Recurrent Ischemic Colitis Associated with Chronic Low-Flow Physiology: Diagnostic and Therapeutic Implications

Ischemic colitis is the most common form of intestinal ischemia and is typically associated with acute hypoperfusion states such as shock or dehydration.1 Chronic low-flow states related to persistently low baseline blood pressure may represent an underrecognized contributor to recurrent disease in the absence of classic acute triggers.2 We present a case of a 54-year-old woman with recurrent, biopsy-proven ischemic colitis occurring in the setting of persistently low blood pressure documented across multiple clinical encounters. Unlike many patients with ischemic colitis, she lacked documented atherogenic, autoimmune, radiation-related, or vasospastic risk factors, and CT angiography showed patent mesenteric vasculature. Review of her longitudinal course demonstrated recurrent left-sided ischemic colitis over several years, patent mesenteric vasculature on CT angiography, and persistently low outpatient and periprocedural blood pressures. Blood pressure–directed therapy with midodrine and nonpharmacologic measures was associated with improved blood pressure control and decreased frequency of episodes. This case highlights chronic low-flow physiology related to persistently low baseline blood pressure as a plausible contributor to recurrent nonocclusive ischemic colitis and emphasizes the importance of reviewing longitudinal blood pressure patterns in patients without an obvious acute precipitant.