AUTHOR AND EDITOR INFORMATION

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• Introduction
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• Workup
• Treatment
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• Follow-up
• Miscellaneous
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INTRODUCTION

Section 2 of 11  

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Background

Mesenteric ischemia is a relatively rare disorder seen in the emergency department (ED); however, it is an important diagnosis to make because of its high mortality rate. Vague and nonspecific clinical findings and limitations of diagnostic studies make the diagnosis a significant challenge. Moreover, delays in diagnosis lead to increased mortality rates. Despite recent advances in diagnosis and treatment, mortality rates continue to remain high.

Pathophysiology

Mesenteric ischemia is caused by decreased intestinal blood flow that can be caused by a number of mechanisms. Decreased intestinal blood flow results in ischemia and subsequent reperfusion damage at the cellular level that may progress to the development of mucosal injury, tissue necrosis, and metabolic acidosis.

The blood supply to the intestine is derived predominantly from 3 major gastrointestinal arteries that arise from the abdominal aorta: the celiac axis, the superior mesenteric artery (SMA), and the inferior mesenteric artery (IMA). The intestine has significant collateral circulation at all levels that allows for some protection from ischemia and is able to compensate for approximately a 75% acute reduction in mesenteric blood flow for up to 12 hours, without substantial injury.

The pathophysiology of intestinal ischemia can be divided into arterial and venous etiologies and acute and chronic ischemia. The vast majority of cases are secondary to arterial causes. All diseases and conditions that affect arteries, including atherosclerosis, arteritis, aneurysms, arterial infections, dissections, arterial emboli, and thrombosis, are reported to occur in the intestinal arteries.

Acute mesenteric ischemia (AMI) can be further divided into embolic, thrombotic, or nonocclusive causes.

• Arterial embolism
  • Arterial embolism accounts for approximately one third of acute cases of AMI.
  • Emboli to the mesenteric arteries are usually from a dislodged cardiac thrombus.
  • The SMA is most commonly affected with the IMA rarely affected due to its small caliber.
• Arterial thrombosis
  • Arterial thrombosis accounts for approximately one third of acute cases of AMI.
  • It is usually due to acute worsening of ischemia in patients who have preexisting atherosclerosis of the mesenteric arteries.
  • Thrombosis often involves at least 2 of the major splanchnic vessels.
• Nonocclusive etiology
  • Nonocclusive etiology accounts for approximately one third of acute cases of AMI.
  • The primary mechanism is severe and prolonged intestinal vasoconstriction.
  • The most common setting is severe systemic illness with systemic shock usually secondary to reduced cardiac output.
  • Intestinal vasospasm has also been seen to occur in cocaine ingestion, ergot poisoning, digoxin use, and with alpha-adrenergic agonists.
  • A small proportion of cases are from venous thrombosis, seen mostly in patients with hypercoagulable states.
  • Venous thrombosis of the visceral vessels may precipitate an acute ischemic event as compromised venous return leads to interstitial swelling of the bowel wall, with subsequent impedance of arterial flow and eventual tissue necrosis.

Chronic mesenteric ischemia (CMI) usually results from long-standing atherosclerotic disease of 2 or more mesenteric vessels. Other nonatheromatous causes of CMI include the vasculitides such as Takayasu arteritis. Symptoms are caused by the gradual reduction in blood flow to the intestine that occurs during eating since total blood flow to the intestine can increase by 15% during meals.

Frequency

United States

AMI is involved in up to 0.1% of all hospital admissions, although this number is likely to rise as the population ages.

Mortality/Morbidity

• Mortality rates are high and range from 60-100% depending on the source of obstruction. Early and aggressive diagnosis and treatment has been shown to significantly decrease the mortality rate if the diagnosis is made prior to the development of peritonitis.
• One report of 21 patients with SMA embolus, intestinal viability was achieved in 100% of patients before diagnosis if the duration of symptoms was less than 12 hours, in 56% if it was between 12 and 24 hours, and in only 18% if symptoms were more than 24 hours in duration.
• Another study found that even at hospital centers with angiography available 24 hours, mortality rates still were approximately 70%.

Sex

No sex predilection exists.

