Colon non tumor
Colitis (non-infectious)
Ischemic colitis

Author: Hanni Gulwani, M.D. (see Authors page)

Revised: 27 December 2016, last major update May 2013

Copyright: (c) 2003-2016,, Inc.

PubMed Search: ischemic colitis[title]colon
Cite this page: Ischemic colitis. website. Accessed February 20th, 2018.
Definition / general
  • Ischemic changes may be mucosal, mural (due to hypoperfusion) or transmural (major vessels involved)
  • Chronic ischemia may produce similar changes as acute ischemia, may be segmental and patchy
  • Usually age 50+ years, but also infants with necrotizing enterocolitis
  • Intestinal ischemia occurs in 3% of renal transplant patients (Arch Pathol Lab Med 2002;126:1201)
  • Splenic flexure and transverse colon are "watershed" areas, at borders of territory supplied by inferior and superior mesenteric arteries (Wikipedia)
  • Causes: bowel obstruction, diabetes, drugs (Kayexalate, NSAIDs, potassium chloride pills), hypercoagulable states (South Med J 2004;97:120), intestinal Behcet's disease, pseudomembranous colitis, radiation, stress ulcer, surgery, vascular disease (atherosclerosis, dissecting aneurysms, small vessel vasculitis, thromboemboli), uremia (eMedicine)
  • In younger patients, associated with amyloidosis, birth control pills (Am J Surg Pathol 1995;19:454), cocaine (South Med J 2000;93:909), collagen vascular disease, hypovolemia or marathon running (J Emerg Med 2006;30:321), phlebitis, thromboemboli, vasoactive drugs, Wegener's granulomatosis; often is idiopathic (J Gastrointest Surg 2001;5:388)
  • Note: loss of one major colonic vessel may not cause symptoms due to rich anastomotic interconnections; however lesions of end arteries causes small, focal ischemic lesions
Clinical features
  • Endoscopy: petechial hemorrhages, edematous and fragile mucosa, segmental erythema, scattered erosion, longitudinal ulcerations, sharply defined segment of involvement (Dig Dis Sci 2009;54:2009)
  • Symptoms: sudden onset of abdominal pain and bleeding
  • Complications: intestinal gangrene in 1 - 4 days, bacterial superinfection, enterotoxin formation (pseudomembranes), stricture; perforation may be fatal
  • Severe disease associated with tachycardia and peritonism signs (World J Gastroenterol 2006;12:4875)
Case reports
Clinical images

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Colonoscopic findings

Endoscopic images

Gross description
  • Ulceration (may be discrete or serpiginous) with possible cobblestone pattern resembling Crohn’s disease or pseudopolyps resembling ulcerative colitis
  • Appears hemorrhagic due to blood reflow
  • Frank blood or dark mucus in lumen
  • Segmental thinning in areas of full thickness infarction or gangrene
  • Late fibrosis and stricture formation
  • Grossing specimens: carefully dissect blood vessels and submit numerous sections to detect vascular lesions
Gross images

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Splenic flexure and upper rectum

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Superficial hemorrhage

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With ulceration

Microscopic (histologic) description
  • Hallmarks of ischemic bowel are necrotizing phlebitis and thrombi formation
  • Thrombophlebitis morphology differs in viable bowel (lymphocytic) and ischemic bowel (necrotizing lesions) (Int J Surg Pathol 2006;14:200)
  • Necrosis, ulceration and granulation tissue extend into submucosa and surrounding smooth muscle fibers of muscularis mucosa
  • Hemosiderin / hemorrhage and edema in lamina propria; hyaline thrombi in small vessels
  • May see crypt abscesses; deep portion of colonic crypt is often spared
  • Usually few inflammatory cells
  • Suggestive features are surface exudate of neutrophils, fibrin or mucosal necrosis (early) or transmural fibrosis (late)
  • Endoscopically normal mucosa has no microscopic abnormalities
Microscopic (histologic) images

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Superficial ulceration

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Damaged epithelium

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Regenerating crypts

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Atherosclerotic emboli

Differential diagnosis
  • Crohn disease: younger patients, transmural inflammation, no necrosis
  • E. coli O157:H7 infection: occurs in epidemiological clusters, younger patients, right sided
  • Ulcerative colitis: cryptitis and crypt abscesses, basal plasmacytosis, no fibrosis of muscularis propria, no hemosiderin deposition