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Ischemic Colitis: CT Evaluation of 54 Cases¹

¹ From the Department of Radiology, New York University-Bellevue Medical Center, 462 First Ave, New York, NY 10016. Received December 10, 1997; revision requested January 27, 1998; final revision received August 17; accepted November 19. Address reprint requests to E.J.B.

View larger version (156K): [in a new window]   Figure 1a. Ischemic colitis of right colon in an 83-year-old woman with a recent history of atrial fibrillation and a hypotensive episode, who presented with right lower quadrant pain and rectal bleeding. (a, b) Contrast-enhanced CT scans at two different levels show segmental distribution involving the entire ascending colon and hepatic flexure (arrows in a, arrow in b). Circumferential wall thickening and heterogeneous enhancement with layers of low and high attenuation are consistent with colonic edema. Right colon has a shaggy, wet appearance with pericolic streakiness (S in b), pericolic fluid collections (F), and loss of haustra. Diagnosis was confirmed at colonoscopy, and ischemia resolved without complications with conservative therapy. Fluid-filled cysts are present in both kidneys.

View larger version (138K): [in a new window]   Figure 1b. Ischemic colitis of right colon in an 83-year-old woman with a recent history of atrial fibrillation and a hypotensive episode, who presented with right lower quadrant pain and rectal bleeding. (a, b) Contrast-enhanced CT scans at two different levels show segmental distribution involving the entire ascending colon and hepatic flexure (arrows in a, arrow in b). Circumferential wall thickening and heterogeneous enhancement with layers of low and high attenuation are consistent with colonic edema. Right colon has a shaggy, wet appearance with pericolic streakiness (S in b), pericolic fluid collections (F), and loss of haustra. Diagnosis was confirmed at colonoscopy, and ischemia resolved without complications with conservative therapy. Fluid-filled cysts are present in both kidneys.

View larger version (121K): [in a new window]   Figure 2. Ischemic colitis of left colon in a 67-year-old man with left lower quadrant pain and an elevated WBC count, who was suspected of having diverticulitis. Contrast-enhanced CT scan reveals segmental colitis involving the descending and sigmoid colon (arrow, S). The thickened wall of the sigmoid colon has a dry appearance with a sharply defined, homogeneously enhancing wall, without pericolic streakiness or fluid collections. Sigmoidoscopy showed hemorrhagic mucosa with patchy areas of mucosal necrosis. Surgery 18 hours later revealed full-thickness necrosis of the left colon, which necessitated resection. The rectum was normal.

View larger version (111K): [in a new window]   Figure 3a. Ischemic colitis in a 47-year-old man with vasculitis, who presented with abdominal pain and bloody diarrhea. (a) Contrast-enhanced CT scan reveals involvement of the distal transverse colon and splenic flexure (arrows), with marked wall thickening and pericolic streakiness. (b) CT scan shows proximal descending colon with concentric layers of low and high attenuation (double-halo sign) (arrow), consistent with colonic edema. Diagnosis was confirmed at colonoscopy and biopsy. The ischemic process resolved; however, the patient returned 2 months later and died of extensive bowel infarction.

View larger version (103K): [in a new window]   Figure 3b. Ischemic colitis in a 47-year-old man with vasculitis, who presented with abdominal pain and bloody diarrhea. (a) Contrast-enhanced CT scan reveals involvement of the distal transverse colon and splenic flexure (arrows), with marked wall thickening and pericolic streakiness. (b) CT scan shows proximal descending colon with concentric layers of low and high attenuation (double-halo sign) (arrow), consistent with colonic edema. Diagnosis was confirmed at colonoscopy and biopsy. The ischemic process resolved; however, the patient returned 2 months later and died of extensive bowel infarction.

View larger version (130K): [in a new window]   Figure 4a. Ischemic sigmoiditis in a 57-year-old man who presented with fever and had an elevated WBC count and guaiac-positive stools. (a) Contrast-enhanced CT scan reveals a multilocular abscess (A) in the right lobe of the liver. (b) CT scan shows that proximal sigmoid colon (S) has a circumferential thickened wall (open arrow), which contrasts with the normal-appearing distal sigmoid colon (solid arrows). Sigmoidoscopy with biopsy showed erythematous mucosa, moderate inflammation, and marked hemosiderin deposits consistent with ischemic colitis.

