Clinical question: what is the role of Clinical question: what is the role of colonoscopy in the diagnosis of ischemic colitis?colonoscopy in the diagnosis of ischemic colitis?

Filtered resourcesFiltered resources, which, which appraise the quality of studies and often appraise the quality of studies and often make recommendations for practice, include the following:make recommendations for practice, include the following:

Systematic reviews:Systematic reviews: ask a specific clinical question, perform a ask a specific clinical question, perform a comprehensive literature search, eliminate the poorly done studicomprehensive literature search, eliminate the poorly done studies es and attempt to make practice recommendations based on the well and attempt to make practice recommendations based on the well done studies.done studies.

MetaMeta--analyses:analyses: systematic reviews that combines results from systematic reviews that combines results from multiple studies into a single statistical analysis.multiple studies into a single statistical analysis.

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CriticallyCritically--appraised individual articles:appraised individual articles: evaluate and synopsize evaluate and synopsize individual research studies.individual research studies.

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TRIP (Turning Research Into Practice):TRIP (Turning Research Into Practice): Searches evidenceSearches evidence--based based sources of systematic reviews, practice guidelines, and criticalsources of systematic reviews, practice guidelines, and criticallyly--appraised topics and articles (including Medlineappraised topics and articles (including Medline’’s Clinical Queries, s Clinical Queries, medical image databases, emedical image databases, e--textbooks, and patient information textbooks, and patient information leaflets).leaflets).

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The Database of Abstracts of Reviews of Effect (DARE):The Database of Abstracts of Reviews of Effect (DARE): FullFull--text database containing structured abstracts of systematic revitext database containing structured abstracts of systematic reviews ews from a variety of medical journals.from a variety of medical journals.

PubMedPubMed:: bibliographic information primarily from Medline bibliographic information primarily from Medline (extensive coverage of the world's biomedical journal literature(extensive coverage of the world's biomedical journal literaturefrom the National Library of Medicine), from the National Library of Medicine), PreMedlinePreMedline (in(in--process process citations), and publishercitations), and publisher--supplied citations.supplied citations.

PubMedPubMed search results:search results:

Search termSearch term ResultsResults1. Colonoscopy1. Colonoscopy 15498154982. Ischemic colitis2. Ischemic colitis 9249243. 1 and 23. 1 and 2 1671674. Limit 3 to English4. Limit 3 to English 1141145. Limit 4 to reviews5. Limit 4 to reviews 1616

No randomized or nonNo randomized or non--randomized controlled trials randomized controlled trials No case control studiesNo case control studies

Abstract from meeting: Abstract from meeting: RyuRyu KH, et al. The usefulness of KH, et al. The usefulness of colonoscopy in ischemic colitis. colonoscopy in ischemic colitis. Gastrointestinal EndoscopyGastrointestinal Endoscopy 2006 2006 April;63(5):AB212April;63(5):AB212

MethodMethod: Retrospective data analysis from patients diagnosed with : Retrospective data analysis from patients diagnosed with ischemic colitis by colonoscopy. ischemic colitis by colonoscopy.

ConclusionConclusion: Evaluation of the mucosal severities and the extent of : Evaluation of the mucosal severities and the extent of the disease by colonoscopy may be helpful in predicting clinicalthe disease by colonoscopy may be helpful in predicting clinicalstatus and the prognosis of the patients.status and the prognosis of the patients.

Green BT, et al. Ischemic colitis: a clinical review. Green BT, et al. Ischemic colitis: a clinical review. Southern Medical Southern Medical JournalJournal 2005;98(2):2172005;98(2):217--222222

““Colonoscopy has largely supplanted barium enema as thediagnostic modality of choice because of its higher sensitivityfor detecting mucosal changes and the ability to obtain biopsyspecimens if necessary… Care should be taken to avoid overinflationor advancement of the colonoscope beyond the affected region to minimize the risk of bowel perforation”

No referencesNo references for these statements

CappellCappell MS. Intestinal (mesenteric) MS. Intestinal (mesenteric) vasculopathyvasculopathy II. II. Gastroenterology Gastroenterology Clinics of North AmericaClinics of North America 27(4):82727(4):827--860860

