S3908 Watershed at Risk: Ischemic Colitis in a Patient With Peripheral and Coronary Artery Disease

Introduction: Ischemic colitis results from reduced blood flow leading to mucosal inflammation, ulceration, and hemorrhage. Both occlusive and non-occlusive vascular disease contribute to this condition, most commonly affecting the splenic flexure and sigmoid colon. Symptoms include diarrhea, abdominal pain, and hematochezia, necessitating differentiation from colon cancer and infectious colitis. Diagnosis relies on computed tomography (CT) with IV contrast, lower GI endoscopy, and histology. While supportive care is the mainstay of treatment, surgical intervention is needed in cases of circulatory compromise or isolated right-sided ischemic colitis. This report details a 73-year-old man presenting with hematochezia and bilateral foot wounds, with findings consistent with ischemic colitis. Case Description/Methods: A 73-year-old man with coronary artery disease, peripheral vascular disease, and hypertension presented with hematochezia. He had a history of multiple vascular interventions and a below-knee amputation. On admission, he was hypotensive and tachycardic, with hemoglobin decreasing from 7.8 to 6.8 g/dL after a large-volume bowel movement. Management included close monitoring, blood transfusions, and withholding Plavix and nonsteroidal anti-inflammatory drugs to minimize bleeding risk. Colonoscopy on hospital day 2 confirmed ischemic colitis at the splenic flexure, showing a continuous stripe sign. Conservative treatment included parenteral nutrition and hemodynamic support. His ischemic colitis was likely due to chronic vascular disease and acute hypotension. Discussion: Ischemic colitis develops when blood supply fails to meet the metabolic demands of the colon. Risk factors include advanced age, comorbidities, and vasoactive medications. Colonoscopy is key for diagnosis, with hallmark findings including the stripe sign—an anti-mesenteric, linear ulcer indicating mesenteric border involvement. Most cases resolve with supportive care, but severe ischemia or right-sided involvement may necessitate surgical resection. Predictors of poor outcomes include age over 75, multi-organ failure, and elevated preoperative lactate levels. Recognizing ischemic colitis early in high-risk patients is critical to ensuring prompt intervention and optimal management.