of ischemic colitis is the symptom of so-called “finger impressions”. It consists of oval or round filling defects, which are projected by submucosal hemorrhages in the intestinal wall. However, a reliable sign of vascular lesions is their appearance only when the colon is tightly filled with barium. Hemorrhages usually resolve within a few days, and the fingering symptom disappears. With a more pronounced degree of ischemia, the mucous membrane over the site of hemorrhage is rejected, forming an ulcerative defect.

The clinical picture during the formation of a stricture is dominated by symptoms of increasing intestinal obstruction: cramping pain, severe rumbling and periodic bloating, alternating constipation and diarrhea.

Differential diagnosis

Differential diagnosis of ischemic colitis includes ulcerative colitis, Crohn's disease, cancer, diverticulitis and intestinal obstruction.

The vascular nature of the disease should first of all be suspected in elderly people suffering from cardiovascular diseases, with the manifestation of atypical ulcerative colitis and a short history. In cases where an elderly patient complains of intestinal bleeding that appeared shortly after a collaptoid state, hypertensive crisis, etc., the diagnosis of ischemic colitis does not present any particular difficulties. It should be assumed that ulcerative colitis almost invariably occurs with damage to the rectum and in the active stage of the process, rectal biopsy reveals characteristic changes.

Differential diagnosis of ischemic colon disease, ulcerative colitis and Crohn's disease is shown in the table.

Sign	Ischemic colon disease guts	Ulcerative colitis	Crohn's disease
Start	acute	often gradual	gradual
Age 50 and older	80%	less than 10%	less than 5%
Bleeding from the rectum	single	regular	uncharacteristic
Formation of strictures	typical	uncharacteristic	typical
Concomitant diseases of the cardiovascular system	characteristic	rare	rare
Course of the disease	fast changing	chronic, less often acute	Chronic
Segmentation of the lesion	characteristic	uncharacteristic	characteristic
Characteristic localization	splenic flexure, descending, sigmoid, transverse colon	rectum, in some cases, damage to more proximal segments of the colon	terminal ileitis, right half of the colon, total colitis
“Finger indentations” on radiographs	characteristic	very rare	uncharacteristic
Histological picture	macrophages containing hemosiderin	crypt abscesses	sarcoid granulomas

Treatment

Proper treatment of a reversible form of coronary artery disease of the colon requires early diagnosis and continuous monitoring of the patient with careful repeated x-ray monitoring. Therapy for reversible ischemia consists of prescribing diet, mild laxatives, vasodilators and antiplatelet agents. In the future, for preventive purposes, patients are recommended to take prodectin 0.6 g 4 times a day, trental 0.48 g 3 times a day, chimes 200-400 mg/day to improve rheological properties as an antiplatelet agent or other means that improve blood circulation. In some cases, this can be facilitated by the administration of gammalon 25-50 mg 3 times a day in combination with stugeron 0.25 mg 3 times a day.

Vitamin therapy is important: ascorbic acid, ascorutin, B vitamins, multivitamin preparations (undevit, gendevit, ferroplex), etc.

With a more pronounced clinical picture, not accompanied by shock and a picture of peritonitis, transfusion therapy is added to the treatment, aimed at correcting the water-electrolyte balance, blood transfusions, and parenteral nutrition. It should be noted that parenteral nutrition creates physiological rest in the colon and is therefore an important point of treatment. Analgesics should be prescribed with caution so as not to miss the possible development of peritonitis due to disease progression. In the event of a secondary infection, it is necessary to use antibiotics and sulfonamides, taking into account the sensitivity of the flora.

When dilatation of the colon is performed, it is decompressed using a colonoscope and a gas outlet tube. Corticosteroids, in contrast to ulcerative colitis and Crohn's disease, for which they are effective, are contraindicated in ischemic colon disease.

In the complex treatment of ischemic disease of the colon, hyperbaric oxygenation occupies a special place, since it allows dosed increases in the degree of oxygen perfusion due to physically dissolved oxygen and thereby correct tissue hypoxia. Experience with the use of hyperbaric oxygenation in the treatment of ischemic colitis shows that after 2-4 sessions, patients note improved sleep and mood, and a surge of vigor. In a relatively short time, pain is eliminated and reparative processes in the colon are accelerated. Hyperbaric oxygen therapy potentiates the effects of anti-inflammatory drugs.

