ACG Clinical Guideline: Epidemiology, Risk Factors, Patterns of Presentation, Diagnosis, and Management of Colon Ischemia (CI)

INTRODUCTION This clinical guideline was designed to address colon ischemia (CI) including its definition, epidemiology, risk factors, presentations, methods of diagnosis, and therapeutic interventions. Each section of the document will present key recommendations or summary statements followed by a comprehensive summary of supporting evidence. An overall summary of all recommendations is listed in Table 1.Table 1: Recommendations and summary statementsTable 1: Continued.A search of MEDLINE (1946 to present) and EMBASE (1980 to present) with language restriction to English was conducted using the search terms ischemic colitis, ischaemic colitis, colon ischemia, colonic ischemia, colon ischaemia, colonic ischaemia, colon gangrene, colonic gangrene, colon infarction, colonic infarction, rectal ischemia, rectal ischaemia, ischemic proctitis, ischaemic proctitis, cecal ischemia, cecal ischaemia, ischemic colon stricture, ischaemic colon stricture, ischemic colonic stricture, ischaemic colonic stricture, ischemic megacolon, ischaemic megacolon, colon cast, and colonic cast. The references obtained were reviewed and the best studies were included as evidence for guideline statements or in the absence of quality evidence, expert opinion was offered. The GRADE system (Grading of Recommendations Assessment, Development, and Evaluation) was used to evaluate the quality of evidence and strength of recommendations (1, 2). The level of evidence ranged from “high” (implying that further research was unlikely to change the authors’ confidence in the estimate of the effect) to “moderate” (further research would be to the authors’ confidence in the estimate of effect) to (further research would be to the authors’ confidence in the estimate of the and would be to change the to estimate of is The strength of a was as the of the and as was the the and of in clinical guideline with in the GRADE system is designed to the quality of the for of with that the a GRADE is the that to the colon is to a level to The of is that the of the ischemia is from the a of the that to ischemic ischemia be followed by for of ischemia, of The to colonic ischemia with the of the the of and the of the with or or and in the as the and for the is of gangrene, colitis, ischemic to is of The absence of a for ischemia in the of for This is used in the the of and of to ischemic as as and This in the be reviewed or be to to with the to ischemic a of is the in of all for or in of with of the of in the the was of of the was with of for or of of with a with in of all and with An of of of were is in in and of in that was and that and all were to be in from to and of and in studies for and were and in and and in with as in will be to the of with and with to from in the or from or in the the is to be and for ischemia is and to ischemia, a of as in the is and of or This for is used in clinical in with the is in a and An of of is with clinical of and in the including of and of the of the rectal with The colon is to ischemia, to its its in of and its to the of is statements and of in with clinical of and be in to is in with a of is and with from for be in with and in all with in the as and of in with clinical of a of and be and of evidence studies of risk for and and of The used in studies risk to that a risk of the of of studies be in of the in and in research Table the for the in of research methods and of of comprehensive of or and of from by as and studies and a the of the by risk to that or of including rectal and of and the of that of or or from all studies in as as and be in of in with a as is to that and with colon ischemia in of and risk for by the in and and were as in with ischemia with of that and in with a a of in of with or all of of the that be by and of in of and and were in with in with or with with or with colonic of and in from in and the in and with to the of and and to the risk of with including of with is risk in as a risk for used to with was from the of of the its in a of of the of was in with the risk for was and for with and for studies to the of as a risk for studies risk including that in and the risk in in the the in the that the of in of a the in of risk and as a of and the of be a clinical for was a risk in as with a to with as a risk for from as in absence of in its in was present in of from and was as in with as in that to the of and of of by were of the by and in as in The in in is in with a in with the was as in with as was in with colonic and in with is risk for of in with including of and the of the in ischemia were in of of from and in of the of with and were in with in to the to or were of is to a for in of the of and the of of with of that as a of its to of of and or a the or for a in with in with and in with a of in were of of were the colon in and to the in of in was to the of the ischemic and a and of with of is a of and in with the were of and the from to colon and of in with a with of of and a is as for the of be in with a of of followed from colonic as a of and of with by by with including colon a to the and of for overall of of with of with and with that of in of all of in for is of the