eMedicine Specialties > Gastroenterology > Intestine

Chronic Mesenteric Ischemia: Differential Diagnoses & Workup

Author: Deron J Tessier, MD, Staff Surgeon, Kaiser Permanente Medical Center, Fontana, CA
Coauthor(s): Russell A Williams, MBBS, Program Director, Professor, Department of Surgery, University of California Medical Center at Irvine
Contributor Information and Disclosures

Updated: Oct 10, 2006

Differential Diagnoses

Acute Mesenteric Ischemia
Gastric Ulcers
Biliary Colic
Gastritis, Acute
Biliary Obstruction
Gastritis, Chronic
Cholangitis
Hiatal Hernia
Cholecystitis
Pancreatitis, Chronic
Diverticulitis
Pyelonephritis, Chronic
Duodenal Ulcers
Gastric Cancer

Other Problems to Be Considered

Small bowel obstruction

Workup

Laboratory Studies

  • CBC count may demonstrate anemia, leukopenia, or lymphopenia secondary to chronic malnourishment.
  • Chemistries may show electrolyte abnormalities from malnutrition, vomiting, or diarrhea.
  • Urinalysis should be performed to rule out stones or infection.
  • Liver function tests may show hypoalbuminemia from malnutrition.
  • If a patient presents with steatorrhea, send stool fat for examination.
  • Preoperative considerations include the following;
    • CBC count
    • Chemistries
    • Prothrombin time (PT)
    • Activated partial thromboplastin time (aPTT)
    • International normalized ratio (INR)

Imaging Studies

  • Perform chest radiography to rule out pneumonia (see Media file 2).
  • Perform dipyridamole-thallium scanning if coronary artery disease is a suspected comorbidity.
  • Arteriography is the criterion standard and will show occlusion (see Media file 4) of 2 visceral branches of the aorta, with severe stenosis of the remaining visceral branch, usually the celiac or superior mesenteric artery. Look for a dilated meandering artery (see Media file 3), which indicates well-developed collateral flow.
  • Mesenteric duplex ultrasonography is a noninvasive method of analyzing flow through the vessels. Unfortunately, intraperitoneal gas, respiratory movements, obesity, and any previous abdominal surgeries limit results.
  • MRI is under investigation as a future diagnostic tool.
  • Preoperative studies include the following:
    • Chest radiography
    • Dipyridamole-thallium scanning
    • Arteriography

Other Tests

  • Perform ECG to rule out cardiac disease.

Histologic Findings

Transected mesenteric vessels show diffuse atherosclerosis. The histological findings from the bowel include atrophy of the tips of the villi, which leads to loss of the absorptive surface in the small bowel. The loss of the absorptive surface in conjunction with the patient's fear of eating results in the malnourished state commonly seen in persons with this condition.

More on Chronic Mesenteric Ischemia

Overview: Chronic Mesenteric Ischemia
Differential Diagnoses & Workup: Chronic Mesenteric Ischemia
Treatment & Medication: Chronic Mesenteric Ischemia
Follow-up: Chronic Mesenteric Ischemia
Multimedia: Chronic Mesenteric Ischemia
References
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References

  1. Cappell MS. Intestinal (mesenteric) vasculopathy. I. Acute superior mesenteric arteriopathy and venopathy. Gastroenterol Clin North Am. Dec 1998;27(4):783-825, vi. [Medline].

  2. Chahid T, Alfidja AT, Biard M, et al. Endovascular treatment of chronic mesenteric ischemia: results in 14 patients. Cardiovasc Intervent Radiol. Nov-Dec 2004;27(6):637-42. [Medline].

  3. Chang JB, Stein TA. Mesenteric ischemia: acute and chronic. Ann Vasc Surg. May 2003;17(3):323-8. [Medline].

  4. English WP, Pearce JD, Craven TE, et al. Chronic visceral ischemia: symptom-free survival after open surgical repair. Vasc Endovascular Surg. Nov-Dec 2004;38(6):493-503. [Medline].

