Intestinal ischemia

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Intestinal ischemia
Other namesBowel ischemia
Ischemicbowel.PNG
Computed tomography (CT) showing dilated loops of small bowel with thickened walls (black arrow), findings characteristic of ischemic bowel due to thrombosis of the superior mesenteric vein.
Specialty General surgery, vascular surgery, gastroenterology
Symptoms Acute: sudden severe pain [1]
Chronic: abdominal pain after eating, unintentional weight loss, vomiting [2] [1]
Usual onset> 60 years old [3]
TypesAcute, chronic [1]
Risk factors Atrial fibrillation, heart failure, chronic kidney failure, being prone to forming blood clots, previous myocardial infarction [2]
Diagnostic method Angiography, computed tomography [1]
Treatment Stenting, medications to break down clot, surgery [1] [2]
Prognosis ~80% risk of death [3]
FrequencyAcute: 5 per 100,000 per year (developed world) [4]
Chronic: 1 per 100,000 [5]

Intestinal ischemia is a medical condition in which injury to the large or small intestine occurs due to not enough blood supply. [2] It can come on suddenly, known as acute intestinal ischemia, or gradually, known as chronic intestinal ischemia. [1] The acute form of the disease often presents with sudden severe abdominal pain and is associated with a high risk of death. [1] The chronic form typically presents more gradually with abdominal pain after eating, unintentional weight loss, vomiting, and fear of eating. [1] [2]

Contents

Risk factors for acute intestinal ischemia include atrial fibrillation, heart failure, chronic kidney failure, being prone to forming blood clots, and previous myocardial infarction. [2] There are four mechanisms by which poor blood flow occurs: a blood clot from elsewhere getting lodged in an artery, a new blood clot forming in an artery, a blood clot forming in the superior mesenteric vein, and insufficient blood flow due to low blood pressure or spasms of arteries. [3] [6] Chronic disease is a risk factor for acute disease. [7] The best method of diagnosis is angiography, with computed tomography (CT) used when that is not available. [1]

Treatment of acute ischemia may include stenting or medications to break down the clot provided at the site of obstruction by interventional radiology. [1] Open surgery may also be used to remove or bypass the obstruction and may be required to remove any intestines that may have died. [2] If not rapidly treated outcomes are often poor. [1] Among those affected even with treatment the risk of death is 70% to 90%. [3] In those with chronic disease bypass surgery is the treatment of choice. [1] Those who have thrombosis of the vein may be treated with anticoagulation such as heparin and warfarin, with surgery used if they do not improve. [2] [8]

Acute intestinal ischemia affects about five per hundred thousand people per year in the developed world. [4] Chronic intestinal ischemia affects about one per hundred thousand people. [5] Most people affected are over 60 years old. [3] Rates are about equal in males and females of the same age. [3] Intestinal ischemia was first described in 1895. [1]

Signs and symptoms

While not always present and often overlapping, three progressive phases of intestinal ischemia have been described: [9] [10]

Clinical findings

Symptoms of intestinal ischemia vary and can be acute (especially if embolic), [11] subacute, or chronic. [12]

Case series report prevalence of clinical findings and provide the best available, yet biased, estimate of the sensitivity of clinical findings. [13] [14] In a series of 58 patients with intestinal ischemia due to mixed causes: [14]

Diagnostic heuristics

In the absence of adequate quantitative studies to guide diagnosis, various heuristics help guide diagnosis:

Diagnosis

It is difficult to diagnose intestinal ischemia early. [17]

Blood tests

In a series of 58 patients with intestinal ischemia due to mixed causes: [14]

In very early or very extensive acute intestinal ischemia, elevated lactate and white blood cell count may not yet be present. In extensive mesenteric ischemia, bowel may be ischemic but separated from the blood flow such that the byproducts of ischemia are not yet circulating. [18]

During endoscopy

A number of devices have been used to assess the sufficiency of oxygen delivery to the colon. The earliest devices were based on tonometry, and required time to equilibrate and estimate the pHi, roughly an estimate of local CO2 levels. The first device approved by the U.S. FDA (in 2004) used visible light spectroscopy to analyze capillary oxygen levels. Use during aortic aneurysm repair detected when colon oxygen levels fell below sustainable levels, allowing real-time repair. In several studies, specificity has been 83% for chronic intestinal ischemia and 90% or higher for acute colonic ischemia, with a sensitivity of 71–92%. This device must be placed using endoscopy, however. [19] [20] [21]