““Colonoscopy is preferred over barium enema because of highersensitivity; the ability to obtain mucosal biopsy specimens to excludeother pathologic entities; and the ability to perform subsequentangiography, which is indicated when superior mesenteric arteriopathy is suspected… The colonoscopist should exercise caution in colonic insufflation because high intraluminal pressure diminishes intestinal perfusion. With frank necrosis, colonoscopy reveals cyanotic, dusky, gray or black mucosa. The colonoscopistshould discontinue colonoscopic intubation when encountering necrotic bowel because of the risk of perforation.”

Reference:Toursarkissian B, et al. Ischemic colitis. Surgical Clinics of North Surgical Clinics of North AmericaAmerica 1997;77:4611997;77:461--470470

Toursarkissian B, et al. Ischemic colitis. Surgical Clinics of North Surgical Clinics of North AmericaAmerica 1997;77:4611997;77:461--470 470

““The definitive diagnosis of ischemic colitis is most frequently obtained by endoscopic examination. Endoscopy can also be used to grade the severity of the disease… Caution should be exercisedin advancing the scope beyond areas of marked necrosis for fear ofiatrogenic perforation. The appearance of the colon at endoscopymay be difficult to distinguish from that of other forms of colitis such as Crohn’s or ulcerative colitis, infectious colitis, or radiation colitis. Biopsy for histologic examination can be helpful in the differential diagnosis.”

Reference: Price AB. Ischemic colitis. Current Topics in Pathology1990;81:229-246

UptoDate:

“Colonoscopy or sigmoidoscopy is often required to establish the diagnosis of ischemic colitis. They are usually performed without bowel preparation (to avoid reducing blood flow from dehydratingcathartics), and with minimization of air insufflation (to avoid distention and perforation). Colonoscopy is preferable to contrast enemas since it is more sensitive in detecting mucosal lesions, permits biopsies to be obtained, and does not interfere with subsequent angiography.””

No references for these statementsNo references for these statements

AGA Technical Review on Intestinal Ischemia. AGA Technical Review on Intestinal Ischemia. GastroenterologyGastroenterology2000;118:9542000;118:954--968968

““Over the last 25 years, colonoscopy has replaced barium enema asOver the last 25 years, colonoscopy has replaced barium enema asthe most common diagnostic tool and not only allows direct the most common diagnostic tool and not only allows direct visualization of the mucosa, but has the additional benefit of tvisualization of the mucosa, but has the additional benefit of tissue issue sampling. With the rare exception of mucosal gangrene, however,sampling. With the rare exception of mucosal gangrene, however,biopsy findings usually are not helpful and show only nonspecifibiopsy findings usually are not helpful and show only nonspecific c abnormalities.abnormalities.””

References (not available onReferences (not available on--line):line):

SnowcroftSnowcroft CW. Colonoscopy in ischemic colitis. CW. Colonoscopy in ischemic colitis. Gastrointestinal Gastrointestinal EndoscopyEndoscopy 1981;27:1561981;27:156--161161

Brandt LJ, et al. Colonic ischemia. Brandt LJ, et al. Colonic ischemia. Surgical Clinics of North AmericaSurgical Clinics of North America1992;72:2031992;72:203--229229

American Gastroenterological Association Medical Position American Gastroenterological Association Medical Position Statement: Guidelines on Intestinal Ischemia. Statement: Guidelines on Intestinal Ischemia. GastroenterologyGastroenterology2000;118:9512000;118:951--953953

““Diagnosis Diagnosis (of colonic ischemia)(of colonic ischemia) is by colonoscopy or barium enema, is by colonoscopy or barium enema, and mesenteric angiography plays little role in diagnosis unlessand mesenteric angiography plays little role in diagnosis unless only only the right side of the colon is affected or the individual has mothe right side of the colon is affected or the individual has more pain re pain than is customarily seen with CI.than is customarily seen with CI.””

No references (position statement)No references (position statement)

“Colonic Ischemia”UpToDate