Long-term results indicate that the positive clinical effect is maintained for 3-5 months, after which it is advisable to repeat the course of hyperbaric oxygenation.

It must be emphasized that if ischemic damage lasts for 7-10 days, despite treatment, or if symptoms increase, surgical treatment should be used.

In the presence of a stricture, the indication for surgery is signs of intestinal obstruction or suspicion of malignant degeneration in the area of narrowing. It is better to perform the operation as planned, which creates the conditions for resection of the colon with simultaneous restoration of its patency.

For the gangrenous form of ischemic disease of the colon, the only treatment method is emergency surgery, which consists of resection of necrotic colon according to Mikulicz or Hartmann. Simultaneous restoration of colonic patency is undesirable, since it is very difficult to determine the true extent of ischemic damage. Incorrect determination of the boundaries of resection leads to repeated surgical interventions due to ongoing necrosis and dehiscence of the anastomotic sutures. It is quite understandable, given the advanced age of patients, the importance of careful preoperative preparation and postoperative care, as well as the prevention of hypovolemia, sepsis, and renal dysfunction.

PROMOTION! SIGN UP FOR A CONSULTATION AND RECEIVE A 50% DISCOUNT!

Ischemic colitis is an inflammatory disease that occurs in the large intestine as a result of impaired blood circulation in its walls.

Ischemia of intestinal vessels leads to disturbances in its functions and structure.

This disease is accompanied by symptoms such as abdominal pain, stool upset, nausea, vomiting, flatulence, weight loss, and bleeding. In the chronic course, the patient loses weight. In severe acute formIntestinal colitis may cause an increase in temperature and general intoxication of the body.

The length of the colon is about 1.5 m, the diameter varies from 5-8 cm along its entire length. The contents of the intestine are moved through the contractile movements of special muscles. The large intestine has 3 bends (hepatic, splenic and sigmorectal).

The intestinal wall consists of mucous, submucosal, two muscular and outer (serous) layers. Falling from small intestine portions of digested food, processed by intestinal flora (various microorganisms) during the fermentation process.

Pathogenic microbes and toxic substances are destroyed (with the participation of the liver) and removed from the body with feces. If the intestinal microflora is disturbed, its immune system suffers protective function. In this case, internal infection and autoimmune diseases may develop.

Blood circulation in its vessels plays a very important role in the normal functioning of the intestines. The vessels and nerves serving the large intestine are located inside the mesentery. Two mesenteric arteries with thin branches supply blood to all parts of the large intestine. The portal vein carries venous blood to the liver for purification. If emboli enter the mesenteric arteries or narrow for other reasons, the blood supply to the large intestine is disrupted. As a result, ischemic colitis (acute or chronic) develops.

Types and forms of ischemic colitis

Types of acute colitis:

accompanied by infarction (death) of the intestinal mucosa;
with the advent intramural infarction (necrosis inside the wall) of the intestine;
with transmural infarction, which covers all layers of the intestinal wall.

Types of chronic colitis:

ischemic;
intestinal strictures (narrowing of part of the intestine).

There are 3 forms of intestinal colitis:

transient – circulatory disturbances periodically occur in the intestinal vessels, which leads to inflammation. The intestinal mucosa suffers, erosions and ulcers are replaced by granulation tissue;
stenosing ( pseudotumorous) – due to circulatory disorders and inflammatory processes, scarring of the intestinal wall and its narrowing occur. Adhesions and adhesions often appear in intestinal flexures;
gangrenous (the most severe form of colitis) - all layers of the intestinal wall are affected, which is accompanied by various complications. Intestinal infarction develops with areas of necrosis, ischemia and damage.

Transitory Ischemic colitis is characterized by:

sudden attacks of pain in the left iliac region;
diarrhea;
bloating;
tenesmus false urge to defecate;
increase in temperature;
flow of blood along with feces.

A blood test shows leukocytosis, and the doctor, upon examination, detects pain symptoms in the left side of the abdomen.

With stenotic form of colitis, strictures form and symptoms indicate partial intestinal obstruction:

stool retention;
cutting cramping pain in the abdomen;
accumulation of gases and poor discharge;
bloating.