View larger version (113K): [in a new window]   Figure 4b. Ischemic sigmoiditis in a 57-year-old man who presented with fever and had an elevated WBC count and guaiac-positive stools. (a) Contrast-enhanced CT scan reveals a multilocular abscess (A) in the right lobe of the liver. (b) CT scan shows that proximal sigmoid colon (S) has a circumferential thickened wall (open arrow), which contrasts with the normal-appearing distal sigmoid colon (solid arrows). Sigmoidoscopy with biopsy showed erythematous mucosa, moderate inflammation, and marked hemosiderin deposits consistent with ischemic colitis.

View larger version (119K): [in a new window]   Figure 5a. Ischemia involving the entire colon in a 77-year-old man with relapsing polychondritis, arteriosclerotic heart disease, and myocardial infarction, who had previously undergone coronary artery bypass surgery. Abdominal pain and rectal bleeding were present. (a) Contrast-enhanced CT scan shows heterogeneous enhancement and wall thickening of the transverse colon, as well as the right and left colon (arrows), with loss of haustral markings. (b) CT scan shows sigmoid colon and rectum (arrows) with alternate layers of high and low attenuation consistent with edema. Findings mimic an acute inflammatory colitis. Diagnosis was confirmed at colonoscopy. A benign cyst is present in the left kidney.

View larger version (117K): [in a new window]   Figure 5b. Ischemia involving the entire colon in a 77-year-old man with relapsing polychondritis, arteriosclerotic heart disease, and myocardial infarction, who had previously undergone coronary artery bypass surgery. Abdominal pain and rectal bleeding were present. (a) Contrast-enhanced CT scan shows heterogeneous enhancement and wall thickening of the transverse colon, as well as the right and left colon (arrows), with loss of haustral markings. (b) CT scan shows sigmoid colon and rectum (arrows) with alternate layers of high and low attenuation consistent with edema. Findings mimic an acute inflammatory colitis. Diagnosis was confirmed at colonoscopy. A benign cyst is present in the left kidney.

View larger version (164K): [in a new window]   Figure 6a. Infarcted right colon in a 72-year-old man with atrial fibrillation who presented with abdominal pain and fever and had an elevated WBC count. (a) Contrast-enhanced CT scan shows pneumatosis affecting the cecum (C) and ascending colon (arrows) and ascites (A) in the pelvis. (b) CT scan shows air in the intrahepatic branches of the portal vein (arrow). At surgery, the right colon was infarcted, and the pelvic fluid was infected.

View larger version (155K): [in a new window]   Figure 6b. Infarcted right colon in a 72-year-old man with atrial fibrillation who presented with abdominal pain and fever and had an elevated WBC count. (a) Contrast-enhanced CT scan shows pneumatosis affecting the cecum (C) and ascending colon (arrows) and ascites (A) in the pelvis. (b) CT scan shows air in the intrahepatic branches of the portal vein (arrow). At surgery, the right colon was infarcted, and the pelvic fluid was infected.

View larger version (124K): [in a new window]   Figure 7a. Ischemia of transverse colon in an 81-year-old man with arteriosclerosis, a recent syncopal episode, abdominal tenderness, fever, an elevated WBC count, and a decrease in the hematocrit. (a) CT scan obtained without intravenous contrast material shows high-attenuation fluid consistent with abdominal hemorrhage (h) that is associated with an ahaustral transverse colon (T) with a thickened wall. Small collection of air (arrow) was present adjacent to the proximal transverse colon. (b) Radiograph obtained after administration of diatrizoate meglumine (Hypaque Meglumine; Sterling Winthrop, New York, NY) enema shows narrowing of transverse colon (T) with small extravasation (arrow) consistent with sealed-off perforation. Findings obtained at surgery performed 3 weeks after the initial episode confirmed these findings.

