mesenteric ischemia (ischemic enteritis)
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Etiology
- acute ischemia
- obstruction of the superior mesenteric artery
- 85% of cases*
- due to emboli* in 95%
- most emboli orginate in the left atrium
- ventricular mural thrombi
- atrial fibrillation most likely etiology of emboli
- non-occlusive ischemia due to poor cardiac output
- acute heart failure, hypotension, hypovolemia, sepsis[5]
- vasopessors, ergot alkaloids, triptans, cocaine, digitalis
- occlusion of the superior mesenteric vein
- 10% of cases of bowel ischemia
- risk factors
- obstruction of the superior mesenteric artery
- chronic ischemia (uncommon)
- at least 2 of 3 major splanchnic vessels must be occluded
- risk factors:
* ref 3 reports 60% of cases are non-thrombotic (low-flow state)
* chronic mesenteric ischemia is almost always associated with atherosclerosis[5]
Epidemiology
- age of patients with small bowel ischemia varies with cause
Clinical manifestations
- acute ischemia involving superior mesenteric artery
- small intestine ischemia
- severe abdominal pain (poorly localized)
- pain out of proportion to abdominal exam
- peritoneal signs suggest intestinal infarction
- urge to defecate
- vomiting
- diarrhea
- bloody diarrhea late feature
- short-bowel syndrome
- patients appear very ill
- small intestine ischemia
- chronic mesenteric ischemia
- postprandial abdominal pain*
- sitophobia (fear of eating)*
- weight loss*
- signs & symptoms of atherosclerosis
- abdominal bruit
- may progress to persistent abdominal pain even without eating[5]
- occlusion of the superior mesenteric vein
- abdominal pain gradually becoming more severe
* classic triad of chronic mesenteric ischemia
Laboratory
- complete blood count:
- basic metabolic panel: metabolic acidosis
- plasma lactate: lactic acidosis (increases anion gap metabolic acidosis)
- serum amylase may be elevated
- lactate dehydrogenasemay be elevated
Diagnostic procedures
- abdominal ultrasound insufficiently sensitive[5]
Radiology
- CT angiography 1st line imaging study[5]
- abdominal CT may show intestinal wall thickening & dilation mesenteric edema, trace free pelvic fluid &/or intestinal pneumatosis (air within the intestinal wall)
- images[8]
- magnetic resonance angiography
- lengthy procedure; limited use in acute setting
- useful in patients with renal failure[5]
- splanchnic angiography considered invasive in contrast to CT angiography thus is not first line[5]
- procedure does allow for endovascular intervention
- abdominal radiograph
- ileus
- small bowel obstruction
- later, gas in portal vein
Management
- acute superior mesenteric artery ischemia:
- embolectomy or intra-arterial thrombolysis
- broad spectrum empiric antibiotics
- surgical resection of necrotic bowel
- occlusion of the superior mesenteric vein
- surgery
- chronic ischemia: surgical revascularization
More general terms
More specific terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 338
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 305-306
- ↑ Journal Watch 21(13):106, 2001 Endean ED et al Surgical management of thrombotic acute intestinal ischemia. Ann Surg 233:801, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11407335
- ↑ Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology. 2000 May;118(5):954-68. PMID: https://www.ncbi.nlm.nih.gov/pubmed/10784596
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2021.
- ↑ Pecoraro F1, Rancic Z, Lachat M et al Chronic mesenteric ischemia: critical review and guidelines for management. Ann Vasc Surg. 2013 Jan;27(1):113-22 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23088809
- ↑ Wyers MC Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010 Mar;23(1):9-20. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20298945
- ↑ 8.0 8.1 Clair DG, Beach JM (images) Mesenteric Ischemia. N Engl J Med 2016; 374:959-968. March 10, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26962730 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMra1503884
- ↑ NEJM Knowledge+. Nov 22, 2016 http://knowledgeplus.nejm.org/question-of-week/433/
- ↑ Wang JM, Chang SC. Images in clinical medicine. Acute mesenteric infarction associated with atrial fibrillation. N Engl J Med 2011 Apr 7; 364:1349 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21470012 Free full text <Internet> http://www.nejm.org/doi/full/10.1056/NEJMicm1001885
- ↑ van Dijk LJ, van Noord D, de Vries AC, et al. Clinical management of chronic mesenteric ischemia. United European Gastroenterol J. 2019;7:179-188. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31080602