Internal Medicine

0521779407-10 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:44

874 Irritable Bowel Syndrome Ischemic Bowel Disease

follow-up

■Reevaluate 3–6 weeks after initiation of therapy to assess response

■More extensive evaluation (symptom-dependent) is considered in

patients who have had a change or progression of symptoms, or in

those who do not respond

complications and prognosis

■Good with normal life span

Ischemic Bowel Disease...............................

JOHN P. CELLO, MD

history & physical

■Variable manifestations ranging from intestinal angina to necrotic

bowel; classically, pain out of proportion to the physical finding; must

always consider ischemic bowel when a patient at risk for ischemia

(age >50, arrhythmia, CHF, diabetes, known coronary artery or gen-

eral atherosclerosis) has new onset of abdominal pain with or with-

out hematochezia

■Presentation depends upon sit blood flow, collateral circulation

present and rapidity of restoration of normal perfusion.

■Large bowel:

➣Transient loss of flow and good collateral circulation (usually

a “low flow state” from diminished cardiac output) – minimal

abdominal pain and some hematochezia; may be recurrent for

weeks

➣Abrupt loss of perfusion (e.g. embolus or acute thrombosis) long

lasting ischemia with poor collaterals

moderately severe abdominal pain and hematochezia

■Total loss of perfusion – “dead bowel” – severe abdominal pain with

cardiovascular collapse and sepsis; a surgical emergency

■Small Bowel:

➣Transient loss of flow and good collaterals – usually stressed

byfood intake – “intestinal angina” – classically “fear of eating”

No classic physical or laboratory findings – weight loss common

■Abrupt loss of perfusion, long lasting with poor collaterals –

➣severe abdominal pain out of proportion to physical exam

findings; may actually have normal abdominal exam yet patient

looks and acts sick – believe him/her and proceed with rapid

evaluation