Age

Mesenteric ischemia is generally a disease of the older population, with the typical age of onset being older than 60 years; however, with risk factors and other predisposing factors, it may be seen in younger patients.

CLINICAL

Section 3 of 11  

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History

• The clinical presentation is largely dependent on the underlying etiology, with AMI and CMI presenting very differently.
• The classic picture of a patient with AMI involves severe abdominal pain with a paucity of significant abdominal findings in patients with significant underlying risk factors.
• Because the pathologic process is ischemia, the pain is initially visceral in nature and generally poorly localized.
• Acute pain may occur if an embolus is the cause, but it is essential to remember that a gradual onset of pain is more common in the overall spectrum of mesenteric ischemia.
• The pain is usually severe and may occasionally be refractory to opioid analgesics.
• Prior episodes of a similar pain, often related to meals (intestinal angina), may be reported.
• Abdominal pain may be absent in 15-25% of cases; associated GI symptoms are common and caution must be taken to not be misled.
• Nausea and vomiting are frequent, and diarrhea may occur in as many as 50% of patients with mesenteric ischemia.
• The classic triad of SMA embolism includes GI emptying, abdominal pain, and underlying cardiac disease.
• Chronic mesenteric ischemia typically causes postprandial abdominal pain and weight loss that results in chronic dull pain as the obstructive process worsens.
• Patients with chronic mesenteric ischemia may also report sitophobia (fear of eating).

Physical

• The sine qua non of mesenteric ischemia is a relatively normal abdominal examination in the face of severe abdominal pain.
• Advanced ischemia may be signified by increasing abdominal distention, ileus, frank peritonitis, and shock.
• Theoretically, before the onset of significant mucosal injury, blood in the GI tract should be absent early in the disease process.
• Melena or hematochezia occurs in 15% of cases, and occult blood is detected in approximately 50% of patients.

Causes

• Acute arterial embolus: Embolic lesions are usually secondary to conditions that predispose the patient to embolus formation such as atrial fibrillation, ventricular aneurysm, and valvular disease.
• Acute arterial thrombosis
• • Acute arterial thrombosis usually occurs following a superimposed insult in patients with preexisting atherosclerosis.
  • Other causes include aortic aneurysm, aortic dissection, and arteritis.
• Nonocclusive ischemia
• • The causes of nonocclusive mesenteric ischemia include all of the causes of splanchnic vasoconstriction including hypovolemia, cardiac shock, sepsis, alpha-agonism, ergots, cocaine, and digitalis.
  • Case reports exist of marathon runners developing ischemic colitis following a marathon that resolved in most runners with supportive treatment.
• Mesenteric venous thrombosis
• • Approximately 75% of patients with mesenteric venous thrombosis have an underlying hypercoagulable state or other risk factors including portal hypertension, intra-abdominal sepsis, cirrhosis, pancreatitis, malignancy, and trauma.
  • Oral contraceptive use accounts for 9-18% of the episodes of mesenteric venous thrombosis in young women.

DIFFERENTIALS

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Other Problems to be Considered

Crohn disease colitis
Ulcerative colitis
Perforated viscus
Appendicitis
Pancreatitis
Diverticulitis
Volvulus
Bowel obstruction
Abdominal aortic aneurysm
Hepatobiliary disease

WORKUP

Section 5 of 11  

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Lab Studies

• No laboratory test sufficiently rules in or rules out the diagnosis of mesenteric ischemia. Laboratory findings in mesenteric ischemia are nonspecific and generally unreliable.
• Of patients with AMI, 75% have a leukocytosis greater than 15,000 cells/mm³.
• Elevated serum lactate level raises the suspicion of intestinal ischemia; however, elevation of lactate is often a late finding. One small study found that increased plasma lactate concentration had a sensitivity of 96% (24/25) for recognizing AMI in patients with abdominal complaints.
• Several studies have found that serum D-dimer may be used as an early marker for AMI, although it appears to be insensitive.

