Mesenteric ischemia

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Mesenteric ischemia
Other namesMesenteric ischaemia, mesenteric vascular disease
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]

Mesenteric ischemia is a medical condition in which injury to the small intestine occurs due to not enough blood supply. [2] It can come on suddenly, known as acute mesenteric ischemia, or gradually, known as chronic mesenteric 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 mesenteric 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) being 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 mesenteric ischemia affects about five per hundred thousand people per year in the developed world. [4] Chronic mesenteric 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] Mesenteric ischemia was first described in 1895. [1]

Signs and symptoms

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

Clinical findings

Symptoms of mesenteric 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 mesenteric 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 mesenteric ischemia early. [17] One must also differentiate ischemic colitis, which often resolves on its own, from the more immediately life-threatening condition of acute mesenteric ischemia of the small bowel.[ citation needed ]

Blood tests

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

In very early or very extensive acute mesenteric 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 mesenteric 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

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 mesenteric 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 mesenteric 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.[ citation needed ]

In non-occlusive mesenteric ischemia, 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 mesenteric ischaemia related to an occlusion of the vessels supplying the bowel, but thrombolytic medical treatment and vascular interventional radiological techniques have a growing role. [34]

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. [35]

Methods for revascularization

Prognosis

The prognosis depends on prompt diagnosis (less than 12–24 hours and before gangrene) [36] and the underlying cause: [37]

In the case of prompt diagnosis and therapy, acute mesenteric ischemia can be reversible. [38]

History

Acute mesenteric 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]

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Bowel obstruction Medical condition

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Ischemia Restriction in blood supply to tissues

Ischemia or ischaemia is a restriction in blood supply to tissues, 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 means local anemia in a given part of a body sometimes resulting from constriction. Ischemia comprises not only insufficiency of oxygen, but also reduced availability of nutrients and inadequate removal of metabolic wastes. Ischemia can be partial or total.

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Mesentery Contiguous fold of tissues that supports the intestines

The mesentery is an organ that attaches the intestines to the posterior abdominal wall in humans and is formed by the double fold of peritoneum. It helps in storing fat and allowing blood vessels, lymphatics, and nerves to supply the intestines, among other functions.

Meckels diverticulum Medical condition

A Meckel's diverticulum, a true congenital diverticulum, is a slight bulge in the small intestine present at birth and a vestigial remnant of the omphalomesenteric duct. It is the most common malformation of the gastrointestinal tract and is present in approximately 2% of the population, with males more frequently experiencing symptoms.

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Intussusception (medical disorder) Medical condition

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 bowel and less commonly the large bowel. 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.

Volvulus 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.

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Gastrointestinal perforation Medical condition

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Portal vein thrombosis Disease of the liver

Portal vein thrombosis (PVT) is a vascular disease of the liver that occurs when a blood clot occurs in the hepatic portal vein, which can lead to increased pressure in the portal vein system and reduced blood supply to the liver. The mortality rate is approximately 1 in 10.

Ischemic colitis Medical condition

Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply. 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.

Bowel infarction 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.

Superior mesenteric artery syndrome Medical condition

Superior mesenteric artery (SMA) syndrome is a gastro-vascular disorder in which the third and final portion of the duodenum is compressed between the abdominal aorta (AA) and the overlying superior mesenteric artery. This rare, potentially life-threatening syndrome is typically caused by an angle of 6°–25° between the AA and the SMA, in comparison to the normal range of 38°–56°, due to a lack of retroperitoneal and visceral fat. In addition, the aortomesenteric distance is 2–8 millimeters, as opposed to the typical 10–20. However, a narrow SMA angle alone is not enough to make a diagnosis, because patients with a low BMI, most notably children, have been known to have a narrow SMA angle with no symptoms of SMA syndrome.

Acute limb ischaemia Occurs when there is a sudden lack of blood flow to a limb

Acute limb ischaemia (ALI) occurs when there is a sudden lack of blood flow to a limb.

Non-occlusive disease (NOD) or Non-occlusive mesenteric ischaemia (NOMI) is a life-threatening condition including all types of mesenteric ischemia without mesenteric obstruction. It affects mainly elderly patients above 50 years of age who suffer from cardiovascular disease, hepatic, chronic kidney disease or diabetes mellitus. It can be triggered also by a previous cardiac surgery with a consequent heart shock. It represents around 20% of cases of acute mesenteric ischaemia.

References

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