When examining the lower part of the intestine, bloody mucus is found in place of normal mucous membrane.

Gangrenous the form is characterized by a worsening of heart disease, the appearance of signs of a diffuse catastrophe of the abdominal cavity:

severe, intense abdominal pain;
the patient's state of shock (low blood pressure, pallor and the appearance of sticky cold sweat);
bloody diarrhea;
in the left side of the abdomen there are peritoneal symptoms (daggering pain that intensifies with any movement, acute abdomen, nausea and vomiting, repeated diarrhea, etc.);
intoxication of the patient’s body (fever, tachycardia, dry tongue).

Ischemic colitis is accompanied frequent relapses. About 50% of elderly patients die from intestinal gangrene. It is necessary to consult a doctor in a timely manner, undergo full treatment, prevent intestinal gangrene.

Reasons

atherosclerosis of intestinal vessels, caused by the deposition of fats (lipids) on the vascular walls;
formation of thrombi (blood clots) in blood vessels;
inflammation of blood vessels (vasculitis);
deterioration of blood supply to the large intestine (hypoperfusion);
Disseminated intravascular coagulation syndrome is massive blood clotting in vessels of various sizes;
neoplasms (tumors);
liver transplant;
hereditary diseasesickle cell anemia, in which the oxygen transport function of hemoglobin is impaired;
taking certain medications, for women – oral contraceptives;
intestinal obstruction.

Symptoms

The disease ischemic colitis causes symptoms, the severity of which depends on the degree of development of the disease. The larger the area of intestinal damage, the stronger the degree of circulatory impairment, the brighter and more painful the symptoms:

Abdominal pain is localized at the site of intestinal damage. The pain may be felt in one side of the abdomen, or it may become encircling. The pain can be paroxysmal or constant; blunt or sharp, pulling cutting. The intensity of pain may increase and radiate to the area of the shoulder blades, neck, and lower back.

The pain may intensify:

at physical activity(lifting weights, brisk walking, physical work in a bent position);
for constipation;
after eating (especially dairy, hot, spicy dishes, sweets);
at night or while lying down.

In addition to the above, the following symptoms also appear:

nausea and vomiting, belching;
stool disorders (diarrhea and constipation);
bloating, flatulence (increased gas formation);
weight loss caused by indigestion, poor absorption and fear of eating due to pain;
dizziness, weakness, loss of performance;
sleep disturbance;
intestinal bleeding caused by ulcers and erosions on the intestinal mucosa;
sweating, chills;
headaches;
temperature rise.

Tension of the abdominal muscles, increased pain sensitivity during palpation, signs of irritation of the peritoneum for several hours require urgent hospitalization of the patient and observation in a hospital. At gAngrenous colitis may require urgent surgical intervention.

Diagnostics

To make a correct diagnosis:

carry out an analysis of the patient’s complaints (types and frequency of abdominal pain, whether there is blood in the stool, stool abnormalities), medical history (what symptoms and how long have they been bothering you);
analyze the patient’s medical history (have there been any surgeries, tumors, diseases of the abdominal cavity, what medications does he take on a regular basis);
conduct a general examination;
pressure and temperature measurement.

Laboratory tests:

general blood test;
on blood clotting;
general urinalysis;
analysis lipid spectrum blood serum;
stool analysis.

Instrumental examination:

Electrocardiography (ECG);
Ultrasound of the aorta and abdominal branches to determine the degree of vascular damage;
Angiographic examination of the abdominal aorta and its branches;
Doppler examination of the abdominal arteries;
X-ray (irrigoscopy) of the intestines to determine the degree of changes in the intestines;
Colonoscopy is an examination of the inner surface of the rectum using an endoscope. At the same time, a piece of tissue is taken for biopsy;
laparoscopy (if necessary) to examine organs or perform surgery through a small hole in the front wall of the abdomen.

Treatment

On initial stage the disease is carried out conservative treatment: nutritional correction, mild laxatives, vasodilators, antiplatelet agents (drugs that inhibit blood clots). Prescribe a complex of vitamins, special diet(No. 5), excluding fried, fatty, spicy foods.