Imaging Studies

• The American Gastroenterological Association in 2000 released recommended algorithms for the diagnosis and management of mesenteric ischemia (see below). However, this was prior to improved data on multidetector computed tomography (CT) scans, which now have a greater role in the diagnosis of mesenteric ischemia.
• Plain films
• • Plain abdominal radiographs are generally normal or nonspecific and therefore should not be used to rule out mesenteric ischemia. Thumbprinting, pneumatosis intestinalis, or portal venous gas raises the suspicion for mesenteric ischemia, though these are findings that are found later in the disease process.
  • Plain films are best used for rapid identification of intestinal obstruction or perforation and to hasten surgical intervention.
• CT scan
• • Multidetector row CT has emerged as a valuable tool for the evaluation of mesenteric ischemia. Multidetector row CT and 3-dimensional imaging provide a detailed examination of small bowel and mesenteric vessels. Multiple studies have shown a sensitivity ranging from 96-100% and specificity ranging from 89-94%. Findings of AMI included mesenteric arterial or venous thrombus, mesenteric venous gas, pneumatosis intestinalis, bowel-wall thickening, increased or decreased enhancement of the bowel wall, bowel dilatation, mesenteric or perienteric fat stranding, ascites, pneumoperitoneum, and solid organ infarction.
  • CT scan of the abdomen is the diagnostic test of choice if suspicion for mesenteric venous thrombosis is high; sensitivities are greater than 90%. CT findings include a central lucency in the mesenteric vein, enlargement of the superior mesenteric vein, and a sharply defined vein wall with a rim of increased density.
• Angiography
• • For many years, angiography has been considered to be the criterion standard for the diagnosis of acute arterial occlusion.
  • Abrupt cutoff of the SMA with the absence of collateral circulation is diagnostic, with nearly 100% sensitivity in acute embolic occlusion.
  • Angiography has the added advantage of therapeutic options as well, including administration of intra-arterial thrombolytic agents for acute arterial thrombosis as well as intra-arterial papaverine infusion for all types of arterial ischemia.
  • The disadvantages of angiography are that it is highly invasive and is not suitable in critically ill patients, often is not readily available and may delay surgical management, and nephrotoxicity may occur due to the effects of intravenous contrast on the kidneys. Angiography also has a relatively high false-negative rate in patients presenting early in the course of the disease.
  • Despite the disadvantages, if suspicion for AMI is high, the EP should aggressively pursue angiography as the diagnostic study of choice.
  • Prompt laparotomy is indicated in patients with suspected AMI in whom expeditious angiography is not available.
  • If suspicion of mesenteric venous thrombosis is high, such as in a patient with a history of hypercoagulable state, angiography is not indicated. CT scan of the abdomen is the diagnostic test of choice in this situation.
• MRI
• • MRI has been evaluated for the diagnosis of CMI and has been shown to have accurate imaging of the mesenteric vasculature. However, in the acute setting, MRI does not have much benefit over CT imaging.
  • MRI should not be the initial test in the ED due to time constraints.
• Ultrasonography
• • Duplex ultrasonography has shown promising results as a screening tool for the diagnosis of CMI. However, the utility of these tests are largely dependent on operator training, bowel gas patterns, and patient body habitus.
  • For all practical purposes, ultrasonography should not be the initial diagnostic choice for the EP.

Procedures

• Nasogastric decompression: The placement of a nasogastric tube is diagnostically useful, both to evaluate the presence of blood, and therapeutically, to relieve distention secondary to ileus.
• The placement of a central line may be useful in hemodynamically unstable patients.

TREATMENT

Section 6 of 11  

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Prehospital Care

• Cardiac monitor, intravenous access, oxygen
• May require intravenous fluid resuscitation

