Chronic Mesenteric Ischemia


Article Author:
Ronak Patel
Abdul Waheed


Article Editor:
Michael Costanza


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
5/11/2019 11:28:28 AM

Introduction

Mesenteric ischemia is a manifestation of peripheral vascular disease in which the blood supply fails to meet the metabolic demands of visceral organs. Acutely, it is a surgical emergency resulting in severe abdominal pain classically described as "pain out of proportion to physical examination." However, chronic mesenteric ischemia (CMI) often presents with vague abdominal pain that may be difficult to differentiate from other, more common causes of abdominal pain.[1][2][3][4]

Etiology

Factors that predispose the mesenteric vessels to atherosclerosis include the following:

  • Diabetes

  • Hypertension

  • Smoking

  • Hyperlipidemia

When the arterial lumen narrows secondary to atherosclerosis, any demand in blood supply that occurs during eating can result in severe abdominal pain and even mesenteric ischemia.[5][6]

Epidemiology

Mesenteric artery stenosis is relatively common, occurring in up to 10% of the population over 65 years of age. However, CMI has a very low incidence, accounting for less than 1 in 1000 hospital admissions for abdominal pain. Patients are typically between the ages of 50 and 70 years of age, with a strong female predominance, and have other coexisting manifestations of atherosclerotic disease.

Pathophysiology

The mesenteric circulation consists of three primary vessels that supply blood to the small and large bowel: the celiac artery, superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). Blood flow through these arteries increases within an hour after eating due to an increase in metabolic demand of the intestinal mucosa. Diffuse atherosclerosis, usually occurring at the origin of these vessels, is the primary mechanism and accounts for 95% of CMI. Chronic occlusion of a single vessel allows collateral blood flow to compensate, thus symptoms do not typically present until at least two primary vessels are occluded. Less common causes include vasculitis, fibromuscular dysplasia, and radiation.[7][8]

Histopathology

The bowel that is excised at surgery will usually reveal diffuse atherosclerosis in the mesenteric vessels. There is usually atrophy of the villi, which leads to loss of absorptive surface.

History and Physical

Patients typically present with “intestinal angina.” Postprandial abdominal pain occurring within 15 to 30 minutes and lasting up to 4 hours that is associated with a fear of eating, ultimately results in weight loss. Additional nonspecific symptoms include nausea, vomiting, early satiety, diarrhea, or constipation. The majority of patients will have a history of symptoms related to diffuse atherosclerotic disease, such as angina, transient ischemic attacks/cerebrovascular accidents, or lower extremity claudication. Physical exam may reveal diffuse mild abdominal tenderness without rebound or guarding, but is more often normal. An abdominal bruit may be audible in up to 50% of patients, but is neither specific nor sensitive.

Evaluation

Most patients undergo an extensive gastrointestinal (GI) disease workup for more common causes of postprandial abdominal pain and weight loss, such as peptic ulcers, cholecystitis, and malignancy, which delays the diagnosis of CMI. Demonstrating the stenosis or occlusion of the primary mesenteric vessels via vascular imaging is required for the diagnosis of CMI. CT angiography (CTA) is the preferred initial, non-invasive modality, as it identifies or excludes atherosclerotic stenosis of the mesenteric vessels while simultaneously ruling out other abdominal etiologies. In the outpatient setting, duplex ultrasonography is a reasonable screening modality, with peak systolic velocities greater than 275 cm/second and 200 cm/second indicating greater than 70% stenosis of the spinal muscular artery and celiac artery, respectively. Arterial digital subtracted angiography (DSA) is the gold standard for confirming the diagnosis of CMI if the results of noninvasive imaging are equivocal, and it is used to plan therapeutic interventions.

