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Acute mesenteric ischemia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: Intestinal ischemia; intestinal ischaemia; bowel ischemia; bowel ischaemia

Overview

Overview

Classification

Classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Rim Halaby

Overview

Acute mesenteric ischemia can be classified into three main groups according to the different underlying causes: occlusive arterial, occlusive venous and non occlusive acute mesenteric ischemia. Each of these types has a characteristic clinical presentation and a different management plan.

Classification

1- Occlusive Arterial Acute Mesenteric Ischemia

2- Occlusive Venous Acute Mesenteric Ischemia

  • Thrombosis in mesenteric portal veins

3- Non occlusive Mesenteric Ischemia

  • Systemic decrease in blood flow with associated constriction of the mesenteric vasculature.[1]

References

  1. ↑ Klar E, Rahmanian PB, Bücker A, Hauenstein K, Jauch KW, Luther B: Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int 2012; 109(14): 249–56. DOI: 10.3238/arztebl.2012.0249
Pathophysiology

Pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby

Overview

Acute mesenteric ischemia is caused by a sudden decrease in the blood flow to the small bowels leading to reperfusion and hypoxic injuries. The main protective mechanism, which is the supply of blood by collateral vessels, becomes no longer effective as the mesenteric vasculature constricts in response to ischemia. Hypoperfusion is caused either by occlusive or non occlusive causes.

Pathophysiology

  • The main mechanism underlying mesenteric ischemia is decreased blood flow to the small intestine. The decrease in blood flow can be caused by:
    • Occlusion
    • Systemic hypoperfusion
    • Spasm in the mesentery
  • When blood flow to the mesentery decreases, collateral vessels try to compensate. However, following prolonged decrease in blood flow, vasoconstriction of the mesenteric vessels occurs leading to decreased blood flow in the collaterals, which were initially the main protective mechanism against ischemia.[1]
  • It is worth mentioning that mesenteric vessel vasoconstriction can persist after the blood flow is restored which explains the use of vasodilator in the management of acute mesenteric ischemia.[1]
  • Ischemia associated injury to the mesentery is either reperfusion injury when the ischemia occurs for a brief period of time or hypoxic injury when the ischemia occurs for a prolonged time.[1][2]
Shown below is a diagram depicting the pathophysiology of acute mesenteric ischemia.
Pathophysiology of acute mesenteric ischemia: decreased blood flow complicated by vasospasm of the mesenteric vasculature
Pathophysiology of acute mesenteric ischemia: decreased blood flow complicated by vasospasm of the mesenteric vasculature

Mesenteric Arterial Occlusion

  • Decreased blood flow in arterial occlusion occurs when the vessel, mainly superior mesenteric artery, is blocked by an embolism that has originated from the left heart or from a thrombus that has formed secondary to atherosclerosis, trauma or infection.[1][3]
  • Strangulation of the small bowels might also lead to occlusion of the mesenteric arteries and subsequent ischemia.

Mesenteric Venous Occlusion

  • Decreased blood flow to the mesentery in venous occlusion occurs with a sequence of events different from that of arterial occlusion. In hypercoagulable states, whether inherited or acquired, a blood clot is formed in the venous mesenteric vasculature. When the venous blood clot is formed, the resistance in the venous blood flow of the mesentery increases with subsequent increase in the fluid movement across the blood vessels. The result is bowel edema and systemic hypotension that leads to systemic hypoperfusion to the different organs, including the mesentery.[4]

Non Occlusive Mesenteric Ischemia

  • Non occlusive mesenteric ischemia occurs when the blood flow to the mesentery decreases secondary to systemic hypoperfusion complicated by secondary mesenteric vasospasm. Non occlusive acute mesenteric ischemia occurs mainly in elderly with multiple cardiovascular risks and cardiovascular comorbidities in the setting of hypotension secondary to medication use, sepsis, myocardial infarction, congestive heart failre, kidney or liver failure. When hypotension occurs, the blood flow to the mesentery decreases and then it is complicated by further constriction of the mesenteric vasculature.[5]
  • Cocaine can be a cause of non occlusive acute mesenteric ischemia.[6]

