Mesenteric ischemia overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
Historical Perspective
In 1843, Tiedemann described mesenteric occlusion and bowel infarction, followed by Virchow who added two more patients to the literature. In 1921, Klein wrote a thesis on embolism and thrombosis, in which he pointed out a relationship between SMA stenosis and episodic abdominal pain. In 1936, Dunphy was the first one to establish an association between mesenteric artery occlusion and bowel infarction. In 1971, The first book written on all aspects of mesenteric ischemia named 'Vascular Disorders of the Intestines was published and edited by Boley, Schwartz, and Williams.
Classification
Mesenteric ischemia (MI) is classied into various subdivisions based on the difference in pathogenesis and treatment of each type. MI is primarily classified into acute and chronic, on the basis of severity; occlusive and non occlusive based on their pathophysiology.
Pathophysiology
The factors that regulate the intestinal blood flow play a vital role in the development of mesenteric ischemia. Mucosa of the intestines has a high metabolic activity and accordingly a high blood flow requirement. The majority of blood supply of the intestine comes from the superior mesenteric artery, with a collateral blood supply from superior and inferior pancreaticoduodenal arteries (branches of the celiac artery) as well as the inferior mesenteric artery. The splanchnic circulation (arteries supplying the viscera) receives 15-35% of the cardiac output, making it sensitive to the effects of decreased perfusion. Mesenteric ischemia occurs when intestinal blood supply is compromised by more than 50% of the original blood flow without activation of adaptive responses. This can lead to disruption of mucosal barrier, allowing the release of bacterial toxins (present in the intestinal lumen) and vasoactive mediators which ultimately lead to complete necrosis (cell death) of the intestinal mucosa. This can further progress to depression in myocardial activity, sepsis, multiorgan failure, and without prompt intervention, even death.
Causes
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 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.