Ischaemic
colitis (IC) is the most common form of ischaemic injury to the gastrointestinal (GI) tract. IC typically presents with the sudden onset of lower
abdominal pain, cramping and rectal
bleeding, and is usually self-limited with low morbidity, although it may cause gangrenous or fulminant
colitis, especially when the right colon is involved. Multiple medical conditions, as well as several pharmacological agents, are associated with IC, including
irritable bowel syndrome (IBS) and drugs used for its treatment that act on gut
serotonin 5-HT receptors. These include the selective 5-HT(3) receptor antagonist
alosetron, currently approved for the treatment of severe diarrhoea-predominant IBS in women who fail to respond to conventional treatment, and
cilansetron, another 5-HT(3) receptor antagonist that is no longer in clinical development. In addition, the 5-HT(4) receptor partial agonist
tegaserod, which was approved for the treatment of
constipation-predominant IBS in women, was associated with IC in the postmarketing setting, as was
renzapride, a 5-HT(4) agonist/5-HT(3) antagonist. Although several hypotheses have been proposed, the pathophysiological basis for development of IC with 5-HT(3) receptor antagonists or 5-HT(4) receptor agonists remains unknown. Of interest, several population-based studies demonstrated that a diagnosis of IBS (independent of serotonergic
therapies) increases the risk of developing IC 2- to 4-fold. As a result, IBS patients with the acute onset of
abdominal pain, tenderness, diarrhoea or lower intestinal
bleeding, especially those with predisposing conditions or medications, should be evaluated promptly for IC. The management of IC remains supportive; most cases of non-gangrenous IC, as seen in the
alosetron and
tegaserod databases, have been transient and have resolved spontaneously without complications or death. Despite the small number of deaths associated with
alosetron in patients with complications of
constipation and because of the ongoing requirement to prescribe
alosetron under a risk management plan, misconceptions persist regarding the definition, incidence, severity and outcome of IC in clinical trials and the postmarketing setting. In this article, the frequency and clinical characteristics of IC associated with the use of
alosetron and other
serotonergic agents are examined, evidence of an association between IC and IBS is reviewed, and a scoring system to aid in the diagnosis of IC in any clinical situation is proposed.