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  • • Blood supply to gut:

    • -Celiac artery

      -Superior mesenteric artery (SMA)

      -Inferior mesenteric artery (IMA)

      -Internal iliac artery

    • Multiple occlusions often well tolerated due to extensive collateral vessels

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Chronic Mesenteric Ischemia

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  • • Also known as "intestinal angina"

    • Results in ischemia upon "stressing" the gut with food bolus, etc

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Acute Mesenteric Ischemia

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  • • Either embolic or thrombotic

    • Eventually results in irreversible bowel ischemia

    • Due to embolus most often in SMA

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Epidemiology

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  • • Stenosis of celiac or SMA caused by

    • -Atherosclerosis

      -Vasculitis (lupus, Takayasu)

    • Women aged 25-50 years may develop median arcuate ligament syndrome, causing external compression of celiac artery

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Symptoms and Signs

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Chronic Mesenteric Ischemia

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  • • Postprandial pain 15-30 min after eating

    • Epigastric pain, radiating to left upper quadrant/right upper quadrant

    • Weight loss from fear of eating

    • 80% have epigastric bruit

    • Pain out of proportion to physical exam

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Imaging Findings

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  • • Arteriography in anteroposterior and lateral views necessary

    • -Patients should be well hydrated to prevent risk of hypercoagulability and bowel infarction

    • Duplex and magnetic resonance angiography used to screen but may have low sensitivity and specificity

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  • • Angiogram necessary prior to operative repair

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Rule Out

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  • • Should have high clinical suspicion of acute mesenteric ischemia

    • For chronic mesenteric ischemia, rule out other causes of postprandial pain

    • Peptic ulcer disease

    • Gastroesophageal reflux disease

    • Cholecystitis

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  • • Physical exam

    • MRI of mesenteric vasculature

    • Angiography

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Acute Mesenteric Ischemia

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  • • Identify occluded vessel, arteriotomy, pass Fogarty, may need bypass

    • If bowel not viable, bowel resection

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Chronic Mesenteric Ischemia

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  • Atherosclerotic lesion: Surgical revascularization via endarterectomy or bypass

    Median arcuate ligament syndrome: Divide ligament with or without arterial bypass

    Avoid operation if due to vasculitis: Treat with corticosteroids and immunosuppressive drugs

    • Percutaneous transluminal angioplasty + stent for focal, nonorificial stenosis

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Surgery

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Indications

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  • • Acute mesenteric ischemia

    • Chronic symptomatic ischemia with flow limiting lesion(s)

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Prognosis

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  • Chronic ischemia: If surgical revascularization is not performed, high risk of bowel infarction or initiation

    Acute ischemia: Early diagnosis essential or outcome is poor

    Median arcuate ligament compression: Do well with surgical repair

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References

Foley MI et al. Revascularization of the superior mesenteric artery alone for treatment of intestinal ischemia. J Vasc Surg. 2000;32:37.  [PubMed: 10876205]
Herbert GS, Steele SR: Acute and chronic mesenteric ischemia. Surg Clin North Am 2007;87:1115.  [PubMed: 17936478]
Jimenez JG et al: Durability of antegrade synthetic aortomesenteric bypass for chronic mesenteric ischemia. J Vasc Surg 2002;35:1078....

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