References

  1. ↑ 1.0 1.1 1.2 1.3 Reinus JF, Brandt LJ, Boley SJ (1990). “Ischemic diseases of the bowel”. Gastroenterol Clin North Am. 19 (2): 319–43. PMID 2194948.
  2. ↑ Lapchak PH, Kannan L, Ioannou A, Rani P, Karian P, Dalle Lucca JJ; et al. (2012). “Platelets orchestrate remote tissue damage after mesenteric ischemia-reperfusion”. Am J Physiol Gastrointest Liver Physiol. 302 (8): G888–97. doi:10.1152/ajpgi.00499.2011. PMID 22301111.
  3. ↑ Rosenblum JD, Boyle CM, Schwartz LB (1997). “The mesenteric circulation. Anatomy and physiology”. Surg Clin North Am. 77 (2): 289–306. PMID 9146713.
  4. ↑ Haglund U. Mesenteric ischemia. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: http://www.ncbi.nlm.nih.gov/books/NBK6883/
  5. ↑ Trompeter M, Brazda T, Remy CT, Vestring T, Reimer P (2002). “Non-occlusive mesenteric ischemia: etiology, diagnosis, and interventional therapy”. Eur Radiol. 12 (5): 1179–87. doi:10.1007/s00330-001-1220-2. PMID 11976865.
  6. ↑ Sudhakar CB, Al-Hakeem M, MacArthur JD, Sumpio BE (1997). “Mesenteric ischemia secondary to cocaine abuse: case reports and literature review”. Am J Gastroenterol. 92 (6): 1053–4. PMID 9177533.
Causes

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby

Overview

Acute mesenteric ischemia is caused in 50% of the cases by an embolism in the arterial mesenteric vasculature and in 30 % of the cases by a thrombus. 5% of the cases of acute mesenteric ischemia are caused by venous occlusion due to hypercoagulable state. In 20 to 30% of the cases, acute mesenteric ischemia is non occlusive and is caused by decreased systemic perfusion in the setting of an elderly patients with multiple co-morbidities and under treatment with medications that affect the effective circulatory volume such as diuretics.[1][2][3]

Causes

Occlusive Arterial Acute Mesenteric Ischemia (65-75%)

Occlusive Venous Acute Mesenteric Ischemia (5%)

Non Occlusive Mesenteric Ischemia (20-30%)

References

  1. ↑ 1.0 1.1 1.2 1.3 Klar E, Rahmanian PB, Bücker A, Hauenstein K, Jauch KW, Luther B: Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int 2012; 109(14): 249–56. DOI: 10.3238/arztebl.2012.0249
  2. ↑ 2.0 2.1 Reinus JF, Brandt LJ, Boley SJ (1990). “Ischemic diseases of the bowel”. Gastroenterol Clin North Am. 19 (2): 319–43. PMID 2194948.
  3. ↑ 3.0 3.1 Rosenblum JD, Boyle CM, Schwartz LB (1997). “The mesenteric circulation. Anatomy and physiology”. Surg Clin North Am. 77 (2): 289–306. PMID 9146713.
  4. ↑ 4.0 4.1 4.2 Haglund U. Mesenteric ischemia. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: http://www.ncbi.nlm.nih.gov/books/NBK6883/
Differentiating Acute mesenteric ischemia from other Diseases

Differentiating Acute mesenteric ischemia from other Diseases

Epidemiology and Demographics

Epidemiology and Demographics

Risk Factors

Risk Factors

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Rim Halaby

Overview

Acute mesenteric ischemia can be grossly divided into three main pathologies, each of which have different risk factors. Occlusive arterial mesenteric ischemia has mainly heart related problems like atrial fibrillation, CAD and heart failure as risk factors. Occlusive venous mesenteric ischemia is associated with inherited and acquired hypercoagulable state. As for non occlusive mesentenric ischemia, it is associated with digitalis use and conditions associated with systemic hypoperfusion.

Risk Factors

Occlusive Arterial Acute Mesenteric Ischemia

Occlusive venous Acute Mesenteric Ischemia

Inherited Hypercoagulable State

Acquired Hepercoagulable State

Non Occlusive Acute Mesenteric Ischemia

References

  1. ↑ 1.0 1.1 1.2 Brandt LJ, Boley SJ (2000). “AGA technical review on intestinal ischemia. American Gastrointestinal Association”. Gastroenterology. 118 (5): 954–68. PMID 10784596.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Klar E, Rahmanian PB, Bücker A, Hauenstein K, Jauch KW, Luther B: Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int 2012; 109(14): 249–56. DOI: 10.3238/arztebl.2012.0249
  3. ↑ Schoots IG, Koffeman GI, Legemate DA, Levi M, van Gulik TM: Systematic review of survival after acute mesenteric ischaemia according to disease aetiology. Br J Surg 2004; 91: 17–27.
  4. ↑ Reinus JF, Brandt LJ, Boley SJ (1990). “Ischemic diseases of the bowel”. Gastroenterol Clin North Am. 19 (2): 319–43. PMID 2194948.
  5. ↑ Haglund U. Mesenteric ischemia. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: http://www.ncbi.nlm.nih.gov/books/NBK6883/
Natural History, Complications and Prognosis

