Mesenteric ischemia
- This article concerns ischemia of the small bowel. See ischemic colitis for ischemia of the large bowel
| Mesenteric ischemia | |
| ICD-10 | K55.9 |
|---|---|
| ICD-9 | 557.9 |
| DiseasesDB | 29034 |
| MedlinePlus | 001156 |
| eMedicine | radio/2726 |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Please Take Over This Page and Apply to be Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [2] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.
Mesenteric ischemia (Mesenteric ischaemia - British English) is a medical condition in which inflammation and injury of the small intestine result from inadequate blood supply.[1][2]. Causes of the reduced blood flow can include changes in the systemic circulation (e.g. low blood pressure) or local factors such as constriction of blood vessels or a blood clot. It is more common in the elderly[3][4].
Diagnosis
It is important to differentiate ischemic colitis, which often resolves on its own, from the more immediately life-threatening condition of acute mesenteric ischemia of the small bowel.
Differential Diagnosis
In alphabetical order. [5] [6]
- Aortic Aneurysm
- Atherosclerosis
- Atrial fibrillation
- Behcet's Syndrome
- Cardiac arrhythmia
- Cardiac thrombus
- Cirrhosis
- Coagulation disorder
- Congestive Heart Failure
- Dermatomyositis
- Drugs
- Endocarditis
- Hemorrhagic blood loss
- Henoch-Schonlein Purpura
- Hypercoagulable state
- Hypotension
- Hypovolemia
- Myocardial Infarction
- Neoplasm
- Peritonitis
- Polyarteritis Nodosa
- Polycythemia Vera
- Progressive systemic sclerosis
- Reiter's Syndrome
- Rheumatoid Arthritis
- Sepsis
- Shock
- Sjogren's Syndrome
- Systemic Lupus Erythematosus
- Trauma
- Valvular Disease
- Vasculitis
- Wegener's Granulomatosis
Signs and symptoms
Three progressive phases of ischemic colitis have been described:[7][8]
- A hyperactive phase occurs first, in which the primary symptoms are severe abdominal pain and the passage of bloody stools. Many patients get better and do not progress beyond this phase.
- A paralytic phase can follow if ischemia continues; in this phase, the abdominal pain becomes more widespread, the belly becomes more tender to the touch, and bowel motility decreases, resulting in abdominal bloating, no further bloody stools, and absent bowel sounds on exam.
- Finally, a shock phase can develop as fluids start to leak through the damaged colon lining. This can result in shock and metabolic acidosis with dehydration, low blood pressure, rapid heart rate, and confusion. Patients who progress to this phase are often critically ill and require intensive care.
Symptoms of mesenteric ischemia vary and can be acute (especially if embolic)[9], subacute, or chronic[10].
Case series report prevalence of clinical findings and provide the best available, yet biased, estimate of the sensitivity of clinical findings[11][12]. In a series of 58 patients with mesenteric ischemia due to mixed causes[12]:
- abdominal pain was present in 95% (median of 24 hours duration). The other three patients presented with shock and metabolic acidosis.
- nausea in 44%
- vomiting in 35%
- diarrhea in 35%
- heart rate > 100 in 33%
- 'blood per rectum' in 16% (not stated if this number also included occult blood - presumably not)
- constipation 7%
In the absence of adequate quantitative studies to guide diagnosis, various heuristics help guide diagnosis:
- Mesenteric ischemia "should be suspected when individuals, especially those at high risk for acute mesenteric ischemia, develop severe and persisting abdominal pain that is disproportionate to their abdominal findings"[2]
- Regarding mesenteric arterial thrombosis or embolism: "...early symptoms are present and are relative mild in 50% of cases for three to four days before medical attention is sought"[13].
- Regarding mesenteric arterial thrombosis or embolism: "Any patient with an arrhythmia such as auricular fibrillation who complains of abdominal pain is hghly suspected of having embolization to the superior mesenteric artery until proved otherwise"[13].
- Regarding nonocclusive intestinal ischemia: "Any patient who takes digitalis and diuretics and who complains of abdominal pain must be considered to have nonocclusive ischemia until proved otherwise"[13].
Blood tests
In a series of 58 patients with mesenteric ischemia due to mixed causes[12]:
- White blood cell count >10.5 in 98% (probably an overestimate as only tested in 81% of patients)
- Lactic acid elevated 91% (probably an overestimate as only tested in 57% of patients)
Plain x-ray
Plain X-rays are often normal or show non-specific findings.[14].
- Bowel wall thickening
- Submucosal focal mural thickening or thumbprinting
- Dilated bowel loops
- Pneumatosis
- Mesenteric or portal venous gas
Computed tomography
Computed tomography (CT scan) is often used.[15][16] The accuracy of the CT scan depends on whether a small bowel obstruction (SBO) is present [17].
SBO absent
- prevalence of mesenteric ischemia 23%
- sensitivity 64%
- specificity 92%
- positive predictive value (at prevalence of 23%) 79%
- negative predictive value (at prevalence of 23%) 95%
SBO present
- prevalence of mesenteric ischemia 62%
- sensitivity 83%
- specificity 93%
- positive predictive value (at prevalence of 62%) 93%
- negative predictive value (at prevalence of 62%) 61%
Findings on CT scan include:
- Mesenteric edema[15]
- Bowel dilatation[15]
- Bowel wall thickening[15]
- Intramural gas[15]
- Mesenteric stranding[18]
Treatment
"Surgical revascularisation remains the treatment of choice for mesenteric ischaemia, but thrombolytic medical treatment and vascular interventional radiological techniques have a growing role" [19].