It is prohibited to use:

pastries (pastry, cakes), fried (pancakes, pies);
broth-based soups (meat, mushroom, fish);
fatty meat (pork, duck, goose);
fish fatty varieties(catfish, sturgeon, stellate sturgeon);
margarine, spread, lard;
green onions, sorrel, radishes;
sour berries and fruits;
hard-boiled and fried eggs;
canned food, smoked meats, pickled vegetables;
pepper, horseradish, mustard;
chocolate, cocoa, coffee, ice cream;
drinks containing alcohol.

Can be used:

non-acidic berry and fruit juices;
V small quantities low-fat cottage cheese, cheeses, sour cream;
rye and wheat bread, biscuits;
vegetable soups with cereals, pasta;
boiled lean meat (lean beef, chicken);
vegetable and butter (50 g per day);
1 egg per day;
Jelly and compotes from non-acidic berries and fruits:
porridge;
sugar, honey, jam;
greens, vegetables.

Meals should be frequent (5-6 times a day) and small (200-300 g) portions with a minimum salt content.

For complications of colitis, antibiotics are prescribed. If the patient's condition is severe, detoxification therapy and blood transfusions are performed to remove toxins from the body.

For patients after surgery in the abdominal cavity, with metabolic disorders or diseases of the digestive system, parenteral nutrition (partial or complete) is used to avoid the occurrence of protein deficiency. To unload the intestines, medicinal drugs are administered intravenously to replenish the body's needs for nutrients. After taking antibiotics in acute period During the course of the disease, bacterial drugs are prescribed.

Surgical intervention for ischemic colitis is indicated when a large area of tissue is affected by necrosis, gangrene of the large intestine, peritonitis or perforation. During the operation, the affected part of the intestine is removed, and postoperative drainage is left. Planned operations are performed for strictures that narrow or block the lumen of the intestine. This is a disease It often affects older people, which is why complications after surgery are not uncommon.

Prevention

Ischemia (narrowing of the lumen) of the intestine more often occurs in old age (after 60 years); for young people, diseases similar in symptoms are nonspecific ulcerative colitis (ulceration of the mucous membrane), Crohn's disease (adhesions, damage to the gastrointestinal tract).

The causes of this disease are not completely clear and there are no specific preventive measures.

If you have pain in the intestines, a doctor's examination is necessary. Moreover, diagnosing these diseases is not easy. Not allowed when acute pain use any traditional methods, for example, applying a heating pad to your stomach.

Timely consultation with doctors, carrying out the necessary treatment, and strict adherence to the diet give a good chance of cure.

Ischemic colitis is an inflammatory disease that affects the large intestine and is formed due to segmental circulatory disorders.

The main reason for the appearance of this disorder is spasm or occlusion of the blood vessels supplying this organ. A large number of diseases and predisposing factors can become sources of such disorders.

The disease has no specific clinical manifestations, which makes diagnosis much more difficult. The main symptoms include pain, increased gas formation, nausea and belching. Establishment correct diagnosis involves the implementation of a number of laboratory and instrumental diagnostic measures.

Treatment can be either conservative or surgical. The basis of therapy is following a gentle diet, prescribing medications and excision of the affected part of the intestine.

Etiology

The large intestine is one of those internal organs that are rather poorly supplied with blood, and its functional activity leads to an even greater decrease in blood flow. It is for this reason that a wide range of pathologies can lead to the development of ischemia and ischemic colitis.

The main sources of this disease can be considered:

heart failure;
atherosclerotic damage to blood vessels - with this disorder, lipids accumulate in the walls of blood vessels;
blood clot formation;
DIC syndrome, which is characterized by a violation of the blood clotting process;
hypoperfusion or insufficient blood supply to this organ;
leakage inflammatory process in the vessels of the large intestine;
aortic dissection;
such hereditary pathology, like sickle cell anemia;
intestinal obstruction;
transplantation of a donor organ, namely the liver;
malignant or benign tumors in the intestines;
severe blood loss due to injury or surgery;
loss large quantity liquid on background infectious processes in the intestines;
systemic vasculitis;
allergic reactions.

Often, ischemic colitis affects the sigmoid or transverse colon, especially when the factor causing the disease is atherosclerosis. However, this does not mean that damage to other parts of this organ is completely excluded.

Classification

According to the nature of the disease, it is divided into:

acute ischemic colitis - characterized by the rapid development of symptoms and a significant deterioration in the person’s condition. Accompanied by infarction of the mucous or submucosal layer, as well as the entire intestine;
chronic ischemic colitis - characterized by an undulating course and over time can be complicated by the formation of strictures.