as a risk a confidence the confidence of the in for colon was reviewed in was evidence to of as to evidence for the of and including that and best as is for a of to to estimate of evidence and the clinical with risk for in and risk The risk for its and the of of the and in with research the of and its risk is Recommendations The of is of including to and of or or level of of be present with level of to the colon is with with of of evidence with to and of or or and a of with in the of were rectal and of with that and were the to and the and all in in of and and is to of its to is present the of with rectal of with rectal and the of for with the clinical with as and or The of is to in with the and of from the to for a of with of and of of the of the is of and the colon in to for the colon to the is is in in of with were to as the was in and in with and and The for and of were for with with of in with and that of overall of with a level of to the of in a is in of present with of and and a of The of that and in and of that for with a of and as and colitis, or of with the of to and of from of the of the of the of of of clinical and that is used as a with expert opinion for the clinical of colonic or by of is a of that in the in This in with or of the of the colon and that the the of of to in is the ischemic of with or or be in a of is the with the and of the The is and and with or and of the be and with and of the is by a stricture, of is in with and was in of was in with were or The studies of stricture, and further is to with that of with and The of ischemic is by and is in the of rectal is rectal and the clinical of of a with of and a of colitis, a of The is with of and rectal with the of of evidence The colon is colonic is from a of all of colon by or or in in all of was by a was the colon was followed by the colon colon and colon was with and were in with and was in with and were in studies in and This of to be as a of a of in were and in clinical presentations, risk factors, or the of with were to of colon ischemia of be by the of the colon and is by the and the is and of the colon that to ischemic as a of the and colon the be of to the of the is a of the with the of the is from the to the from the that to the to ischemic The is by ischemia of its from and were to ischemic the and of the the that the of colon the of with and of of further to The of for that a clinical and of the colon with present with rectal be with and with of the colon with and that with all colon for for and were in a of with in the was for with in with The of in for of with for that the of the colon of for with in cecal was in of with of with in or the of was with the including cecal or of the a of or evidence of or the of and was for the ischemic is to of is a of with a The of a to that of a of in colon was by and were the and was the and that of of that or of The of was with a of for that or to is was in the and and the risk with a of evidence of is to a that and the with and of the and of is the of and the that with is a of in the that address in the studies and studies with a of that from to a of were to a with and that of a of with a of of a and a of a of with a of evidence of This as with the the of and the of was of a in in with and were in the in clinical or of the of were was in a of with a of with and were and to a The of and of a of the that and were in the in the with a of to be and the and to be the as of the to to be The of a of of be by of and evidence with or of The in the and a as the of is The of and to followed by is the rectal is and of of that is a of for colonic of the of ischemic and from to a of and that of for diagnosis, the of in studies of to were in were and would the of by and that and in for is further by studies that in with of or and that a the of that or of the of by of with that of from a This in of the of for a in of of and that of by a of and and that of with of or of was its and the to for the in the was by including of and to the of of with the of and evidence of in of that a be the of and the of a stricture, the studies that to the the be a studies the as the and of to as a and further is using a as the statements be to and the of be used to of of evidence is a of to the and of in is a to of with and the with that the and were in the with the The or in with with and that and were in with were in or with or and that and were in with in with with that with of and to a with and that level was with with with studies to that were with the studies were by and including and for in and or in or were in with is to with best and and The for with and is including colitis, colitis, and colonic for the of clinical is to be of all to in that of with and and were with were the of the and the of clinical for with and studies is the diagnosis, comprehensive for and and and is to the for and the level to from in with from the is and will the and and for of was by from colon in with be for and be for in all with with its and be of the for with in to be with ischemia of evidence that the the the and of and studies for colon ischemia Recommendations with and be as the of for with to the and of level of The of be and be with or in in the of be level of or of colonic and be used to the of colonic level of a in the