Treatment / Management

Asymptomatic patients with CMI are managed conservatively, with smoking cessation and antiplatelet therapy. These patients have a five-year mortality of 40%, with the majority of deaths attributed to myocardial infarction or cardiovascular death. [9][10][11][12]Symptomatic CMI is an indication for either open or endovascular revascularization, as patients with untreated symptomatic CMI carry a five-year mortality rate that approaches 100%.[13][14]

Indications for Surgery

  • Signs of peritonitis on physical exam

  • Massive lower GI hemorrhage

  • Ongoing signs of abdominal pain, fever, or  sepsis

  • Symptoms that have persisted for more than 14 to 21 days

  • Chronic malabsorption leading to protein-losing colopathy

  • Colonoscopic evidence of segmental colitis with frank ulceration

  • Presence of an ischemic stricture and abdominal symptoms

Open revascularization is accomplished via antegrade inflow (aortomesenteric or aortoceliac bypass) or retrograde inflow (from the iliac artery), with either a vein or prosthetic conduit. Endovascular revascularization has surpassed open revascularization as the preferred initial treatment as it is minimally invasive with few perioperative complications. The occluded vessels are accessed via the femoral artery, and blood flow is reconstituted by balloon angioplasty followed by stent placement.

Nutritional status is an important preoperative assessment as patients are often malnourished at the time of diagnosis; total parenteral nutrition may be necessary both pre- and postoperatively. The optimal revascularization approach depends heavily on the anatomy and preoperative condition of the patient.

Surgical Complications

Because these patients have diffuse atherosclerosis, they are prone to myocardial infarction during and after surgery. Thus, prior to any elective surgery, the patient must be well hydrated and the medical condition optimized. Recovery is best done in the intensive care unit.

A very common complication in the postsurgical period is renal failure, which can be permanent. Thus, the patient must be seen by the nephrologist prior to surgery. Hydration is the key to preventing renal dysfunction.

Prognosis

Chronic mesenteric ischemia can lead to the following complications:

  • Poor quality of life

  • Avoidance of food and malnutrition

  • Thrombosis leading to ischemia of the colon

  • Repeated hospital admissions

  • GI tract bleeding

  • Infection

  • Prolonged ileus

For most patients with chronic mesenteric ischemia, the quality of life is poor. The constant fear of abdominal pain that may occur when eating food leads to significant weight loss. The malnourished state often leads to other metabolic and endocrine problems, bone thinning and easy bruising.

Pearls and Other Issues

While endovascular revascularization is associated with shorter hospital stays and fewer serious complication rates, it also is associated with lower long-term patency rates and a shorter time to the return of symptoms when compared to open surgical revascularization. Restenosis occurs in up to 40% of patients, many of whom will require reintervention.

Postprandial pain also is associated with biliary disease, peptic ulcer disease, pancreatitis, diverticulitis, gastric reflux, irritable bowel syndrome, and gastroparesis. Malignancy must be ruled out in an older patient presenting with GI symptoms and weight loss.

Enhancing Healthcare Team Outcomes

Chronic mesenteric ischemia is a difficult diagnosis and thus best managed by an interprofessional team that includes a radiologist, gastroenterologist, nurse practitioner, general surgeon and an internist. Once the diagnosis is made, the novel treatments include endovascular stenting. However, since most of these patients have cardiac risk factors, a referral to a cardiologist is recommended. The cause of death in nearly 40% of patients is an adverse cardiac event. Thus, the primary care giver and nurse practitioner should educate the patient on discontinuing smoking, eating healthy and maintaining a healthy weight.


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Chronic Mesenteric Ischemia - Questions

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A 67-year-old thin female has recurrent abdominal pain every time she eats. She has lost weight and has a soft epigastric systolic abdominal murmur. Which of the following does she most likely have?



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Compression of the celiac artery by the median arcuate ligament can lead to which of the following?



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Fear of eating is most likely to be found in a patient with which of the following disorders?



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Chronic mesenteric ischemia typically presents with which of the following?



