Mesenteric Artery Ischemia


Article Author:
Alin Gragossian


Article Editor:
Patrick Dacquel


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
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
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
2/28/2019 8:12:06 PM

Introduction

Intestinal ischemia can affect the small intestine or the colon. Whereas, “colonic ischemia” refers to ischemia that affects the colon, “mesenteric ischemia” refers to ischemia that affects the blood vessels of the small intestine. It can be secondary to occlusive or nonocclusive obstruction of the arteries or can be caused by obstruction of venous outflow.[1][2][3]

  • Acute mesenteric ischemia is the sudden onset of small intestinal hypoperfusion. Patients usually present with sudden-onset abdominal pain. They are at high risk of deterioration and need emergent surgical intervention.
  • Chronic mesenteric ischemia is seen in patients with mesenteric atherosclerosis. It causes intermittent intestinal hypoperfusion that usually worsens with eating.

Etiology

The major etiologies of mesenteric ischemia are as follows:

Mesenteric Arterial Embolism

Emboli generally lodge in the superior mesenteric artery (SMA), which supplies the small intestine. This causes an acute onset of pain. Predisposing factors include cardiomyopathy, atrial fibrillation, recent angiography, underlying vasculitis and valvular disorders.

Mesenteric Arterial Thrombosis

Acute arterial thrombosis is usually a result of atherosclerosis, either secondary to acute plaque rupture, or gradual build-up until there is critical stenosis. Predisposing factors include patients with atherosclerosis, peripheral arterial disease, hypercoagulability, estrogen therapy, and prolonged hypotension.

Mesenteric Venous Thrombosis

Mesenteric venous thrombosis causes increases in the resistance of mesenteric venous blood flow. Patients who have local intra-abdominal inflammatory processes (such as inflammatory bowel disease) are at higher risk for this. Patients who are hypercoagulable (in other words those with heritable and acquired thrombophilias and malignancies) are also at a higher risk.

Nonocclusive Mesenteric Ischemia (NOMI)

These cases usually involve a “spasm” of the SMA, which can ultimately cause hypoperfusion to the small intestine and colon. Risk factors include peripheral artery disease, septic shock, vasoconstrictive medications (such as digoxin), cocaine abuse, hemodialysis, among many other conditions.

Epidemiology

Mesenteric ischemia is rare. It is thought to have a prevalence of 0.09% to 0.2% of all hospital admissions in the United States, although the exact percentage is truly unknown. [4][5]Below is the estimated prevalence of each etiology of mesenteric ischemia:

  • Mesenteric arterial embolism (50%)
  • Mesenteric arterial thrombosis (15% to 25%)
  • Mesenteric venous thrombosis (5%)
  • Nonocclusive mesenteric ischemia due to intestinal hypoperfusion (20%)

Usually, mesenteric ischemia is seen in elderly patients, especially those with cardiovascular disease. In younger patients who have no known cardiovascular disease, venous thrombosis is the main cause of mesenteric ischemia.

Pathophysiology

The arterial supply to the intestines consists of the SMA and the inferior mesenteric artery (IMA). The venous system parallels the arterial circulation (drains into the body’s portal venous system). The superior mesenteric artery supplies most of the small intestine, whereas the inferior mesenteric artery supplies the colon. The celiac artery (which mostly supplies the liver and spleen) provides collateral blood flow to the small and large intestines.

Mesenteric ischemia can be either acute or chronic and can be caused by arterial emboli, arterial thrombi, venous thrombi, or vasospasm of the mesenteric artery. No matter the etiology, ischemic injury occurs when there is not enough oxygen delivery required for cellular metabolism. However, intestinal injury occurs when there is tissue hypoxia, followed by reperfusion. Thus, mesenteric ischemia not only inflicts injury via hypoperfusion but through reperfusion as well. This multifactorial response, characterized by free radicals, toxic byproducts, and neutrophil activation results in multisystem failure.[6][7][8]

History and Physical

It is important to obtain a thorough personal and family history for patients who may have mesenteric ischemia. Patients with acute embolic mesenteric ischemia have a history of a prior embolic event about 30% of the time. Also, those with acute mesenteric venous thrombosis have a personal or family history of deep vein thromboses or pulmonary emboli roughly 50% of the time.