View larger version (112K): [in a new window]   Figure 7b. Ischemia of transverse colon in an 81-year-old man with arteriosclerosis, a recent syncopal episode, abdominal tenderness, fever, an elevated WBC count, and a decrease in the hematocrit. (a) CT scan obtained without intravenous contrast material shows high-attenuation fluid consistent with abdominal hemorrhage (h) that is associated with an ahaustral transverse colon (T) with a thickened wall. Small collection of air (arrow) was present adjacent to the proximal transverse colon. (b) Radiograph obtained after administration of diatrizoate meglumine (Hypaque Meglumine; Sterling Winthrop, New York, NY) enema shows narrowing of transverse colon (T) with small extravasation (arrow) consistent with sealed-off perforation. Findings obtained at surgery performed 3 weeks after the initial episode confirmed these findings.

View larger version (167K): [in a new window]   Figure 8a. Ischemic colitis associated with carcinoma of the colon in a 92-year-old man who presented with abdominal pain and rectal bleeding. (a) Contrast-enhanced CT scan shows a circumferentially thickened wall of the proximal sigmoid colon (S) and a circumferential infiltrating lesion consistent with carcinoma in the distal sigmoid (arrows). (b) Radiograph obtained after administration of diatrizoate meglumine (Hypaque Meglumine; Sterling Winthrop) enema shows the obstructing carcinoma (curved arrow) and the associated proximal ischemic colitis (straight arrows). Findings were confirmed at surgery and histopathologic examination.

View larger version (148K): [in a new window]   Figure 8b. Ischemic colitis associated with carcinoma of the colon in a 92-year-old man who presented with abdominal pain and rectal bleeding. (a) Contrast-enhanced CT scan shows a circumferentially thickened wall of the proximal sigmoid colon (S) and a circumferential infiltrating lesion consistent with carcinoma in the distal sigmoid (arrows). (b) Radiograph obtained after administration of diatrizoate meglumine (Hypaque Meglumine; Sterling Winthrop) enema shows the obstructing carcinoma (curved arrow) and the associated proximal ischemic colitis (straight arrows). Findings were confirmed at surgery and histopathologic examination.

View larger version (159K): [in a new window]   Figure 9a. Colonic infarction of mid–ascending colon in a 99-year-old woman who presented with acute right lower quadrant pain of unknown cause. (a, b) Contrast-enhanced CT scans obtained at adjacent levels show a segmental area of heterogeneous wall thickening of the right colon (thick arrow in a and b) with pericolic streakiness and a small pericolic fluid collection (thin arrow in a). A large cyst is present in the right kidney. Right colectomy performed 6 hours later revealed infarcted bowel. (c) Photomicrograph from histopathologic examination shows mucosal necrosis with transmural hemorrhage (solid arrows) and submucosal edema (open arrows). (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (162K): [in a new window]   Figure 9b. Colonic infarction of mid–ascending colon in a 99-year-old woman who presented with acute right lower quadrant pain of unknown cause. (a, b) Contrast-enhanced CT scans obtained at adjacent levels show a segmental area of heterogeneous wall thickening of the right colon (thick arrow in a and b) with pericolic streakiness and a small pericolic fluid collection (thin arrow in a). A large cyst is present in the right kidney. Right colectomy performed 6 hours later revealed infarcted bowel. (c) Photomicrograph from histopathologic examination shows mucosal necrosis with transmural hemorrhage (solid arrows) and submucosal edema (open arrows). (Hematoxylin-eosin stain; original magnification, x40.)

View larger version (126K): [in a new window]   Figure 9c. Colonic infarction of mid–ascending colon in a 99-year-old woman who presented with acute right lower quadrant pain of unknown cause. (a, b) Contrast-enhanced CT scans obtained at adjacent levels show a segmental area of heterogeneous wall thickening of the right colon (thick arrow in a and b) with pericolic streakiness and a small pericolic fluid collection (thin arrow in a). A large cyst is present in the right kidney. Right colectomy performed 6 hours later revealed infarcted bowel. (c) Photomicrograph from histopathologic examination shows mucosal necrosis with transmural hemorrhage (solid arrows) and submucosal edema (open arrows). (Hematoxylin-eosin stain; original magnification, x40.)