In addition, there are several more forms of the disease:

transient - expressed in periodic disruption of blood circulation in the vessels of this organ. Against this background, an inflammatory process develops, which is then independently neutralized;
stenosing or pseudotumorous - a scarring process occurs due to constant inflammation and circulatory disorders. This leads to a narrowing of the affected organ;
gangrenous - considered the most severe type of disease, since all layers of the large intestine are involved in the pathogenic process. In almost all cases, this form leads to the development of complications.

Separately, it is worth highlighting idiopathic ischemic colitis, the causes of which could not be determined.

Symptoms

Manifestation clinical signs Such an ailment directly depends on the degree of circulatory impairment in the affected organ - the larger the area affected, the more pronounced the symptoms will be. Thus, the symptoms of ischemic colitis will be as follows:

pain syndrome. Its location will correspond to the site of intestinal damage. Pain can occur in the left or right side of the abdomen, and is often girdling in nature. There is a spread of pain to the lumbar region, shoulder blades, neck and back of the head;
increase in abdominal size;
increased gas formation and sweating;
bowel dysfunction, which is expressed in alternating constipation and diarrhea. There are impurities of blood and mucus in the stool;
loss of body weight, which occurs against the background of refusal to eat, which, in turn, is caused by the appearance of symptoms precisely after eating food;
sleep disturbance - drowsiness is noted in daytime days and complete absence sleep at night;
weakness of the body and rapid fatigue, which reduces a person’s performance;
attacks of severe headache;
increase in body temperature;
pale skin;
the formation of xanthelasmas and xanthomas - often they are located on the chest, elbows and back;
intestinal bleeding.

If the above clinical manifestations begin to go away on their own, after which they increase sharply, this indicates that the disease has become irreversible.

Diagnostics

Have the greatest diagnostic value instrumental methods examinations of the patient, however, before prescribing them, the clinician must independently perform several manipulations:

conduct a detailed survey of the patient regarding the severity of symptoms;
get acquainted with the medical history and life history of the patient - to identify what etiological factors preceded the development of the disease;
Perform a thorough physical examination, which includes measuring blood pressure and temperature, as well as palpating the anterior peritoneal wall.

Laboratory research is aimed at:

clinical blood test;
samples to study blood clotting;
lipid spectrum of blood serum;
general urine examination;
microscopic examination of feces - it is possible to detect impurities of blood and mucus.

Instrumental diagnosis of ischemic intestinal colitis involves the following:

Ultrasound of the abdominal organs with Doppler ultrasound;
ECG - to monitor the functioning of the heart;
functional tests using an exercise bike or treadmill - to study how the patient tolerates physical activity;
intestinal irrigoscopy;
colonoscopy - to evaluate the inner surface of the large intestine;
biopsy - carried out during the previous procedure and is aimed at collecting a small piece of the affected organ for subsequent histological analyses;
endoscopic laparoscopy – to examine the abdominal organs.

Differential diagnosis of such a disease is carried out with:

various diseases of infectious etiology;
Crohn's syndrome;
oncology;
ulcerative colitis of a nonspecific nature.

Treatment

Elimination of ischemic colitis requires an integrated approach and includes:

maintaining a gentle diet is taken as a basis diet table number five;
taking medications such as vasodilators, mild laxatives and antiplatelet agents;
detoxification therapy – such treatment is necessary in severe cases of the disease;
normalization of water and electrolyte balance;
blood transfusion;
antibacterial therapy.

Surgical intervention is indicated when complications are identified and is aimed at excision of the affected part of the large intestine.

Complications

Delayed treatment quite often leads to the development of such consequences as:

partial or complete intestinal obstruction;
rupture of the wall of the affected organ;
pathological expansion of the affected organ;
intestinal hemorrhage;
peritonitis;
formation of strictures;
oncology.

Prevention and prognosis

Due to the fact that ischemic colitis is a complication of many diseases, their timely elimination can be considered the only preventive measure. In addition, it is recommended to adhere to the rules of diet No. 5.

The prognosis of the disease is often favorable, but depends on the patient’s age and general condition, as well as the presence of complications and concomitant ailments.