mesenteric ischemia (ischemic enteritis)
(Redirected from Superior mesenteric artery thrombosis)
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
- may progress to persistent abdominal pain even without eating[5]
- occlusion of the superior mesenteric vein
- abdominal pain gradually becoming more severe
- mild, moderate & severe acute ischemia
- mild: crampy abdominal pain, nausea, episode of hematochezia
* 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 dehydrogenase may be elevated
- mild ischemia: WBC 11K, serum-CRP 2.4 mg/dL
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
- imaging unnecessary if mild
Complications
- intestinal infarction
- bowel pneumatosis, portal mesenteric gas, peritoneal signs
Management
- acute superior mesenteric artery ischemia:
- embolectomy or intra-arterial thrombolysis
- broad spectrum empiric antibiotics
- exploratory laparotomy if evidence of intestinal infarction
- occlusion of the superior mesenteric vein
- surgery
- chronic ischemia: surgical revascularization
- mild form: IV fluids & bowel rest[13]
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://pubmed.ncbi.nlm.nih.gov/11407335
- ↑ Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology. 2000 May;118(5):954-68. PMID: https://pubmed.ncbi.nlm.nih.gov/10784596
Brandt LJ, Feuerstadt P, Longstreth GF ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia (CI). Am J Gastroenterol. 2015 Jan;110(1):18-44;. PMID: https://pubmed.ncbi.nlm.nih.gov/25559486 No abstract available - ↑ 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.
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ 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://pubmed.ncbi.nlm.nih.gov/23088809
- ↑ Wyers MC Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010 Mar;23(1):9-20. PMID: https://pubmed.ncbi.nlm.nih.gov/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://pubmed.ncbi.nlm.nih.gov/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://pubmed.ncbi.nlm.nih.gov/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://pubmed.ncbi.nlm.nih.gov/31080602
- ↑ Sardar P, White CJ. Chronic mesenteric ischemia: diagnosis and management. Prog Cardiovasc Dis. 2021;65:71-75. PMID: https://pubmed.ncbi.nlm.nih.gov/33901516
- ↑ 13.0 13.1 Geriatric Review Syllabus (GRS12) Colburn JL, Westcott AM, Potter JF (eds) American Geriatrics Society. 2025
- ↑ Hung A, Calderbank T, Samaan MA et al Ischaemic colitis: practical challenges and evidence-based recommendations for management. Frontline Gastroenterol. 2019;12(1):44-52 PMID: https://pubmed.ncbi.nlm.nih.gov/33489068 PMCID: PMC7802492 Free PMC article
- ↑ Lendzion RJ, Frahm-Jensen G, Keck J. Acute mesenteric ischemia. Clin Colon Rectal Surg. 2022;35:227-236. PMID: https://pubmed.ncbi.nlm.nih.gov/35966379