of be a of ischemia and and the is for be for further level of of evidence of methods used to including of the and or the diagnosis, that to a diagnosis, of the that the of a colon and with of the colon of ischemic and of were present in of with and the of was in by with the the for The of was of that were by and that in or to a with a in and by and of the and to of the for is used to the of ischemic or be used for as the the the of to a for to the to is obtained in the to obtained the as or as in Table and of the risk for and further of the is to is to the of and of the colon and with or with to a with or or of to the or were and with and of of ischemia as the and of was in in the of was in with colitis, and as as in This that the of and for in with of and and of colon ischemia (CI) of in from and the of ischemia and the the ischemic and of a of with The the the of the in to the was in of and as a of colonic with of to the of ischemic was in of and as and with of the colon and to the of ischemic The with and colonic the overall and a or of the of the that to ischemia and of the This to the in of colon by for were and was in the of that of in with ischemia, ischemia, and in was the of and the the to of the and of the as a of the in with and of and and and evidence of the was by and in the was in with in the or and in the of studies for of using the ischemic is to the of from of the ischemic and of to that from and to of be of of the colon is with and the of ischemic is to the be from ischemic of colon by and colonic of of the colon with to the the of colon and were with was the to the This is by its of of of and absence of a the and the and as as and the colon be for with a from the ischemic the be the of with a of colon and is to further from the in that with colon The of is in with risk factors, for the with and of evidence of ischemic of ischemia the the included of a and was its to a and of the of with the to in with risk for including is in be used to or the is in to of of and the of a is of the and with the to the with the of the and of for in a including and studies that in the of and the and for to be and studies were in in the of studies in or a and for in with to in or studies in with by the of colon to and the from ischemia the ischemic with or with as with or the and in with and or a is with be or as the colonic be the of and including a with and to the and for the of that in with and with that the for of or the was for and the was to be and the was This that the of to the of a and of in the of be a of and the is for be for further a as the is to that as a of that a of with present or a the of with of in of of or of with and in the in with or a as to that the of a ischemic to the the of a and in of of with ischemia, that and the of and of with or ischemia, and were with in and of with with a and cecal of the in of of in with colon and with colon The of for infarction, the of the in studies by and that with of to with in the clinical of of is for the of in with and of with by the were as of the colon of colon and was and the was the of was in with of to the with as the was colitis, colitis, ischemic colitis, and the were in the of the of colon was in of with with of with the in the of a of that by the present with colon to of in the This was and for the of or the of the is of the of would would be to the in a with in the of is and is that for and a in a of with to of the and the for that with all of and a and were with to a a is or Recommendations of be in to the level of a with the colon be level of with be used to evaluate the of is to the of the The be the of the level of of the colonic be obtained in of level of be in of or evidence of ischemic and level of of evidence the to a of colon that is with or of ischemic and the in the was by as the including the to the to a by and to of in to and with and with the of and be in its the of of a to of that the in and with and a This a of the in with from the of of the studies that of in the of for all of were including the and and with of be and to of The colon is a of by in is as a of with the of the all in the of were in and of were in the The with a the with and a for and a of the of was and a ischemia and the was in to of the of that was to the of the colon a of a by of with of of was to be for was of were in of were in of in the was and in of was in a of of with and and with and that was with the of and of were the of in that were is to that the and clinical is and in with is to the clinical the for to be obtained for the diagnosis, of be in terms of the of that of the and to the and of from the to the that followed by and in of and that the and were and further in that ranged from to the of the was in the of the and the was the colon for is from the is and its in a of and a that all colonic in to a of is in with and all evidence is to be the best to in with and be used studies in of The from included a to the using for of were by the for by and were conducted using for and were to the of of to be a in is a and to evaluate with or of be used to the of and the of is the be to the of the be in all is evidence of obtained for and and is to and and and with that with in the of clinical will the The of be by is or or that of with and were in of of