Mesenteric Ischemia

Mesenteric Ischemia – Quick Consult

Last Updated / Reviewed: June 2022

Definition
Key History
Key Physical Exam
Risk Factors for Mesenteric Ischemia
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment

Definition

Mesenteric ischemia is a reduction in intestinal blood flow. There are four causes of mesenteric ischemia: arterial emboli, arterial thrombosis, venous thrombosis or non-occlusive ischemia. Mesenteric ischemia may lead to sepsis, bowel infarction, and death. If diagnosis takes place before infarction occurs mortality is low. Diagnoses made after infarction results in mortality ranging between 70%-90%. Vague nonspecific symptoms make this a challenge to diagnose.

Intestinal ischemia can be divided into acute and chronic, based upon the rate of onset and the degree to which blood flow is compromised. Acute mesenteric ischemia refers to the sudden onset of intestinal hypoperfusion, which can be due to occlusive or nonocclusive obstruction of arterial or venous blood flow. Chronic mesenteric ischemia (also called intestinal angina) refers to episodic or constant intestinal hypoperfusion, which usually develops in patients with mesenteric atherosclerotic disease.

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Key History

Acute severe onset of persistent abdominal pain
Pain can be periumbilical, crampy, dull, diffuse
Pain is often out of proportion to exam findings
A patient with a history of sudden pain followed by forceful bowel evacuation with minimal abdominal signs should be evaluated for mesenteric ischemia.

Sudden onset of pain is often associated with embolic ischemic disease. A slower onset of pain is seen with vasculitis, thrombotic or non-occlusive mesenteric ischemia.
Pain often precedes vomiting.
Chronic mesenteric ischemia may present with abdominal pain after eating, weight loss, nausea, vomiting and diarrhea.

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Physical Exam

The hallmark is pain out of proportion to exam findings.
The abdominal exam may be normal.
Abdominal distention – worsening as ischemia progresses
Heme positive stool – increases in frequency as ischemia progresses

Rebound, tenderness and guarding may be absent.
Later in the presentation the abdomen becomes distended, bowel sounds are absent and peritoneal signs are present.
Foul smelling breath may be present.

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Risk Factors for Mesenteric Ischemia

Advanced age – over 50
Arteriosclerotic disease
Cardiac arrhythmias
Cardiac valvular diseases
Cardiovascular disease
History of abdominal angina
History of abdominal malignancy

History of DVT or other venous thrombosis
Hypercoagulable state – paroxysmal nocturnal hemoglobinuria, factor V Leiden mutation, myeloproliferative syndromes
Low cardiac output states
Systemic vasculitis

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Differential Diagnosis

Gastrointestinal	Genitourinary	Other
Appendiceal neoplasm Abdominal aortic aneurysm Appendicitis Cecal diverticulitis Cholecystitis Cholelithiasis Constipation Crohn's disease Diverticulitis Gastroenteritis GERD GI bleed Hepatitis Intestinal obstruction Intussusception Irritable bowel syndrome Meckel’s diverticulitis Mesenteric adenitis Omental torsion Pancreatitis Peptic ulcer disease Perforated ulcer Peritonitis Small bowel obstruction Typhlitis	Dysmenorrhea Ectopic pregnancy Endometriosis Gynecological Menorrhagia Nephritis Ovarian torsion PID Prostatitis Pyelonephritis Renal colic Ruptured cyst (Mittelschmerz) Testicular torsion Tubal ovarian abscess Twisted ovarian cyst Ureterolithiasis Urinary tract infection	Diabetes ketoacidosis Hemolytic uremic syndromes Henoch-Schönlein purpura Herpes zoster Pneumonia Sickle cell crisis Streptococcal pharyngitis
		Cardiovascular
		CHF Empyema Endocarditis Myocardial infarction Myocarditis Pericarditis Pleurodynia Pneumonitis Pneumothorax Pulmonary Embolism

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Diagnostic Testing

Text / literature information and recommendations include:

Labs:
- Guaiac evaluation
- CBC - may show leukocytosis, elevated hematocrit consistent with hemoconcentration
- Complete metabolic profile (CMP) may demonstrate a metabolic acidosis.
- Serum lactate may be elevated – sensitivity ranging from 77-100%. Elevated serum lactate should raise the suspicion of mesenteric ischemia. Unfortunately the elevation rises after the bowel has necrosed.
- Amylase has been shown to be elevated in about 50% of patients with intestinal ischemia.
- LDH has been shown to be elevated in bowel infarction but does not distinguish between ischemia and infarction.
Imaging:
- Abdominal CT is commonly used to screen hemodynamically stable patients with acute abdominal pain.
- If the index of suspicion for intestinal ischemia is high, consider multi-detector CT angiography or magnetic resonance angiography.
- CT should be performed without oral contrast, which can obscure the mesenteric vessels, obscure bowel wall enhancement, and lead to a delay in diagnosis.
- CT is generally preferred over MR due to related cost, speed and availability.
- More data is needed regarding whether CT or MR is more sensitive related to small thromboemboli and early reversible ischemia.

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Clinical Risk and Safety Pearls

Immediate treatment of hemodynamic status (hypotension, CHF)
Any abdominal pain patient with a metabolic acidosis should be considered for mesenteric ischemia until proven otherwise.
Normal labs do not exclude the diagnosis of mesenteric ischemia
A rectal exam may be of particular use in these patients with abdominal pain. A positive guaiac with no other apparent cause of GI bleeding may increase clinical suspicion for mesenteric ischemia.
A rectal exam is generally required in all patients with abdominal pain. A positive guaiac with no other apparent cause of GI bleeding my increase clinical suspicion for mesenteric ischemia.
Patients with mesenteric ischemia and signs of peritonitis generally require immediate surgical intervention.
This diagnosis is often delayed. Risk of delay can be reduced by maintaining a high clinical suspicion and use of early diagnostic imaging and early surgical consultation.

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Treatment

Common text / literature recommendations include:

Surgical Consult – emergent
IV hydration
Triple antibiotic coverage – clindamycin, genatmycin and metronidazole.
Further treatment is guided by results of the arteriography or multidetector CT scan.
Acute arterial embolus: treatment options include papaverine infusion, surgical embolectomy, and intra-arterial thrombolysis.
Acute arterial thrombosis: treatment options include papaverine infusion and arterial reconstruction either through aortosuperior mesenteric arterial bypass grafting or re-implantation of the SMA to the aorta.
Nonocclusive mesenteric ischemia: treatment is papaverine infusion.
Mesenteric venous thrombosis: treatment is anticoagulation with heparin/warfarin either alone or in combination with surgery.
Chronic mesenteric ischemia: treatment options are angioplasty with or without stent placement or surgical revascularization.
Avoid drugs that decrease mesenteric circulation – digoxin, propranolol, pitressin and vasopressors

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Acosta S, Björck M. Modern treatment of acute mesenteric ischaemia. Br J Surg. 2014; 101:e100.
Acosta S, Alhadad A, Svensson P, Ekberg O. Epidemiology, risk and prognostic factors in mesenteric venous thrombosis. Br J Surg. 2008; 95:1245.
Aschoff AJ, Stuber G, Becker BW, et al. Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography. Abdom Imaging. 2009; 34:345.
Carver TW, Vora RS, Taneja A. Mesenteric ischemia. Crit Care Clin. 2016;32(2):155-171.
Cudnik MT, Darbha S, Jones J, et al. The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis. Acad Emerg Med. 2013; 20:1087.
Demirpolat, G, Oran, I, Tamsel, S, et al. Acute mesenteric ischemia: endovascular therapy. Abdom Imaging 2007; 32:299.
Kärkkäinen JM, Acosta S. Acute mesenteric ischemia (part 1) – Incidence, etiologies and how to improve early diagnosis. Best Pract Res Clin Gastroenterol. 2017;31(1):15-25.
Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: systematic review and meta-analysis. Radiology. 2010; 256:93.
Sise MJ. Acute mesenteric ischemia. Surg Clin North Am. 2014;94(1):165-181.

This is intended solely as reference material and is not a recommendation for any specific patient. The practitioner must rely upon his or her own professional judgment and medical decision-making to determine whether it is relevant in a particular case. Materials are derived from medical and nursing texts, medical literature and national guidelines and should not be considered complete or authoritative. Users must rely on specific patient presentation, experience and judgment when utilizing any of the information contained herein relative to an actual patient.

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