A 70-year-old man with atrial fibrillation develops sudden left-sided abdominal pain followed by bloody diarrhoea. CT shows thickening of the bowel wall at the splenic flexure with submucosal oedema producing a 'thumbprint' pattern. He is afebrile with a soft abdomen and normal lactate. The most appropriate initial management is:

• A Emergency laparotomy with segmental resection
• B Systemic thrombolysis
• C Urgent colonoscopy with balloon dilatation of the narrowed segment
• D Conservative management with bowel rest, intravenous fluids, and broad-spectrum antibiotics ✓

Explanation

Ischaemic colitis most often affects watershed zones such as the splenic flexure and rectosigmoid junction. In the absence of peritonitis, perforation, gangrene, or rising lactate, the majority resolve with conservative treatment, and repeat imaging confirms resolution. Laparotomy is reserved for full-thickness infarction or perforation. Colonoscopy carries perforation risk in the acute phase and is avoided, while thrombolysis plays no routine role because most episodes are due to transient hypoperfusion rather than embolic occlusion of a named artery.

Reference: Schwartz Principles of Surgery, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.