Findings on gastroscopy may include edematous gastric mucosa, [22] and hyperperistalsis. [23]

Finding on colonoscopy may include: fragile mucosa, [24] segmental erythema, [25] longitudinal ulcer, [26] and loss of haustrations [27]

Plain X-ray

Plain X-rays are often normal or show non-specific findings. [28]

Computed tomography

CT image showing mesenteric ischemia with pneumatosis intestinalis and gas in mesenterial and liver veins Mesenteriale Ischaemie mit Pneumatosis intestinalis und Gas in Mesenterial- und Lebervenen 80M - CT - 001.jpg
CT image showing mesenteric ischemia with pneumatosis intestinalis and gas in mesenterial and liver veins

Computed tomography (CT scan) is often used. [29] [30] The accuracy of the CT scan depends on whether a small bowel obstruction (SBO) is present. [31]

SBO absent

SBO present

Early findings on CT scan include:

In embolic acute intestinal ischemia, CT-Angiography can be of great value for diagnosis and treatment. It may reveal the emboli itself lodged in the superior mesenteric artery, as well as the presence or absence of distal mesenteric branches. [18]

Late findings, which indicate dead bowel, include:

Angiography

As the cause of the ischemia can be due to embolic or thrombotic occlusion of the mesenteric vessels or nonocclusive ischemia, the best way to differentiate between the etiologies is through the use of mesenteric angiography. Though it has serious risks, angiography provides the possibility of direct infusion of vasodilators in the setting of nonocclusive ischemia. [33]

Treatment

The treatment of intestinal ischemia depends on the cause and can be medical or surgical. However, if bowel has become necrotic, the only treatment is surgical removal of the dead segments of bowel. [34]

In non-occlusive disease, where there is no blockage of the arteries supplying the bowel, the treatment is medical rather than surgical. People are admitted to the hospital for resuscitation with intravenous fluids, careful monitoring of laboratory tests, and optimization of their cardiovascular function. NG tube decompression and heparin anticoagulation may also be used to limit stress on the bowel and optimize perfusion, respectively.[ citation needed ]

Surgical revascularisation remains the treatment of choice for intestinal ischaemia related to an occlusion of the vessels supplying the bowel, but thrombolytic medical treatment and vascular interventional radiological techniques have a growing role. [35]

If the ischemia has progressed to the point that the affected intestinal segments are gangrenous, a bowel resection of those segments is called for. Often, obviously dead segments are removed at the first operation, and a second-look operation is planned to assess segments that are borderline that may be savable after revascularization. [36]

Methods for revascularization

Prognosis

The prognosis depends on prompt diagnosis (less than 12–24 hours and before gangrene) [37] and the underlying cause: [38]

In the case of prompt diagnosis and therapy, acute intestinal ischemia can be reversible. [39]

History

Acute intestinal ischemia was first described in 1895, while chronic disease was first described in the 1940s. [1] Chronic disease was initially known as angina abdominis. [1]

Terminology

The related term mesenteric ischemia or small intestine ischemia generally defined as ischemia of the small bowel specifically. [40] It has also been defined as poor circulation in the vessels supplying blood flow to any or several of the mesenteric organs, including the stomach, liver, colon and intestine. The terms colonic ischemia, large intestine ischemia, or ischemic colitis refers to ischemia of the large bowel. [41] [42]

In the large intestine

Ischemia of the large intestine (colon) is termed ischemic colitis. Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. [43] [44] [45] Causes of the reduced blood flow can include changes in the systemic circulation (e.g. low blood pressure), or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified. [46]

Ischemic colitis is usually suspected on the basis of the clinical setting, physical examination, and laboratory test results; the diagnosis can be confirmed by endoscopy or by using sigmoid or endoscopic placement of a visible light spectroscopic catheter (see Diagnosis). Ischemic colitis can span a wide spectrum of severity; most patients are treated supportively and recover fully, while a minority with very severe ischemia may develop sepsis and become critically, [47] sometimes even fatally, ill. [48]

Patients with mild to moderate ischemic colitis are usually treated with IV fluids, analgesia, and bowel rest (that is, no food or water by mouth) until the symptoms resolve. Those with severe ischemia who develop complications such as sepsis, intestinal gangrene, or bowel perforation may require more aggressive interventions, such as surgery and intensive care. Most patients make a full recovery; occasionally, after severe ischemia, patients may develop long-term complications such as a stricture [49] or chronic colitis. [50]

Related Research Articles

<span class="mw-page-title-main">Crohn's disease</span> Type of inflammatory bowel disease