The most common presenting symptom is abdominal pain. The patient’s symptoms and presentation may help determine the etiology of the ischemia. An arterial embolism usually causes sudden, severe, periumbilical pain and is associated with nausea and vomiting. Thrombotic mesenteric arterial occlusion is usually associated with pain that is worse after eating. Patients with mesenteric venous thrombosis usually have slower-onset, “waxing and waning” abdominal pain.

The physical exam may be normal. In fact, patients present with pain that is out of proportion to the initial physical exam. There may be mild distension present, but peritoneal signs only begin to show when transmural bowel infarction and necrosis develops.

Evaluation

The gold standard for diagnosis of mesenteric ischemia is mesenteric angiography. However, computed tomography (CT) angiography is a sufficient initial diagnostic modality. Lab tests, including white blood cell count, d-dimer, and lactate can aid in the diagnosis of mesenteric ischemia, but clinicians should not solely rely on these tests. In fact, lactate and d-dimer are not very specific. A thorough history and physical examination, along with serial abdominal exams, are more important.[9][10]

Treatment / Management

Patients with acute mesenteric ischemia usually need immediate surgical intervention. Treatment should begin promptly in the emergency department with aggressive fluid resuscitation and broad-spectrum antibiotics (with coverage for bowel flora). If the patient remains hypotensive despite aggressive fluid resuscitation, a norepinephrine drip should be started. However, vasopressors can technically worsen ischemia and should be used with caution.[11][12][13]

Mesenteric arterial occlusion from an embolism is treated with early surgical laparotomy with embolectomy. Although still being researched, some patients with a very early diagnosis of mesenteric arterial embolism (without signs of peritonitis) can be treated with local infusion of a thrombolytic agent. Mesenteric arterial thrombosis usually needs surgical revascularization or stenting. Mesenteric venous thrombosis can sometimes be managed medically with systemic anticoagulation, but it is dependent upon disease severity. Treatment of NOMI aims to eliminate the underlying cause that is causing the ischemia, for example, removing the vasoconstrictive medications that are causing the mesenteric artery to spasm.

As long as there are no contraindications, patients are usually treated with systemic anticoagulation after surgical intervention.

Differential Diagnosis

Mesenteric ischemia can present in many different ways, and initially has very nonspecific physical exam findings. It is important to keep the diagnosis at the top of the differential diagnoses, especially in elderly patients with risk factors. Differential diagnosis includes:

  • Ruptured abdominal aortic aneurysm
  • Perforated bowel
  • Bowel obstruction
  • Any acute, surgical abdomen: The differential diagnosis is broad. The important concept is to always consider the diagnosis in the correct setting.

Prognosis

Mortality is estimated to be 60% to 80%, especially in those with more than a 24-hour delay in diagnosis. Surgical intervention within 6 hours of symptom onset increases survival rates. In general, prognosis depends on the etiology. Patients with an arterial etiology have worse survival outcomes than those with a venous etiology.

Complications

Mesenteric ischemia can have many complications. If mesenteric ischemia is not treated in time, complications include: 

  • Necrosis of intestinal tissue
  • Perforation of the intestinal wall
  • Death

Postoperative and Rehabilitation Care

Patients with acute mesenteric ischemia require intensive care and should be placed in the hospital’s intensive care unit after surgery. Most patients require a “second-look laparotomy” 24 to 48 hours after mesenteric revascularization, as it is important to re-evaluate the bowel. Unless contraindicated, patients should be on long-term systemic anticoagulation after their hospital stay. If a mesenteric artery stent is placed, it is important to have periodic surveillance of the stent (either with duplex ultrasound or CT angiography), although there have been few studies done on specific surveillance intervals.