Prognosis
The prognosis depends on prompt diagnosis (less than 12-24 hours and before gangrene)[1] and the the underlying cause[20]:
- venous thrombosis - 32% mortality
- arterial embolism - 54% mortality
- arterial thrombosis - 77% mortality
- non-occlusive ischemia - 73% mortality
References
- ↑ 1.0 1.1 Brandt LJ, Boley SJ (2000). "AGA technical review on intestinal ischemia. American Gastrointestinal Association". Gastroenterology. 118 (5): 954–68. PMID 10784596.
- ↑ 2.0 2.1 American Gastroenterological Association (2000). "American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia". Gastroenterology. 118 (5): 951–3. PMID 10784595. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3069&nbr=2295
- ↑ Greenwald D, Brandt L, Reinus J (2001). "Ischemic bowel disease in the elderly". Gastroenterol Clin North Am. 30 (2): 445–73. PMID 11432300.
- ↑ McKinsey JF, Gewertz BL (1997). "Acute mesenteric ischemia". Surg. Clin. North Am. 77 (2): 307–18. PMID 9146714.
- ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
- ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
- ↑ Boley, SJ, Brandt, LJ, Veith, FJ. Ischemic disorders of the intestines. Curr Probl Surg 1978; 15:1.
- ↑ Hunter G, Guernsey J (1988). "Mesenteric ischemia". Med Clin North Am. 72 (5): 1091–115. PMID 3045452.
- ↑ Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD (2004). "Acute mesenteric ischemia: a clinical review". Arch. Intern. Med. 164 (10): 1054–62. doi:10.1001/archinte.164.10.1054. PMID 15159262.
- ↑ Font VE, Hermann RE, Longworth DL (1989). "Chronic mesenteric venous thrombosis: difficult diagnosis and therapy". Cleveland Clinic journal of medicine. 56 (8): 823–8. PMID 2691119.
- ↑ Levy PJ, Krausz MM, Manny J (1990). "Acute mesenteric ischemia: improved results--a retrospective analysis of ninety-two patients". Surgery. 107 (4): 372–80. PMID 2321134.
- ↑ 12.0 12.1 12.2 Park WM, Gloviczki P, Cherry KJ, Hallett JW, Bower TC, Panneton JM, Schleck C, Ilstrup D, Harmsen WS, Noel AA (2002). "Contemporary management of acute mesenteric ischemia: Factors associated with survival". J. Vasc. Surg. 35 (3): 445–52. doi:10.1067/mva.2002.120373. PMID 11877691.
- ↑ 13.0 13.1 13.2 Cope's Early Diagnosis of the Acute Abdomen by Zachary Cope and William Silen (2005) - Oxford University Press, USA ISBN 019517545X
- ↑ Smerud M, Johnson C, Stephens D (1990). "Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases". AJR Am J Roentgenol. 154 (1): 99–103. PMID 2104734.
- ↑ 15.0 15.1 15.2 15.3 15.4 Alpern M, Glazer G, Francis I (1988). "Ischemic or infarcted bowel: CT findings". Radiology. 166 (1 Pt 1): 149–52. PMID 3336673.
- ↑ Taourel P, Deneuville M, Pradel J, Régent D, Bruel J (1996). "Acute mesenteric ischemia: diagnosis with contrast-enhanced CT" (PDF). Radiology. 199 (3): 632–6. doi:10.1148/rg.243035084. PMID 8637978.
- ↑ Staunton M, Malone DE (2005). "Can acute mesenteric ischemia be ruled out using computed tomography? Critically appraised topic". Canadian Association of Radiologists journal = Journal l'Association canadienne des radiologistes. 56 (1): 9–12. PMID 15835585.
- ↑ Pereira JM, Sirlin CB, Pinto PS, Jeffrey RB, Stella DL, Casola G (2004). "Disproportionate fat stranding: a helpful CT sign in patients with acute abdominal pain". Radiographics : a review publication of the Radiological Society of North America, Inc. 24 (3): 703–15. doi:10.1148/rg.243035084. PMID 15143223.
- ↑ Sreenarasimhaiah J (2003). "Diagnosis and management of intestinal ischaemic disorders". BMJ. 326 (7403): 1372–6. doi:10.1136/bmj.326.7403.1372. PMID 12816826.
- ↑ Schoots IG, Koffeman GI, Legemate DA, Levi M, van Gulik TM (2004). "Systematic review of survival after acute mesenteric ischaemia according to disease aetiology". The British journal of surgery. 91 (1): 17–27. PMID 14716789.
Template:Skin and subcutaneous tissue symptoms and signs Template:Nervous and musculoskeletal system symptoms and signs Template:Urinary system symptoms and signs Template:Cognition, perception, emotional state and behaviour symptoms and signs Template:Speech and voice symptoms and signs Template:General symptoms and signs