Colonoscopy-related colonic ischemia

Table 1 Summary of proposed pathogenetic factors for colonoscopy-related mesenteric ischemia and suggested interventions to reduce the risk

Pathogenetic factor	Mechanism of action	Type of ischemia	Prevention
Splanchnic circulation impairment	Chronic mesenteric ischemia (atherosclerosis, smoking habits), parietal vessels inflammation (connective tissue diseases, LES, antiphospholipid syndrome)	Vascular thrombosis; microcirculatory mild ischemic injury	Careful evaluation of medical history. Specific and indirect symptoms assessment. Antiplatelet agents according to guidelines. Consider pre-colonoscopy assessments (serum electrolyte, color-Doppler ultrasound)
Bowel preparation (hypertonic, isotonic, laxative)	Serum electrolyte imbalance, dehydration. Potential additional risk if laxative were used (i.e., bisacodyl)	Multifactorial	Give specific information. Consider high-volume isotonic formulations; split-dose regimens; avoid bisacodyl-containing preparations
Sedation (midazolam, opioids, propofol)	Vasodilation, depression of myocardial contractility and hypotension	Multifactorial	Minimal sedation protocol (response to verbal stimulation, patent airways, spontaneous ventilation, and normal cardiovascular function) in high-risk patients. Consider prophylactic fluid infusion
Air insufflation/barotrauma	Increased luminal pressure and consequent vascular resistance	Non-occlusive mesenteric ischemia	Use carbon dioxide (CO2) insufflation. Consider water-exchange colonoscopy technique
Scope manipulation	Mechanical stress on mesocolon, blood flow reduction, microcirculatory damage, and inflammatory cascade activation	Vascular thrombosis	Procedure interruption in case of intense discomfort or endoscopic findings of ischemia. Consider pediatric or “ultra-slim” colonoscopes. Reschedule or reconsider indication in case of complex exams