Take-home pearl #1: whenever somebody presents with SUDDEN ONSET abdominal pain, think about ischemia and perforation at the top of your differential!
Take-home pearl #2: remember that antibiotics in the context of EHEC (E coli O157:H7) can cause HUS!
When thinking through a differential for bloody diarrhea, think about infectious (eg Shigella, Salmonella, enteroinvasive E coli, Entamoeba) and non-infectious causes. Among non-infectious causes, think about ischemic, IBD, malignancy (leading to vessel erotion).
- For ischemic colitis, consider:
- Thromboembolic disease
- Vasospasm (abdominal migraine)
- Hypoperfusion (esp in watershed regions, eg splenic flexure)
- Thank you to several of you for some great additional learning points on ischemic colitis:
- Thank you to Geoff for sharing that 74% of patients with unexplained ischemic colitis have undiagnosed protein C/S deficiency!
- Thank you to Rabih for sharing this article on localization patterns of ischemic colitis – “in patients being treated with NSAIDs, ischemic colitis was observed significantly more often in the right hemicolon”
- Thank you to David for sharing the attached article on ACG guidelines for treatment of ischemic colitis as stratified by mild/mod/severe disease! Link is here. For moderate ischemic colitis, management includes:
- Aggressive IVF
- Antibiotics (to reduce risk of gut translocation)
- Surgery if complete vessel occlusion, perforation
- Early colonoscopy
- *note: antithrombotic therapy is not indicated for most patients with colonic ischemia as the majority of patients have nonocclusive ischemia! But, if a thromboembolic event is found, then will want to w/u for cause (eg hypercoagulability w/u) and anticoagulation is indicated
- *20-30% recurrent of ischemic colitis within 5 years!