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Introduction: Diagnosis of ischemic colitis in critically ill patients has been plagued by lack of standardization of modalities. The utility of lower endoscopy has not been previously reviewed, particularly in regard to prevention of unnecessary operative intervention. In addition, no study compares the diagnostic yield of flexible sigmoidoscopy (FS) versus colonoscopy (COL).Purpose: This project looks at the utility of lower endoscopy alone and in conjunction with other tests in predicting the need for operative intervention, specifically addressing FS versus COL.Methods: The endoscopy database was reviewed for lower endoscopy performed in the intensive care units in our institution over the last five years in cases where ischemic colitis was suspected, and then correlated with clinical course, laboratory values, and need for operative intervention.Results: 64 COL and 24 FS met criteria. Five patients (5.7%) had Grade III ischemia verified as non-viable bowel at laparotomy. 50 (56.8%) had Grade I or no ischemia. 7 proceeded to laparotomy, one for refractory bleeding, and one for duodenal perforation; none had ischemia identified at the time of laparotomy. Of 33 (37.5%) diagnosed with Grade II ischemia, 12 proceeded to laparatomy. One had necrotic bowel. Two additional unstable patients had segments of bowel that were noted to be viable, but these were resected to avoid a second-look laparotomy given their instability. The other 9 patients proceeded to laparotomy for bleeding or need for decompression, not for ischemia.No lab tests correlated with endoscopy or operative findings. In particular, lactic acid did not predict presence or degree of ischemia. 2/64 (3%) COL revealed potentially significant ischemia that would have been missed on FS; one required operative intervention. 1/24 (4%) FS had a clinically significant right-sided lesion that was later discovered. To achieve 0%, the number needed to treat would equal 25.Conclusion: Grade of ischemia on lower endoscopy is the reliable predictor of need for operative intervention in critically ill patients, with equivalence of COL and FL. In the absence of another indication for intervention, Grade I or II ischemia can be managed expectantly. The only way to reliably diagnose the degree of ischemia is through the use of lower endoscopy, with the majority of negative laparotomies predicted pre-operatively.