Video Endoscopic Sequence 1 of 19.

Severe case of Ischemic Colitis

 This 57-year-old male with history of diabetes mellitus
 hypertension and ischemic heart disease
 (including coronary artery bypass 3 years previously). He
 was taking 150 mg aspirin, verapamil 240 mg daily.
 Presents with abdominal pain and passage of maroon blood
 stools the white blood count was 18.000 with 90 neutrofils, a
 colonoscopy was performed finding this images displayed in
 this atlas.

 This patient was successfully treated by surgery. A small
 amount of ascites was observed
 (bacterial culture: negative). The right colon is affected
 with large area of necrosis.

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Video Endoscopic Sequence 2 of 19.

 Discrepancy between subjective symptoms and objective
 findings is a hallmark of ischemic colitis. Thus, diagnosis
 requires a high index of suspicion in the appropriate clinical
 setting.

 The diverse causes, variable clinical presentations, and
 severity makes the diagnosis and management of ischemic
 colitis a challenge.

Video Endoscopic Sequence 3 of 19.

Some diverticulae are seen near of the necrosis.

 Ischemic colitis is the most common form of intestinal
 ischemia. It manifests as a spectrum of injury from
 transient self-limited ischemia involving the mucosa and
 submucosa to acute fulminant ischemia with transmural
 infarction that may progress to necrosis and death.
 Although there are a variety of causes, the most common
 mechanism is an acute, self-limited compromise in
 intestinal blood flow. Patients typically have mild
 abdominal pain and tenderness over the involved segment
 of bowel. There is usually passage of blood mixed with
 stool, but hemodynamically significant bleeding is unusual.
 Although computed tomography may have suggestive
 findings, colonoscopy is the procedure of choice for
 diagnosis.

Video Endoscopic Sequence 4 of 19.

Although frequent in the elderly, younger patients may also be affected.

 The colon is also predisposed to ischemia by its relatively
 low blood flow compared with the rest of the
 gastrointestinal tract.

 There are no endoscopic findings that are specific for
 ischemia, thus the clinical setting must be considered.
 Findings that favor ischemic colitis rather than
 inflammatory bowel disease are segmental area of injury,
 abrupt transition between normal and affected mucosa,
 rectal sparing, and a rapid resolution of mucosal changes
 on serial colonoscopy.

Video Endoscopic Sequence 5 of 19.

 There are numerous conditions that predispose patients to
 ischemic colitis. The most common mechanism is
 hypotension from sepsis or impaired left ventricular
 function and hypovolemia from dehydration or hemorrhage
 producing a compromise in systemic perfusion and
 triggering a reflex mesenteric vasoconstriction.

Video Endoscopic Sequence 6 of 19.

 4 days after the first colonoscopy, a follow up colonoscopy
 was performed because the pathologist required more
 biopsies, the patient was under antibiotherapy.

 Numerous medications may produce colonic ischemia by a
 similar mechanism. The most common offenders are
 antihypertensive agents, diuretics, nonsteroidal
 anti -inflammatory drugs, digoxin, oral contraceptives,
 pseudoephedrine, cocaine, Tegaserod and alosetron.
 Strenuous physical activities, such as long distance running
 or bicycling, have been reported to lead to colonic ischemia,
 presumably by physiologic shunting caused by mesenteric
 vasoconstriction and intravascular volume depletion from
 dehydration.

Video Endoscopic Sequence 7 of 19.

 Although our patient presented the ischemic colitis in the
 right colon ischemic colitis, it is reported that the most
 common sites of involvement are the splenic flexure and
 the sigmoid colon.

 The classic site of involvement is the splenic flexure.
 Usually, there is involvement of the sigmoid colon with
 notable sparing of the rectum. However, because there is
 considerable variation in the collateral blood supply,
 ischemic colitis may occur anywhere in the colon.

Video Endoscopic Sequence 8 of 19.

 Ischemic colitis was first described in relation to vascular
 surgeries and continues to be a potential complication of
 aortic or cardiac bypass surgery. Aortic surgery is
 associated with a 1% to 7% incidence of ischemic colitis,
 often caused by iatrogenic IMA ligation or intraoperative
 hypoperfusion in patients with chronic IMA occlusion, and
 usually affects the distal left colon.

Video Endoscopic Sequence 9 of 19.

 Most patients will present with the acute onset of a mild,
 crampy abdominal pain and tenderness over the affected
 bowel. An urge to defecate is common. Within 24 hours,
 there is usually passage of bright red or maroon blood,
 often mixed with stool. Blood loss is usually minimal,
 without hemodynamic compromise or the need for
 transfusion.

Video Endoscopic Sequence 10 of 19.

 Complications of ischemic colitis include chronic ischemic
 colitis, gangrene of the bowel with resulting perforation and
 peritonitis, and stricture, which usually develops 3 to 4
 weeks after the acute insult. Rare complications include
 inflammatory polyposis, pyocolon.

Video Endoscopic Sequence 11 of 19.

 Ischemic colitis occurs as the result of a compromise in
 intestinal blood flow that can produce a spectrum of injury
 from transient self-limited ischemia to fulminant ischemia
 or transmural infarction. Its diagnosis requires a high index
 of suspicion, and the clinician should consider the diagnosis
 in patients with acute abdominal pain and bloody stools.
 Although most patients improve within several days with
 supportive care, others will require laparotomy with bowel
 resection.

Video Endoscopic Sequence 12 of 19.

Cecal appendix and the Cecum

Video Endoscopic Sequence 13 of 19.

Video Endoscopic Sequence 14 of 19.

Video Endoscopic Sequence 15 of 19.

Open Surgical Specimen that shows extensive necrosis

Video Endoscopic Sequence 16 of 19.

Video Endoscopic Sequence 17 of 19.

 Ischemic colitis encompasses a number of clinical entities,
 all with an end result of insufficient blood supply to a
 segment or the entire colon. This disease results in
 ischemic necrosis of varying severities that can range from
 superficial mucosal involvement to full-thickness
 transmural necrosis.

Video Endoscopic Sequence 18 of 19.

Video Endoscopic Sequence 19 of 19.

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Ulcer with Fibrosis and arterioesclerosis.