Mesenteric ischemia

This article concerns ischemia of the small bowel. See ischemic colitis for ischemia of the large bowel
Mesenteric ischemia
Synonyms Mesenteric ischaemia, mesenteric vascular disease
Computer 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 Gastroenterology
Symptoms Acute: sudden severe pain[1]
Chronic: abdominal pain after eating, unintentional weight loss, vomiting[2][1]
Usual onset > 60 years old[3]
Types Acute, chronic[1]
Risk factors Atrial fibrillation, heart failure, chronic renal failure, being prone to forming blood clots, previous myocardial infarction[2]
Diagnostic method Angiography, computer tomography[1]
Treatment Stenting, medications to break down the clot, surgery[1][2]
Prognosis ~80% risk of death[3]
Frequency Acute: 5 per 100,000 per year (developed world)[4]
Chronic: 1 per 100,000[5]

Mesenteric ischemia is a medical condition in which injury of 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] Acute disease often presents with sudden severe pain.[1] Symptoms may come on more slowly in those with acute on chronic disease.[2] Signs and symptoms of chronic disease include abdominal pain after eating, unintentional weight loss, vomiting, and being afraid of eating.[2][1]

Risk factors include atrial fibrillation, heart failure, chronic renal 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 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 computer 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

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.

Blood tests

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

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.[18][19][20]

Plain X-ray

Plain X-rays are often normal or show non-specific findings.[21]

Computed tomography

Computed tomography (CT scan) is often used.[22][23] The accuracy of the CT scan depends on whether a small bowel obstruction (SBO) is present.[24]

SBO absent

SBO present

Findings on CT scan include:

Angiography

As the cause of the ischemia can be due to embolic or thrombotic occlusion of the mesenteric vessels or nonocclusive ichemia, 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.[26]

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.

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.

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. [27]

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.[28]

Prognosis

The prognosis depends on prompt diagnosis (less than 12–24 hours and before gangrene)[29] and the underlying cause:[30]

In the case of prompt diagnosis and therapy, acute mesenteric ischemia can be reversible.[31]

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]