Emergency Department Care

• Resuscitation
• • Resuscitation is often needed because patients are usually very toxic or rapidly become toxic.
  • Early intubation in unstable patients may improve oxygenation and allow for more aggressive fluid resuscitation.
  • Parenteral opioid analgesics
  • Parenteral broad-spectrum antibiotics
• All cases of mesenteric ischemia with signs of peritonitis, regardless of the etiology, generally require immediate surgical intervention for the resection of ischemic or necrotic intestines.
• Intra-arterial papaverine during angiography can be used regardless of the etiology of the intestinal ischemia. Papaverine is an opium derivative that functions as a phosphodiesterase inhibitor, which acts to relax vascular smooth muscle. It is usually infused directly into the SMA, thus improving intestinal blood flow.
• Definitive treatment is generally withheld by the EP until an etiology is determined. In cases of mesenteric ischemia, time is of the utmost essence. Treatment options depend on the etiology of intestinal ischemia as well as the hemodynamic stability of the patient.
• Definitive treatment
• • For acute arterial embolus, options include papaverine infusion, surgical embolectomy, and intra-arterial thrombolysis.
  • For acute arterial thrombosis, options include papaverine infusion and arterial reconstruction either through aortosuperior mesenteric arterial bypass grafting or reimplantation of the SMA to the aorta.
  • For nonocclusive mesenteric ischemia, papaverine infusion is the mainstay of treatment.
  • For mesenteric venous thrombosis, anticoagulation with heparin/warfarin either alone or in combination with surgery.
  • For chronic mesenteric ischemia, management options include angioplasty with or without stent placement or surgical revascularization. Several studies have found a high rate of success with percutaneous stent revascularization for CMI, although repeated interventions may be necessary.

Consultations

• Vascular surgery - Given the need for early diagnosis and treatment, the EP should obtain surgical consultation as soon as the diagnosis is considered.
• Interventional radiology - Angiography and adjunctive treatment
• Intensivist - Patients diagnosed with mesenteric ischemia are often hemodynamically unstable or have a high probability to progress to instability, so most patients require hospitalization in an intensive care unit.

MEDICATION

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The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Drug Category: Antibiotic

Therapy must cover all likely pathogens in the context of the clinical setting.

Drug Category: Vasodilators

These agents can improve blood supply to ischemic areas.

FOLLOW-UP

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Further Inpatient Care

• Admit to the ICU.
• Invasive monitoring may be required.
• Broad-spectrum antibiotics should be continued if the diagnosis is confirmed.
• Indications for surgical management of acute or chronic mesenteric ischemia include peritonitis, massive hemorrhage, recurrent fever or sepsis, continuation of symptoms beyond 2-3 weeks, chronic protein-losing colopathy, chronic segmental colitis with ulceration, and symptomatic ischemic stricture.

Transfer

• Transfer is appropriate if the required imaging studies or therapeutic interventions are not available.

Complications

• Sepsis/septic shock
• Multiple system organ failure
• Bowel necrosis requiring resection
• Death

Prognosis

• Mortality rates range from 60-100%, depending on the source of obstruction.
• Predictors of mortality included older age, bandemia, hepatic and renal impairment, hyperamylasemia, metabolic acidosis, hypoxia, intramural pneumatosis, and sepsis.
• With an aggressive diagnostic and therapeutic approach, mortality can be reduced. It is essential to act early on clinical suspicion and not to wait for the development of hard evidence.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Because of the high mortality rate and the difficulty of diagnosis, mesenteric ischemia poses a significant legal risk.
• Legal risk is reduced with high clinical suspicion, early and aggressive diagnostic imaging, and early surgical consult with clear documentation of timing.
• One review of 180 consecutive malpractice claims found 7 cases involving AMI with 5 cases alleging failure to make a timely diagnosis, failure to administer anticoagulation in 1 case, and failure to prevent nonocclusive mesenteric ischemia in 1 case (Fink, 2000).

MULTIMEDIA

Section 10 of 11  

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Media file 1:  Pneumatosis intestinalis is one of the few radiographic findings in patients with mesenteric ischemia.
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Media type:  X-RAY

Media file 2:  Diagnosis and treatment of intestinal ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternate management plan. DVT, deep vein thrombosis; SMA, superior mesenteric artery. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
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Media type:  Graph

Media file 3:  Diagnosis and treatment of intestinal ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternate management plan. DVT, deep vein thrombosis; SMA, superior mesenteric artery. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
	View Full Size Image
Media type:  Graph

Media file 4:  Management of chronic mesenteric ischemia (CMI). Solid lines indicate accepted management plan; dashed lines indicate alternative management plan. MRA, magnetic resonance angiography; CT, computerized tomography. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
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Media type:  Graph

Media file 5:  Management of colon ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternative management plan. BE, barium enema; NPO, nothing by mouth; PLC, protein-losing colopathy; IBD, inflammatory bowel disease.Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
	View Full Size Image
Media type:  Graph

REFERENCES

Section 11 of 11

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Article Last Updated: Jul 15, 2008