Consultations

If the diagnosis is suspected in the emergency department, General Surgery should be consulted promptly. Vascular surgery and interventional radiology can also be consulted, but this depends on the hospital’s available services. Palliative medicine can be consulted for poor surgical candidates with extensive infarction.

Pearls and Other Issues

Always keep mesenteric ischemia at the top of the differential diagnosis in patients, especially the elderly ones with risk factors and co-morbidities. Summary and clinical pearls are as follows:

  • There are many different causes of mesenteric ischemia, with the most common being mesenteric arterial embolism.
  • A thorough personal and family medical history can help with the early diagnosis of mesenteric ischemia, as the physical examination can be normal.
  • The differential diagnosis for mesenteric ischemia is very broad. The important concept is to always consider the diagnosis in the correct setting.
  • Specific treatment of mesenteric ischemia depends on the etiology, but most patients will need systemic anticoagulation with or without surgery.
  • Patients with an arterial etiology have worse survival outcomes than those with a venous etiology.

Enhancing Healthcare Team Outcomes

The management of mesenteric ischemia is multidisciplinary. Many of these patients have other comorbidities and need to be assessed by other health professionals. Because of the presence of vascular disease, the other organ systems in the body also need to be closely monitored. For those who have atrial arrhythmias, the patients need long-term anticoagulation. In addition, the pharmacist must ensure that a therapeutic INR has been achieved. Periodic anticoagulation profile is mandatory. The patient should be urged to stop smoking and ensure that the blood pressure is adequately controlled. Many patients may develop diarrhea as a result of bowel resection and may develop malabsorption. Thus, a dietary consult is recommended. In some patients, long-term intravenous hyperalimentation may be required. Finally, patients who end up with a stoma will need to be seen by a stoma nurse. [14][15](Level V)

Outcomes

Even though survival of patients following mesenteric artery ischemia has improved over the past 3 decades, the disorder still carries a very high morbidity and mortality. Depending on the time of presentation and treatment, the mortality can approach 10-80%. Even those who survive are left with a risk of re-thrombosis, short bowel, a colostomy or ileostomy. Many patients are left with a short gut and require long-term parenteral nutrition. The outcomes are usually worse in seniors, those with other comorbidities, sepsis and metabolic acidosis at the time of presentation. Early recognition of the problem can help reduce the mortality. [11][16](Level V)


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Mesenteric Artery Ischemia - Questions

Take a quiz of the questions on this article.

Take Quiz
What is the "classic finding" with acute mesenteric ischemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following vessels should not be ligated due to the risk of life threatening complications?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the "gold standard" imaging modality for mesenteric ischemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Three days after admission for an acute myocardial infarction, a 76-year-old complains of severe, unremitting abdominal pain. A physical exam reveals pain that is out of proportion to the findings. The serum lactate level and white blood cell count are elevated. Which of the following is the most appropriate next step in management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following carries the lowest risk for ischemic bowel?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not a computerized topography feature of mesenteric ischemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
At what site do the majority of emboli cause acute mesenteric ischemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is a common complaint of patients with mesenteric ischemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
If a patient is allergic to iodinated contrast, which imaging modality should be used to diagnose mesenteric ischemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following patients is most at-risk for mesenteric ischemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true regarding the use of vasopressors in acute mesenteric ischemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following etiologies of mesenteric artery ischemia has the worst prognosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is false regarding mesenteric artery ischemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Mesenteric Artery Ischemia - References