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Bobadilla, JL (August 2013). "Mesenteric ischemia.". The Surgical clinics of North America. 93 (4): 925–40, ix. PMID 23885938. doi:10.1016/j.suc.2013.04.002.
  2. 1 2 3 4 5 6 7 8 9 Yelon, Jay A. (2014). Geriatric Trauma and Critical Care (Aufl. 2014 ed.). New York: Springer Verlag. p. 182. ISBN 9781461485018.
  3. 1 2 3 4 5 6 Britt, L.D. (2012). Acute care surgery (1st ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 621. ISBN 9781608314287.
  4. 1 2 Geoffrey D. Rubin (2012). CT and MR Angiography: Comprehensive Vascular Assessment. Lippincott Williams & Wilkins. p. 318. ISBN 9781469801834.
  5. 1 2 Gustavo S. Oderich (2014). Mesenteric Vascular Disease: Current Therapy. Springer. p. 105. ISBN 9781493918478.
  6. Creager, Mark A. (2013). Vascular medicine : a companion to Braunwald's heart disease (2nd ed.). Philadelphia, PA: Elsevier/Saunders. pp. 323–324. ISBN 9781437729306.
  7. Sreenarasimhaiah, J (April 2005). "Chronic mesenteric ischemia.". Best practice & research. Clinical gastroenterology. 19 (2): 283–95. PMID 15833694. doi:10.1016/j.bpg.2004.11.002.
  8. Liapis, C.D. (2007). Vascular surgery. Berlin: Springer. p. 420. ISBN 9783540309567.
  9. Boley, SJ, Brandt, LJ, Veith, FJ (1978). "Ischemic disorders of the intestines". Curr Probl Surg. 15 (4): 1–85. PMID 365467. doi:10.1016/S0011-3840(78)80018-5.
  10. Hunter G, Guernsey J (1988). "Mesenteric ischemia". Med Clin North Am. 72 (5): 1091–115. PMID 3045452.
  11. Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD (2004). "Acute mesenteric ischemia: a clinical review". Arch. Intern. Med. 164 (10): 1054–62. PMID 15159262. doi:10.1001/archinte.164.10.1054.
  12. Font VE, Hermann RE, Longworth DL (1989). "Chronic mesenteric venous thrombosis: difficult diagnosis and therapy". Cleveland Clinic journal of medicine. 56 (8): 823–8. PMID 2691119. doi:10.3949/ccjm.56.8.823.
  13. Levy PJ, Krausz MM, Manny J (1990). "Acute mesenteric ischemia: improved results--a retrospective analysis of ninety-two patients". Surgery. 107 (4): 372–80. PMID 2321134.
  14. 1 2 3 Park WM, Gloviczki P, Cherry KJ, Hallett JW, Bower TC, Panneton JM, Schleck C, Ilstrup D, Harmsen WS, Noel AA (2002). "Contemporary management of acute mesenteric ischemia: Factors associated with survival". J. Vasc. Surg. 35 (3): 445–52. PMID 11877691. doi:10.1067/mva.2002.120373.
  15. "American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia.". Gastroenterology. 118 (5): 951–3. May 2000. PMID 10784595. doi:10.1016/s0016-5085(00)70182-x.
  16. 1 2 3 Cope, Zachary; Silen, William (April 2005). Cope's Early Diagnosis of the Acute Abdomen (21st ed.). New York: Oxford University Press. ISBN 978-0-19-517545-5. LCCN 2004058138. OCLC 56324163.
  17. Evennett NJ, Petrov MS, Mittal A, Windsor JA (July 2009). "Systematic review and pooled estimates for the diagnostic accuracy of serological markers for intestinal ischemia". World J Surg. 33 (7): 1374–83. PMID 19424744. doi:10.1007/s00268-009-0074-7.
  18. Lee ES, Bass A, Arko FR, et al. (2006). "Intraoperative colon mucosal oxygen saturation during aortic surgery". The Journal of surgical research. 136 (1): 19–24. PMID 16978651. doi:10.1016/j.jss.2006.05.014.
  19. Friedland S, Benaron D, Coogan S, et al. (2007). "Diagnosis of chronic mesenteric ischemia by visible light spectroscopy during endoscopy". Gastrointest Endosc. 65 (2): 294–300. PMID 17137857. doi:10.1016/j.gie.2006.05.007.
  20. Lee ES, Pevec WC, Link DP, et al. (2008). "Use of T-stat to Predict Colonic Ischemia during and after Endovascular Aneurysm Repair: A case report". J Vasc Surg. 47 (3): 632–634. PMC 2707776Freely accessible. PMID 18295116. doi:10.1016/j.jvs.2007.09.037.
  21. Smerud M, Johnson C, Stephens D (1990). "Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases". AJR Am J Roentgenol. 154 (1): 99–103. PMID 2104734. doi:10.2214/ajr.154.1.2104734.
  22. 1 2 3 4 5 Alpern M, Glazer G, Francis I (1988). "Ischemic or infarcted bowel: CT findings". Radiology. 166 (1 Pt 1): 149–52. PMID 3336673. doi:10.1148/radiology.166.1.3336673.
  23. Taourel P, Deneuville M, Pradel J, Régent D, Bruel J (1996). "Acute mesenteric ischemia: diagnosis with contrast-enhanced CT" (PDF). Radiology. 199 (3): 632–6. PMID 8637978. doi:10.1148/radiology.199.3.8637978.
  24. Staunton M, Malone DE (2005). "Can acute mesenteric ischemia be ruled out using computed tomography? Critically appraised topic |". Canadian Association of Radiologists Journal. 56 (1): 9–12. PMID 15835585.
  25. Pereira JM, Sirlin CB, Pinto PS, Jeffrey RB, Stella DL, Casola G (2004). "Disproportionate fat stranding: a helpful CT sign in patients with acute abdominal pain". Radiographics : a review publication of the Radiological Society of North America, Inc. 24 (3): 703–15. PMID 15143223. doi:10.1148/rg.243035084.
  26. Kao, Lillian S., and Tammy Lee. PreTest Surgery: PreTest Self-assessment and Review. New York: McGraw-Hill Medical, 2009.
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  28. Meng, X; Liu, L; Jiang, H (August 2010). "Indications and procedures for second-look surgery in acute mesenteric ischemia.". Surgery today. 40 (8): 700–5. PMID 20676851. doi:10.1007/s00595-009-4140-4.
  29. Brandt, LJ; Boley, SJ (May 2000). "AGA technical review on intestinal ischemia. American Gastrointestinal Association.". Gastroenterology. 118 (5): 954–968. PMID 10784596. doi:10.1016/s0016-5085(00)70183-1.
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