Mesenteric ischemia causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Overview

Narrowing of the arteries that supply blood to the intestine causes mesenteric ischemia. The arteries that supply blood to the intestines travel straight from the aorta. Mesenteric ischemia is often seen in people who have hardening of the arteries in other parts of the body (for example, those with coronary artery disease or peripheral vascular disease). The condition is more common in smokers and in patients with high blood pressure or high blood cholesterol. Mesenteric ischemia can also be caused by an embolus that suddenly blocks one of the mesenteric arteries. The emboli usually come from the heart or aorta. These clots are more commonly seen in patients with arrhythmias, such as atrial fibrillation.

Causes

Mesenteric ischemia is classified into four categories. Each category has their own cause:^[1]^[2]^[3]^[4]^[5]^[6]^[7]^[8]^[9]^[10]^[11]^[12]^[13]

Classification based on etiology
Etiology	Cause	Incidence	Examples	Mechanism
Occlusive causes	Arterial embolism	50-70%	Superior mesenteric artery obstruction (most common cause) Arrhythmia Myocardial infarction Infective endocarditis Valvular heart diseases Ventricular aneurysms History of embolic events Recent angiography	Acute mesenteric arterial embolism: Attributes to 50% cases of mesenteric ischemia. Mesenteric embolus can originate from the left atrium, associated with cardiac arrythmias such as atrial fibrillation. Recent myocardial infarction resulting in segmental wall motion abnormality leading to poor ejection fraction and embolus formation. Infective endocarditis: vegetations on the cardiac valves resulting in turbulence in blood flow predisposing to formation of emboli into the blood stream.
	Arterial thrombosis	15-25%	Atherosclerosis Advanced age Prolonged hypotension Hypercoagulabilty states Peripheral arterial disease Traumatic injury	Acute mesenteric arterial thrombosis: 25% cases of mesenteric ischemia result from mesenteric arterial thrombosis. Most likely due to underlying atherosclerosis(plaque formation) leading to stenosis. An underlying plaque(fatty streak) in the superior mesenteric artery leads to critical stenosis over the years forming collaterals.
	Venous thrombosis	5%	Right-sided heart failure Previous deep venous thrombosis (20-40% risk) Primary clotting disorder Pancreatitis Polycythemia Sickle cell anemia Recent abdominal surgery or infection Visceral infections Perforated viscus Inherited thrombophilia- Factor V Leidin mutation Prothrombin G20210A mutation Protein S deficiency Antithrombin III deficiency Activated protein C resistance Anti-phospholipid syndrome Myeloproliferative disorders(JAK2 V617F) mutation.	Mesenteric venous thrombosis: Thrombosis is attributed to the combination of virchow's triad: Stasis Vascular inflammation Hypercoagulability
Non-Occlusive causes	Non-occlusive ischemia	20-30%	Low cardiac output states(most common cause) Hypovolemia Vasoconstrictive drugs (Digoxin, alpha-adrenergic agonists) Septic shock Aortic insufficiency Cocaine abuse or ergot poisoning Inflammatory bowel disease	Occurs mainly because of superior mesenteric artery vasoconstriction leading to low splanchnic blood flow.
Rare causes	Splanchnic artery stenosis Superior mesenteric artery syndrome

References

↑ Reinus JF, Brandt LJ, Boley SJ (1990). "Ischemic diseases of the bowel". Gastroenterol Clin North Am. 19 (2): 319–43. PMID 2194948.
↑ Di Fabio F, Obrand D, Satin R, Gordon PH (2009). "Intra-abdominal venous and arterial thromboembolism in inflammatory bowel disease". Dis Colon Rectum. 52 (2): 336–42. doi:10.1007/DCR.0b013e31819a235d. PMID 19279432.
↑ Ha C, Magowan S, Accortt NA, Chen J, Stone CD (2009). "Risk of arterial thrombotic events in inflammatory bowel disease". Am J Gastroenterol. 104 (6): 1445–51. doi:10.1038/ajg.2009.81. PMID 19491858.
↑ Stone JR, Wilkins LR (2015). "Acute mesenteric ischemia". Tech Vasc Interv Radiol. 18 (1): 24–30. doi:10.1053/j.tvir.2014.12.004. PMID 25814200.
↑ Acosta S, Ogren M, Sternby NH, Bergqvist D, Björck M (2006). "Fatal nonocclusive mesenteric ischaemia: population-based incidence and risk factors". J Intern Med. 259 (3): 305–13. doi:10.1111/j.1365-2796.2006.01613.x. PMID 16476108.
↑ Acosta S, Ogren M, Sternby NH, Bergqvist D, Björck M (2005). "Clinical implications for the management of acute thromboembolic occlusion of the superior mesenteric artery: autopsy findings in 213 patients". Ann Surg. 241 (3): 516–22. PMC 1356992. PMID 15729076.
↑ Acosta S (2015). "Mesenteric ischemia". Curr Opin Crit Care. 21 (2): 171–8. doi:10.1097/MCC.0000000000000189. PMID 25689121.
↑ ter Steege RW, Sloterdijk HS, Geelkerken RH, Huisman AB, van der Palen J, Kolkman JJ (2012). "Splanchnic artery stenosis and abdominal complaints: clinical history is of limited value in detection of gastrointestinal ischemia". World J Surg. 36 (4): 793–9. doi:10.1007/s00268-012-1485-4. PMC 3299959. PMID 22354487.
↑ Otte JA, Huisman AB, Geelkerken RH, Kolkman JJ (2008). "Jejunal tonometry for the diagnosis of gastrointestinal ischemia. Feasibility, normal values and comparison of jejunal with gastric tonometry exercise testing". Eur J Gastroenterol Hepatol. 20 (1): 62–7. doi:10.1097/MEG.0b013e3282ef633a. PMID 18090993.
↑ Uemura S, Suzuki K, Katayama N, Imai H (2017). "Superior mesenteric artery syndrome leading to reversible mucosal gangrene". Acute Med Surg. 4 (3): 375–376. doi:10.1002/ams2.283. PMC 5674473. PMID 29123896.
↑ Moore HB, Moore EE, Lawson PJ, Gonzalez E, Fragoso M, Morton AP; et al. (2015). "Fibrinolysis shutdown phenotype masks changes in rodent coagulation in tissue injury versus hemorrhagic shock". Surgery. 158 (2): 386–92. doi:10.1016/j.surg.2015.04.008. PMC 4492895. PMID 25979440.
↑ Cohn DM, Roshani S, Middeldorp S (2007). "Thrombophilia and venous thromboembolism: implications for testing". Semin Thromb Hemost. 33 (6): 573–81. doi:10.1055/s-2007-985753. PMID D 17768689 D Check |pmid= value (help).
↑ Aschoff AJ, Stuber G, Becker BW, Hoffmann MH, Schmitz BL, Schelzig H; et al. (2009). "Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography". Abdom Imaging. 34 (3): 345–57. doi:10.1007/s00261-008-9392-8. PMID 18425546.