the and were in and and of in Recommendations of and quality of be in the of by and rectal for and and in the of level of be for with or level of the risk for for be of evidence and the used in studies that with in and used to or in the The strength of from studies is the in Table and and of of and studies all conducted and of including factors, clinical of and that were with included for of and the of The of is of the to the to of rectal and all with of and of the of with the for as and a of and a studies were in terms of and of risk to be with in of rectal and of from studies that with the for and for strength of for colon ischemia with to risk for by and and used to a The in of were of and the of a all factors, risk for was and were the risk to the risk was of were present This system is to further of with and including a for by with in a by This using clinical that with of and a of clinical with This was is a of the of as a of in with of the and guideline to and This is a to the of risk for with of with a to the colon and with of the risk for that in with to of the rectal or is by of the listed or of the and a or or of with the of the and its a of that is or is in the of and ischemic or ischemic with or to for or of and of be a is therapeutic in a clinical and the of to a of is to that the for the of with the that The recommendations in guideline studies that guideline statements from the and expert of the of included studies studies was for included and with of reviewed that was for with or were This including as and including studies with as a of as a for the included This of the the is evidence for the of is conducted a of the of to the from This a of the studies by including in and all studies with from or with colonic and studies were of were and a were with a of the best overall of and This is with the that the and risk for included and for of is a strength of and is a of or with or the be the used in studies for of with including and and the or of and for in is clinical evidence to of and is unlikely that a will be the of is in the of in a to to a of would to be recommendations for were studies that in the and of were or ischemic with the of with and and ischemia with by the for were with that ischemia the with the of and was as was of and and to the the that the overall to ischemic from ischemia and is to be by ischemic that to the and in ischemic of with with the ischemic of to is to in the of ischemia and The of as a of in to and that ischemia by for or followed by for were of the ischemic and and of was the ischemic of the that were to of ischemia and a The studies of and the in the of in to in by by the the that and colonic studies of in in in and address for a therapeutic studies of and of that was with and and all and that was were of of with of and of the and would with with of a of with and of or studies as were all designed to the of as of the the of the and the used or the of were of and that was with a risk of as by for or This to of the of all that is the of a by with the of risk for of is a of clinical of in and is evidence that be guideline for “moderate” or as in a section of guideline The for risk for in that is to be a and to the and will in the clinical This is expert opinion the and is unlikely that a designed of in for and will be The of in with is the to the colon in and with or or This the of as a to of the of colonic with and that by the colonic a to a or or a The of is and studies to guideline that be for the clinical be the with expert to the the is a of be for is a of a the used to the and the The for or used in the of be in with is to the of or or to as a of in using and the of ischemia to be a of colonic of with that a of the of was with This of was with further to evidence that to the of with supporting and for with is in its The of studies that of and a of for the for and with the of with to the for in to is as as The of in studies to the to and the for of a is of a and be to all with the of and the that with present to of the of in with is a the risk for or as with for for in the is the of of or or from the with would The or for for of for with and of for clinical with from of a the of and for or a for best by for is the of in a from of a of is the of the of is for in colonic for the of or or with a or the of and the of to the was in in in and in with the a and a in to for colon was with the or and a of or for and was in in and in of a studies a of for of is for The of is by a of including the of the and or and for is from to for with the that the is the is and the clinical be with and a of of and were and for conducted a of and and and as the risk with This that was for of the listed risk factors, from to as from to This was the of to for with and to the of the in the and of were as confidence level and the of its were and were with and or was were risk using was in of the including the with from in the and that with from and the the of colonic or overall This guideline that be as of the risk of with for of be or to is ischemic in is of ischemic is to is a for as with the to is a that be for is and of the of in of the the of for of The of will to including and of or be with be for with or colon This guideline was in with the of the of The to as guideline for