References

Scholtz V,Meyer F,Schulz HU,Albrecht R,Halloul Z, [Vascular surgical aspects in abdominal surgery : Results from a tertiary care center over a 10-year time period]. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2018 Sep 25     [PubMed]
Ehlert BA, Acute Gut Ischemia. The Surgical clinics of North America. 2018 Oct     [PubMed]
Seong EY,Zheng Y,Winkelmayer WC,Montez-Rath ME,Chang TI, The Relationship between Intradialytic Hypotension and Hospitalized Mesenteric Ischemia: A Case-Control Study. Clinical journal of the American Society of Nephrology : CJASN. 2018 Sep 20     [PubMed]
Oderich GS,Macedo R,Stone DH,Woo EY,Panneton JM,Resch T,Dias NV,Sonesson B,Schermerhorn ML,Lee JT,Kalra M,DeMartino RR,Sandri GA,Ramos Tenorio EJ, Multicenter study of retrograde open mesenteric artery stenting through laparotomy for treatment of acute and chronic mesenteric ischemia. Journal of vascular surgery. 2018 Aug     [PubMed]
Chaudhry R,Zaki J,Wegner R,Pednekar G,Tse A,Sheinbaum R,Williams GW, Gastrointestinal Complications After Cardiac Surgery: A Nationwide Population-Based Analysis of Morbidity and Mortality Predictors. Journal of cardiothoracic and vascular anesthesia. 2017 Aug     [PubMed]
Al-Diery H,Phillips A,Evennett N,Pandanaboyana S,Gilham M,Windsor JA, The Pathogenesis of Nonocclusive Mesenteric Ischemia: Implications for Research and Clinical Practice: Review Article. Journal of intensive care medicine. 2018 Jan 1     [PubMed]
Nuzzo A,Huguet A,Corcos O, [Modern treatment of mesenteric ischemia]. Presse medicale (Paris, France : 1983). 2018 Jun     [PubMed]
Caudrelier L,Pugnet G,Astudillo L,Delbrel X,Bura Riviere A,Sailler L, Catastrophic multiple arterial dissections revealing concomitant polyarteritis nodosa and vascular Elhers-Danlos syndrome. Clinical and experimental rheumatology. 2018 Mar-Apr     [PubMed]
Kammerer S,Schuelke C,Berkemeyer S,Velasco A,Heindel W,Koehler M,Buerke B, The role of multislice computed tomography (MSCT) angiography in the diagnosis and therapy of non-occlusive mesenteric ischemia (NOMI): Could MSCT replace DSA in diagnosis? PloS one. 2018     [PubMed]
Bala M,Kashuk J,Moore EE,Kluger Y,Biffl W,Gomes CA,Ben-Ishay O,Rubinstein C,Balogh ZJ,Civil I,Coccolini F,Leppaniemi A,Peitzman A,Ansaloni L,Sugrue M,Sartelli M,Di Saverio S,Fraga GP,Catena F, Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World journal of emergency surgery : WJES. 2017     [PubMed]
Luther B,Mamopoulos A,Lehmann C,Klar E, The Ongoing Challenge of Acute Mesenteric Ischemia. Visceral medicine. 2018 Jul     [PubMed]
Björck M,Koelemay M,Acosta S,Bastos Goncalves F,Kölbel T,Kolkman JJ,Lees T,Lefevre JH,Menyhei G,Oderich G,Esvs Guidelines Committee,Kolh P,de Borst GJ,Chakfe N,Debus S,Hinchliffe R,Kakkos S,Koncar I,Sanddal Lindholt J,Vega de Ceniga M,Vermassen F,Verzini F,Document Reviewers,Geelkerken B,Gloviczki P,Huber T,Naylor R, Editor's Choice - Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2017 Apr     [PubMed]
Ananthan K,Onida S,Davies AH, Nutcracker Syndrome: An Update on Current Diagnostic Criteria and Management Guidelines. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2017 Jun     [PubMed]
Chen DC,Armstrong EJ,Singh GD,Amsterdam EA,Laird JR, Adherence to guideline-recommended therapies among patients with diverse manifestations of vascular disease. Vascular health and risk management. 2015     [PubMed]
Corcos O,Nuzzo A, Gastro-intestinal vascular emergencies. Best practice     [PubMed]
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 Jun 11     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Podiatry Cert Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Podiatry Cert Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Podiatry Cert Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Podiatry Cert Medicine. When it is time for the Surgery-Podiatry Cert Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Podiatry Cert Medicine.