  5. Geroulakos G, Tober JC, Anderson L, Smead WL. Antegrade visceral revascularisation via a thoracoabdominal approach for chronic mesenteric ischaemia. Eur J Vasc Endovasc Surg. Jan 1999;17(1):56-9. [Medline].

  6. Hung KH, Lee CT, Lam KK, et al. Ischemic bowel disease in chronic dialysis patients. Chang Keng I Hsueh Tsa Chih. Mar 1999;22(1):82-7. [Medline].

  7. Kazmers A. Operative management of chronic mesenteric ischemia. Ann Vasc Surg. May 1998;12(3):299-308. [Medline].

  8. Kihara TK, Blebea J, Anderson KM, et al. Risk factors and outcomes following revascularization for chronic mesenteric ischemia. Ann Vasc Surg. Jan 1999;13(1):37-44. [Medline].

  9. Lauenstein TC, Ajaj W, Narin B, et al. MR imaging of apparent small-bowel perfusion for diagnosing mesenteric ischemia: feasibility study. Radiology. Feb 2005;234(2):569-75. [Medline].

  10. Mateo RB, O''Hara PJ, Hertzer NR, et al. Elective surgical treatment of symptomatic chronic mesenteric occlusive disease: early results and late outcomes. J Vasc Surg. May 1999;29(5):821-31; discussion 832. [Medline].

  11. Moawad J, Gewertz BL. Chronic mesenteric ischemia. Clinical presentation and diagnosis. Surg Clin North Am. Apr 1997;77(2):357-69. [Medline].

  12. Schaefer PJ, Schaefer FK, Mueller-Huelsbeck S. Chronic mesenteric ischemia: stenting of mesenteric arteries. Abdom Imaging. Sep 6 2006.

  13. Sharafuddin MJ, Olson CH, Sun S, et al. Endovascular treatment of celiac and mesenteric arteries stenoses: applications and results. J Vasc Surg. Oct 2003;38(4):692-8. [Medline].

  14. Sheeran SR, Murphy TP, Khwaja A, et al. Stent placement for treatment of mesenteric artery stenoses or occlusions. J Vasc Interv Radiol. Jul-Aug 1999;10(7):861-7. [Medline].

  15. Silva JA, White CJ, Collins TJ. Endovascular therapy for chronic mesenteric ischemia. J Am Coll Cardiol. Mar 7 2006;47(5):944-50.

  16. Sivamurthy N, Rhodes JM, Lee D. Endovascular versus open mesenteric revascularization: immediate benefits do not equate with short-term functional outcomes. J Am Coll Surg. Jun 2006;202(6):859-67.

  17. Thomas JH, Blake K, Pierce GE, et al. The clinical course of asymptomatic mesenteric arterial stenosis. J Vasc Surg. May 1998;27(5):840-4. [Medline].

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Further Reading

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Keywords

chronic visceral ischemia, postprandial abdominal pain, atherosclerotic plaque, thrombus, superior mesenteric artery, atherosclerosis, visceral atherosclerosis, thromboendarterectomy, malnutrition, malnourishment, coronary artery disease, CAD, transaortic visceral thromboendarterectomy, aortovisceral bypass

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Contributor Information and Disclosures

Author

Deron J Tessier, MD, Staff Surgeon, Kaiser Permanente Medical Center, Fontana, CA
Deron J Tessier, MD is a member of the following medical societies: American College of Surgeons and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Russell A Williams, MBBS, Program Director, Professor, Department of Surgery, University of California Medical Center at Irvine
Russell A Williams, MBBS is a member of the following medical societies: American College of Surgeons, American Pancreatic Association, Association for Surgical Education, Association of VA Surgeons, Society for Surgery of the Alimentary Tract, Southern California Society of Gastroenterology, and Southwestern Surgical Congress
Disclosure: Nothing to disclose.

Medical Editor

Mounzer Al Al Samman, MD, Department of Internal Medicine, Division of Gastroenterology, Assistant Professor, Texas Tech University School of Medicine
Mounzer Al Al Samman, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, and American Gastroenterological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

BS Anand, MD, Department of Internal Medicine, Division of Gastroenterology, Professor, Baylor University College of Medicine
BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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