Crohn's disease is a chronic inflammatory bowel disease characterized by recurrent episodes of intestinal inflammation, primarily manifesting as diarrhea and abdominal pain. Unlike ulcerative colitis, inflammation can occur anywhere in the gastrointestinal tract, though it most frequently affects the ileum and colon, involving all layers of the intestinal wall. Symptoms may be non-specific and progress gradually, often delaying diagnosis. About one-third of patients have colonic disease, another third have ileocolic disease, and the remaining third have isolated ileal disease. Systemic symptoms such as chronic fatigue, weight loss, and low-grade fevers are common, along with extraintestinal manifestations affecting organs like the skin and joints. Complications can include bowel obstructions, fistulas, and an increased risk of intestinal cancers.

<span class="mw-page-title-main">Bowel obstruction</span> Mechanical or functional obstruction of the intestines

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.

<span class="mw-page-title-main">Ischemia</span> Restriction in blood supply to tissues

Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism. Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue i.e. hypoxia and microvascular dysfunction. It also implies local hypoxia in a part of a body resulting from constriction.

<span class="mw-page-title-main">Enteritis</span> Inflammation of the small intestine

Enteritis is inflammation of the small intestine. It is most commonly caused by food or drink contaminated with pathogenic microbes, such as Serratia, but may have other causes such as NSAIDs, radiation therapy as well as autoimmune conditions like coeliac disease. Symptoms include abdominal pain, cramping, diarrhoea, dehydration, and fever. Related diseases of the gastrointestinal system involve inflammation of the stomach and large intestine.

<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.

<span class="mw-page-title-main">Gastrointestinal disease</span> Illnesses of the digestive system

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum; and the accessory organs of digestion, the liver, gallbladder, and pancreas.

Colic in horses is defined as abdominal pain, but it is a clinical symptom rather than a diagnosis. The term colic can encompass all forms of gastrointestinal conditions which cause pain as well as other causes of abdominal pain not involving the gastrointestinal tract. What makes it tricky is that different causes can manifest with similar signs of distress in the animal. Recognizing and understanding these signs is pivotal, as timely action can spell the difference between a brief moment of discomfort and a life-threatening situation. The most common forms of colic are gastrointestinal in nature and are most often related to colonic disturbance. There are a variety of different causes of colic, some of which can prove fatal without surgical intervention. Colic surgery is usually an expensive procedure as it is major abdominal surgery, often with intensive aftercare. Among domesticated horses, colic is the leading cause of premature death. The incidence of colic in the general horse population has been estimated between 4 and 10 percent over the course of the average lifespan. Clinical signs of colic generally require treatment by a veterinarian. The conditions that cause colic can become life-threatening in a short period of time.

<span class="mw-page-title-main">Intussusception (medical disorder)</span> Folding of part of the intestine into itself

Intussusception is a medical condition in which a part of the intestine folds into the section immediately ahead of it. It typically involves the small intestine and less commonly the large intestine. Symptoms include abdominal pain which may come and go, vomiting, abdominal bloating, and bloody stool. It often results in a small bowel obstruction. Other complications may include peritonitis or bowel perforation.

<span class="mw-page-title-main">Volvulus</span> Twisting of part of the intestine, causing a bowel obstruction

A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or significant pain when the abdomen is touched.

<span class="mw-page-title-main">Diverticular disease</span> Problems arising from pouch formations in the large intestinal wall

Diverticular disease is when problems occur due to diverticulosis, a benign condition defined by the formation of pouches (diverticula) from weak spots in the wall of the large intestine. This disease spectrum includes diverticulitis, symptomatic uncomplicated diverticular disease (SUDD), and segmental colitis associated with diverticulosis (SCAD). The most common symptoms across the disease spectrum are abdominal pain and bowel habit changes such as diarrhea or constipation. Otherwise, diverticulitis presents with systemic symptoms such as fever and elevated white blood cell count whereas SUDD and SCAD do not. Treatment ranges from conservative bowel rest to medications such as antibiotics, antispasmodics, acetaminophen, mesalamine, rifaximin, and corticosteroids depending on the specific conditions.

