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Surgical Pathology Criteria

Ischemic Colitis


  • Colitis secondary to arterial or venous vascular compromise

Alternate/Historical Names

  • Acute or chronic intestinal ischemia
  • Acute or chronic mesenteric ischemia

Diagnostic Criteria

  • Early lesions characterized by superficial mucosal hemorrhage, edema and necrosis
    • Necrosis usually spares base of crypts and muscularis propria
      • Leaves residual atrophic microcrypts
    • Capillary thrombi frequent
    • Minimal inflammation in very early lesions
    • Submucosal edema may produce discrete blebs
    • Sloughed necrotic mucosa may produce a microscopic appearance of a pseudomembrane
  • Later lesions may exhibit granulation tissue, submucosal fibrosis and atrophy
    • Frequent hyalinization of lamina propria
    • May mimic chronic architectural changes of inflammatory bowel disease
    • Hemosiderin is frequently present in mucosa and submucosa
    • Submucosal fibrosis may lead to stricture formation
  • Occasional findings
    • Paneth cell metaplasia
    • Endocrine cell hyperplasia
  • Severe, full thickness lesions lead to gangrene and perforation
  • Usually sharply defined area of involvement
    • Most common location is splenic flexure watershed zone
    • All other regions of colorectum can be involved
    • May form a polyp or tumor mass
  • In resection specimens, vascular changes can be seen in about half of cases
    • Arterial thrombus or embolus is most common
    • Frequently atherosclerotic
    • Venous thrombus
    • Causes other than primary vascular disease include radiation, uremic colitis and obstructive colitis
    • Most cases without vascular cause are due to hypoperfusion
  • Most cases in patients over age 50
    • Usually due to cardiovascular disease
    • Rare cases involving younger patients more often due to non-vascular causes
      • Arteritis
      • Coagulation disorders
      • Drugs, including cocaine and oral contraceptives
      • May be seen in long distance runners
  • Patchy epithelial atrophy may represent the effect of transient ischemic colitis
    • Focal hyalinized lamina propria with atrophic microcrypts

Robert V Rouse MD
Department of Pathology
Stanford University School of Medicine
Stanford CA 94305-5342

Original posting : November 11, 2009

Differential Diagnosis

  • Quiescent colitis in inflammatory bowel disease may be histologically indistinguishable from chronic ischemia
    • Clinical correlation is necessary
    • Hemosiderin laden macrophages may suggest ischemia
  • Colitis due to E coli O157:H7 may be histologically indistinguishable from acute ischemia
    • Clinical correlation is necessary
Pseudomembranous Colitis Ischemic Colitis
Diffuse Localized, may form a mass
No hyanization of lamina propria Hyalinized lamina propria
Occasional atrophic crypts Atrophic microcrypts common
Usually only superficial necrosis Necrosis frequently transmural
C difficile titer elevated C difficile titer negative
Associated with antibiotic therapy Not associated with antibiotic therapy


Incidental Chronic Colitis Ischemic Colitis (Chronic)
Crypt distortion and dropout Predominantly hyalinization and fibrosis
Prominent basal plasmacytosis Inflammation not prominent
Virtually restricted to cecum/right colon Most common in splenic flexure
  • Acute ischemic colitis bears no resemblance to incidental chronic colitis


  • Noffsinger A, Fenoglio-Preiser CM, Maru D, Gilinisky N.  Gastrointestinal Diseases, AFIP Atlas of Nontumor Pathology, First Series, Fascicle 5, 2007.
  • Dignan CR, Greenson JK. Can ischemic colitis be differentiated from C difficile colitis in biopsy specimens? Am J Surg Pathol. 1997 Jun;21(6):706-10.
  • Orikasa H, Katayama I. Differentiating ischemic colitis from other colitides. Am J Surg Pathol. 1998 Jun;22(6):773-4.
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