eMedicine Specialties > Gastroenterology > Intestine

Chronic Mesenteric Ischemia

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

Introduction

Background

Antonio Hodgson first described mesenteric ischemia (see Media file 1) in the latter part of the 15th century. During the middle of the 19th century, the medical profession became more interested in this condition. By the turn of the 20th century, many review articles and texts were produced describing the recent advances in both the characterization and treatment of mesenteric ischemia.

In 1901, Schnitzler described a patient with a long history of postprandial abdominal pain. He was found to have an atherosclerotic plaque with an overlying thrombus of the superior mesenteric artery. Schnitzler concluded that if a patient could develop pain in his or her lower extremities secondary to atherosclerosis, the assumption that a patient could present with postprandial pain due to narrowing of the mesenteric vessels would be reasonable.

By the middle of the 20th century, Dunphy hypothesized that mesenteric ischemia was a manifestation of visceral atherosclerosis. In 1958, Shaw and Maynard described the first thromboendarterectomy of the superior mesenteric artery for the treatment of both acute and chronic mesenteric ischemia.

Several other surgical procedures have since been attempted, ranging from reimplantation of the visceral branch into the adjacent aorta to using an autogenous vein graft. In 1972, Stoney and Wylie introduced transaortic visceral thromboendarterectomy and aortovisceral bypass, which have proven to be very effective techniques.

Pathophysiology

In more than 95% of patients, the cause of mesenteric ischemia is diffuse atherosclerotic disease, which decreases the flow of blood to the bowel. As the atherosclerotic disease progresses, symptoms worsen. Usually, all 3 major mesenteric arteries are occluded or narrowed.

The pathophysiologic mechanism by which ischemia produces pain is still not completely understood.

Frequency

United States

Chronic mesenteric ischemia is a rare diagnosis. No reports of the actual incidence have been published. Moawad searched 20 years of literature and found only 330 cases. Because many cases are not reported, the true prevalence could be much higher. Autopsy studies support this theory, with findings of stenosis in up to 30% of selected patients with a history of abdominal pain.

International

No differences in frequency are reported in various regions of the world.

Mortality/Morbidity

  • Chronic mesenteric ischemia by itself does not represent an important cause of mortality.
  • Complications, which include acute thrombosis or embolus, are significant causes of increased mortality and are the main reason to revascularize these patients.
  • Patients with chronic mesenteric ischemia often present with malnutrition secondary to their fear of postprandial abdominal pain. These patients may have a prolonged hospital course due to their chronic malnourished state.

Sex

  • Some studies show an increased prevalence in females compared with males, while other studies show equal distribution.

Age

  • The average age at presentation is 60 years.

Clinical

History

  • Patients typically present with a history of the following:
    • Weight loss
    • Postprandial pain, generally epigastric or periumbilical
    • Fear of eating
    • History of vascular disease involving other organs such as myocardial infarction (MI), cerebral vascular disease, or peripheral vascular disease
  • Other nonspecific symptoms include the following:
    • Nausea
    • Vomiting
    • Diarrhea
    • Constipation
    • Flatulence

Physical

Upon physical examination, the following may be found:

  • Signs of malnutrition
  • Pain disproportionate to examination findings
    • Usually diffuse mild abdominal tenderness
    • No rebound or guarding
  • Abdominal bruit
  • Signs of peripheral vascular disease, such as carotid bruits, decreased pulses, and ischemic feet

Causes

Factors that predispose to atherosclerosis are associated with increased risk for chronic mesenteric ischemia. These include the following:

  • Smoking
  • Hypertension
  • Diabetes mellitus
  • Hypercholesterolemia (although patients may present with hypocholesterolemia because of their chronic malnourished state)

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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