Intestinal malrotation is a congenital anomaly of rotation of the midgut. It occurs during the first trimester as the fetal gut undergoes a complex series of growth and development. Malrotation can lead to a dangerous complication called volvulus, in which cases emergency surgery is indicated. Malrotation can refer to a spectrum of abnormal intestinal positioning, often including:

<span class="mw-page-title-main">Gastrointestinal perforation</span> Hole in the wall of the gastrointestinal tract

Gastrointestinal perforation, also known as gastrointestinal rupture, is a hole in the wall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from the mouth to the anus. Symptoms of gastrointestinal perforation commonly include severe abdominal pain, nausea, and vomiting. Complications include a painful inflammation of the inner lining of the abdominal wall and sepsis.

<span class="mw-page-title-main">Lower gastrointestinal bleeding</span> Bleeding in the small and large intestine

Lower gastrointestinal bleeding (LGIB) is any form of gastrointestinal bleeding in the lower gastrointestinal tract. LGIB is a common reason for seeking medical attention at a hospital's emergency department. LGIB accounts for 30–40% of all gastrointestinal bleeding and is less common than upper gastrointestinal bleeding (UGIB). It is estimated that UGIB accounts for 100–200 per 100,000 cases versus 20–27 per 100,000 cases for LGIB. Approximately 85% of lower gastrointestinal bleeding involves the large intestine, 10% are from bleeds that are actually upper gastrointestinal bleeds, and 3–5% involve the small intestine.

<span class="mw-page-title-main">Ischemic colitis</span> Inflammation of the large intestine due to insufficient blood supply

Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply (ischemia). Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Causes of the reduced blood flow can include changes in the systemic circulation or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified.

An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate surgical treatment.

<span class="mw-page-title-main">Abdominal angina</span> Medical condition

Abdominal angina is abdominal pain after eating caused by a reduction of blood flow to the celiac trunk, superior mesenteric arteries (SMA), inferior mesenteric artery (IMA), or the surrounding organs. Symptoms include abdominal pain, weight loss, diarrhea, nausea, vomiting, and an aversion or fear of eating caused by the pain associated with eating.

<span class="mw-page-title-main">Bowel resection</span> Surgical procedure in which a part of an intestine is removed

A bowel resection or enterectomy is a surgical procedure in which a part of an intestine (bowel) is removed, from either the small intestine or large intestine. Often the word enterectomy is reserved for the sense of small bowel resection, in distinction from colectomy, which covers the sense of large bowel resection. Bowel resection may be performed to treat gastrointestinal cancer, bowel ischemia, necrosis, or obstruction due to scar tissue, volvulus, and hernias. Some patients require ileostomy or colostomy after this procedure as alternative means of excretion. Complications of the procedure may include anastomotic leak or dehiscence, hernias, or adhesions causing partial or complete bowel obstruction. Depending on which part and how much of the intestines are removed, there may be digestive and metabolic challenges afterward, such as short bowel syndrome.

Stercoral ulcer is an ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation due to a large bowel obstruction, damage to the autonomic nervous system, or stercoral colitis. It is most commonly located in the sigmoid colon and rectum. Prolonged constipation leads to production of fecaliths, leading to possible progression into a fecaloma. These hard lumps irritate the rectum and lead to the formation of these ulcers. It results in fresh bleeding per rectum. These ulcers may be seen on imaging, such as a CT scan but are more commonly identified using endoscopy, usually a colonoscopy. Treatment modalities can include both surgical and non-surgical techniques.

<span class="mw-page-title-main">Bowel infarction</span> Injury to the intestine resulting from insufficient blood flow

Bowel infarction or gangrenous bowel represents an irreversible injury to the intestine resulting from insufficient blood flow. It is considered a medical emergency because it can quickly result in life-threatening infection and death. Any cause of bowel ischemia, the earlier reversible form of injury, may ultimately lead to infarction if uncorrected. The causes of bowel ischemia or infarction include primary vascular causes and other causes of bowel obstruction.

<span class="mw-page-title-main">Intestine transplantation</span> Surgical replacement of the small intestine

Intestine transplantation is the surgical replacement of the small intestine for chronic and acute cases of intestinal failure. While intestinal failure can oftentimes be treated with alternative therapies such as parenteral nutrition (PN), complications such as PN-associated liver disease and short bowel syndrome may make transplantation the only viable option. One of the rarest type of organ transplantation performed, intestine transplantation is becoming increasingly prevalent as a therapeutic option due to improvements in immunosuppressive regimens, surgical technique, PN, and the clinical management of pre and post-transplant patients.

References

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  50. ↑ Cappell M (1998). "Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia". Gastroenterol Clin North Am. 27 (4): 827–60, vi. doi:10.1016/S0889-8553(05)70034-0. PMID   9890115.
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