[pmid2194948-1] Reinus JF, Brandt LJ, Boley SJ (1990). "Ischemic diseases of the bowel". Gastroenterol Clin North Am. 19 (2): 319–43. PMID 2194948.

[pmid19279432-2] Di Fabio F, Obrand D, Satin R, Gordon PH (2009). "Intra-abdominal venous and arterial thromboembolism in inflammatory bowel disease". Dis Colon Rectum. 52 (2): 336–42. doi:10.1007/DCR.0b013e31819a235d. PMID 19279432.

[pmid19491858-3] Ha C, Magowan S, Accortt NA, Chen J, Stone CD (2009). "Risk of arterial thrombotic events in inflammatory bowel disease". Am J Gastroenterol. 104 (6): 1445–51. doi:10.1038/ajg.2009.81. PMID 19491858.

[pmid25814200-4] Stone JR, Wilkins LR (2015). "Acute mesenteric ischemia". Tech Vasc Interv Radiol. 18 (1): 24–30. doi:10.1053/j.tvir.2014.12.004. PMID 25814200.

[pmid16476108-5] Acosta S, Ogren M, Sternby NH, Bergqvist D, Björck M (2006). "Fatal nonocclusive mesenteric ischaemia: population-based incidence and risk factors". J Intern Med. 259 (3): 305–13. doi:10.1111/j.1365-2796.2006.01613.x. PMID 16476108.

[pmid15729076-6] Acosta S, Ogren M, Sternby NH, Bergqvist D, Björck M (2005). "Clinical implications for the management of acute thromboembolic occlusion of the superior mesenteric artery: autopsy findings in 213 patients". Ann Surg. 241 (3): 516–22. PMC 1356992. PMID 15729076.

[pmid25689121-7] Acosta S (2015). "Mesenteric ischemia". Curr Opin Crit Care. 21 (2): 171–8. doi:10.1097/MCC.0000000000000189. PMID 25689121.

[pmid22354487-8] ter Steege RW, Sloterdijk HS, Geelkerken RH, Huisman AB, van der Palen J, Kolkman JJ (2012). "Splanchnic artery stenosis and abdominal complaints: clinical history is of limited value in detection of gastrointestinal ischemia". World J Surg. 36 (4): 793–9. doi:10.1007/s00268-012-1485-4. PMC 3299959. PMID 22354487.

[pmid18090993-9] Otte JA, Huisman AB, Geelkerken RH, Kolkman JJ (2008). "Jejunal tonometry for the diagnosis of gastrointestinal ischemia. Feasibility, normal values and comparison of jejunal with gastric tonometry exercise testing". Eur J Gastroenterol Hepatol. 20 (1): 62–7. doi:10.1097/MEG.0b013e3282ef633a. PMID 18090993.

[pmid29123896-10] Uemura S, Suzuki K, Katayama N, Imai H (2017). "Superior mesenteric artery syndrome leading to reversible mucosal gangrene". Acute Med Surg. 4 (3): 375–376. doi:10.1002/ams2.283. PMC 5674473. PMID 29123896.

[pmid25979440-11] Moore HB, Moore EE, Lawson PJ, Gonzalez E, Fragoso M, Morton AP; et al. (2015). "Fibrinolysis shutdown phenotype masks changes in rodent coagulation in tissue injury versus hemorrhagic shock". Surgery. 158 (2): 386–92. doi:10.1016/j.surg.2015.04.008. PMC 4492895. PMID 25979440.

[pmid17768689_D-12] Cohn DM, Roshani S, Middeldorp S (2007). "Thrombophilia and venous thromboembolism: implications for testing". Semin Thromb Hemost. 33 (6): 573–81. doi:10.1055/s-2007-985753. PMID D 17768689 D Check |pmid= value (help).

[pmid18425546-13] Aschoff AJ, Stuber G, Becker BW, Hoffmann MH, Schmitz BL, Schelzig H; et al. (2009). "Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography". Abdom Imaging. 34 (3): 345–57. doi:10.1007/s00261-008-9392-8. PMID 18425546.

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Mesenteric ischemia causes

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