Natural History, Complications and Prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby

Overview

Acute mesenteric ischemia is an emergency that is associated with high rate of mortality as the treatment id delayed. The early initiation of treatment is associated with low mortality rate ranging from 0 to 10%; whereas delayed treatment beyond 24 hours from the onset of symptoms carries an elevated mortality rate that reaches 80 to 100%[1]. Bad prognostic factors are increased age, presence of comorbidities, non occlusive mesenteric ischemia and a delay initiation in the initiation of treatment.[2]

Natural History, Complications and Prognosis

Mortality

  • The mortality associated with acute mesenteric ischemia ranges in general from 50 to 70%, which makes this disease an emergency requiring prompt diagnosis and initiation of treatment.[3]
  • Acute mesenteric ischemia is associated with such an elevated mortality rate because of:
    • The pathophysiology of the disease itself and effects of hypoxia on the survival of cells of the mesentery
    • Delay in diagnosis
    • Delay in treatment[4]
Shown below is a graph depicting the mortality rate in acute mesenteric ischemia depending on the time of initiation of treatment.
Mortality in acute mesenteric ischemia
Mortality in acute mesenteric ischemia

Prognosis

The prognostic factors in acute mesenteric ischemia includes the following:

Delay in diagnosis and treatment:

The early initiation of treatment is associated with low mortality rate ranging from 0 to 10%; whereas delayed treatment beyond 24 hours from the onset of symptoms carries an elevated mortality rate that reaches 80 to 100%.[5]

Location of ischemia:

Ischemia in the peripheral portion of the mesentery are associated with worse prognosis compared to ischemia in the central parts of the small intestine due to the presence of collateral vessels.[2]

Underlying cause and pathophysiology:

Non occlusive mesenteric ischemia is associated with worse prognosis compared to occlusive mesenteric ischemia because nonocclusive mesenteric ischemia usually has a non typical presentation causing a delay in diagnosis and treatment.[2]

Mesenteric thrombosis is associated with less mortality compared to superior mesenteric artery ischemia.[6]

Age of the patient:

Elderly patients have higher risk of mortality compared to younger patients.

Comorbidities

Shown below is an image depicting bad prognostic signs in acute mesenteric ischemia.
Bad prognostic signs in acute mesenteric ischemia
Bad prognostic signs in acute mesenteric ischemia

References

  1. ↑ Paes E, Vollmar JF, Hutschenreiter S, Schoenberg MH, Schölzel E: Diagnostik und Therapie des akuten Mesenterialinfarktes. Chir Gastroenterol 1990; 6: 473–80.
  2. ↑ 2.0 2.1 2.2 Klar E, Rahmanian PB, Bücker A, Hauenstein K, Jauch KW, Luther B: Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int 2012; 109(14): 249–56. DOI: 10.3238/arztebl.2012.0249
  3. ↑ Acosta S: Epidemiology of mesenteric vascular disease: clinical implications. Semin Vasc Surg 2010; 23: 4–8.
  4. ↑ Kortmann B, Klar E: Warum wird die mesenteriale Ischämie zu spät erkannt? Zentralbl Chir 2005; 130: 223–6.
  5. ↑ Paes E, Vollmar JF, Hutschenreiter S, Schoenberg MH, Schölzel E: Diagnostik und Therapie des akuten Mesenterialinfarktes. Chir Gastroenterol 1990; 6: 473–80.
  6. ↑ Brandt LJ, Boley SJ (2000). “AGA technical review on intestinal ischemia. American Gastrointestinal Association”. Gastroenterology. 118 (5): 954–68. PMID 10784596.
Diagnosis

Diagnosis

Guidelines for Diagnosis | History and Symptoms | Physical Examination | Laboratory Findings | Angiography | CT | MRA

Treatment

Treatment

Guidelines for Treatment | Medical Therapy | Surgery | Primary Prevention

Case Studies

Case Studies

Case #1

Related Chapters

This article concerns ischemia of the small bowel. See ischemic colitis for ischemia of the large bowel

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