Mesenteric Ischemia

• • 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

Chronic Mesenteric Ischemia

• • Also known as "intestinal angina"

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

Acute Mesenteric Ischemia

• • Either embolic or thrombotic

  • Eventually results in irreversible bowel ischemia

  • Due to embolus most often in SMA

Epidemiology

• • 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

Symptoms and Signs

Chronic Mesenteric Ischemia

• • 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

Imaging Findings

• • 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

• • Angiogram necessary prior to operative repair

Rule Out

• • 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

• • Physical exam

  • MRI of mesenteric vasculature

  • Angiography

Acute Mesenteric Ischemia

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

  • If bowel not viable, bowel resection

Chronic Mesenteric Ischemia

• • 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

Surgery

Indications

• • Acute mesenteric ischemia

  • Chronic symptomatic ischemia with flow limiting lesion(s)

Prognosis

• • 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

References