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A 68-year-old male has an abdominal bruit and intermittent epigastric pain. An upper gastrointestinal barium study shows an ulcer. Which test would best confirm the presence of chronic mesenteric ischemia?



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Select the correct statement about chronic mesenteric ischemia.



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A 69-year old heavy smoker presents with complaints of vague abdominal pain. She claims that the pain often comes on when she eats and lasts a few hours. Sometimes the pain disappears on its own and at other times she needs to drink water for pain relief. She has lost about 10 pounds over the past 3 months. She did have recent blood work but everything was normal. She also claims that she is not able to walk far without getting cramps in her legs. She is on several bronchodilators. Her physical exam is remarkable only for absent femoral pulses. She undergoes an arteriogram that reveals a prominent meandering mesenteric artery. What diagnosis does this finding indicate in the patient?



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A 77-year old thin female has recurrent abdominal pain every time she eats and has lost 15 pounds over 2 months. She denies diarrhea but has anorexia. She is a heavy smoker and had hypertension. She is on several medications for her hypertension. Physical exam reveals a soft epigastric systolic abdominal murmur and the abdomen is non-tender to palpation. What is the probable diagnosis?



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Chronic Mesenteric Ischemia - References

References

Prakash VS,Marin M,Faries PL, Acute and Chronic Ischemic Disorders of the Small Bowel. Current gastroenterology reports. 2019 May 7;     [PubMed]
Allain C,Besch G,Guelle N,Rinckenbach S,Salomon du Mont L, Prevalence and impact of malnutrition in patients surgically treated for chronic mesenteric ischemia. Annals of vascular surgery. 2019 Apr 19;     [PubMed]
Ben Abdallah I,Cerceau P,Pellenc Q,Huguet A,Corcos O,Castier Y, Laparoscopic Surgery in Chronic Mesenteric Ischaemia: Release of the Superior Mesenteric Artery from the Median Arcuate Ligament using the Transperitoneal Left Retrorenal Approach. Annals of vascular surgery. 2019 Apr 19;     [PubMed]
Robles-Martín ML,Reyes-Ortega JP,Rodríguez-Morata A, A Rare Case of Ischemia-Reperfusion Injury After Mesenteric Revascularization. Vascular and endovascular surgery. 2019 Apr 14;     [PubMed]
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Mohapatra A,Salem KM,Jaman E,Robinson D,Avgerinos ED,Makaroun MS,Eslami MH, Risk factors for perioperative mortality after revascularization for acute aortic occlusion. Journal of vascular surgery. 2018 Dec;     [PubMed]
Nuzzo A,Huguet A,Corcos O, [Modern treatment of mesenteric ischemia]. Presse medicale (Paris, France : 1983). 2018 Jun;     [PubMed]
Kanasaki S,Furukawa A,Fumoto K,Hamanaka Y,Ota S,Hirose T,Inoue A,Shirakawa T,Hung Nguyen LD,Tulyeubai S, Acute Mesenteric Ischemia: Multidetector CT Findings and Endovascular Management. Radiographics : a review publication of the Radiological Society of North America, Inc. 2018 May-Jun;     [PubMed]
Tabriziani H,Ahmad A,Narasimha D,Bergamaschi R,Frishman WH, A Nonsurgical Approach to Mesenteric Vascular Disease. Cardiology in review. 2018 Mar/Apr;     [PubMed]
Mendes BC,Oderich GS,Tallarita T,Kanamori KS,Kalra M,DeMartino RR,Shuja F,Johnstone JK, Superior mesenteric artery stenting using embolic protection device for treatment of acute or chronic mesenteric ischemia. Journal of vascular surgery. 2018 Oct;     [PubMed]
Alahdab F,Arwani R,Pasha AK,Razouki ZA,Prokop LJ,Huber TS,Murad MH, A systematic review and meta-analysis of endovascular versus open surgical revascularization for chronic mesenteric ischemia. Journal of vascular surgery. 2018 May;     [PubMed]

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