eMedicine Specialties > Gastroenterology > Intestine
Chronic Mesenteric Ischemia: Treatment & Medication
Updated: Oct 10, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Because of the high rate of thrombosis, medical management as a sole treatment is warranted only in patients whose risk with surgery outweighs the benefits.
- Some patients may find short-term relief with nitrate therapy; however, this treatment is not curative.
- Medical management includes anticoagulation therapy with warfarin.
- Once a diagnostic arteriogram is obtained and surgery is deemed appropriate, start intra-arterial papaverine to reduce the risk of arterial spasm.
Surgical Care
- After the diagnosis is made by arteriography, patients should undergo surgery because of the risk of continued weight loss, acute infarction, perforation, sepsis, and death.
- Stenting of visceral vessels has been reported with some success and may be an alternative to surgery. One study suggests that stenting may result in equivalent patency rates to that of surgical correction; however, symptomatic improvement may not be as good. Another study suggests that the long-term outcome may be equal to that of surgery.
- Preoperative considerations include the following:
- Because of the long period of malnutrition, patients should receive parenteral nutrition prior to surgery.
- Cross and match 2 units of blood.
- Prepare the patient's bowel the night prior to surgery, and arrange for the patient to ingest nothing by mouth past midnight.
- Obtain informed consent.
- To decrease the risk of vasospasm, intra-arterial papaverine may be started at the time of the angiogram.
- Surgical correction includes (1) transaortic endarterectomy of the celiac or superior mesenteric artery, (2) retrograde bypass from the external iliac artery, and (3) anterograde bypass, which provides the best orientation of the graft to the aorta. Mesenteric artery reimplantation has been performed but is not widely recommended because of the technical difficulties of the procedure.
Consultations
- Because of the high rate of coronary artery disease in these patients, consultation with a cardiologist is warranted to evaluate potential risks associated with surgery.
Diet
- Because chronic mesenteric ischemia is a complication of diffuse atherosclerosis of the arterial tree, these patients should maintain a low-fat diet, similar to that of patients with cardiac disease.
- Some patients report increased postprandial pain after eating large or fatty meals. Therefore, the diet should be appropriately altered to include small, multiple meals or low-fat meals.
Activity
- Encourage regular exercise, as in patients with cardiac disease.
Medication
Drugs used in chronic mesenteric ischemia include heparin and warfarin for anticoagulation and intra-arterial papaverine as a vasodilator.
Anticoagulants
Prevent an acute thrombotic/embolic event.
Warfarin (Coumadin)
Anticoagulant that interferes with epoxide reductase, preventing production of vitamin K–dependent factors II, VII, IX, X, and protein C and S. Because protein C and S are the first factors to be inhibited, a prothrombic effect occurs during initial few days after instituting warfarin. Start patients on heparin first and then switch to warfarin when the PT, aPTT, and INR are therapeutic. Duration of action is 2-5 d.
Adult
5 mg/d PO initially for 2-4 d; adjust dose to desired PT/INR
Pediatric
0.05-0.34 mg/kg/d PO; adjust dose according to desired INR; infants may require doses at or near high end of this range
Drugs that may decrease anticoagulant effects include griseofulvin, carbamazepine, glutethimide, estrogens, nafcillin, phenytoin, rifampin, barbiturates, cholestyramine, colestipol, vitamin K, spironolactone, oral contraceptives, and sucralfate
Medications that may increase anticoagulant effects include oral antibiotics, phenylbutazone, salicylates, sulfonamides, chloral hydrate, clofibrate, diazoxide, anabolic steroids, ketoconazole, ethacrynic acid, miconazole, nalidixic acid, sulfonylureas, allopurinol, chloramphenicol, cimetidine, disulfiram, metronidazole, phenylbutazone, phenytoin, propoxyphene, sulfonamides, gemfibrozil, acetaminophen, and sulindac
Documented hypersensitivity, severe liver or kidney disease, open wounds or GI ulcers
Pregnancy
X - Contraindicated in pregnancy
Precautions
Do not switch brands after achieving therapeutic response; caution in active tuberculosis or diabetes; patients with protein C or S deficiency are at risk of developing skin necrosis
Heparin
Sulfated mucopolysaccharide. Anticoagulant effect is related to ability to activate plasma antithrombin. Main role of heparin in these patients is to prevent thrombus propagation.
Adult
80 U/kg loading dose IV followed by 18 U/kg/h; adjust dose to appropriate aPTT level
Pediatric
50 U/kg loading dose IV followed by 25 U/kg/h
Digoxin, nicotine, tetracycline, and antihistamines may decrease effects; NSAIDs, ASA, dextran, dipyridamole, and hydroxychloroquine may increase heparin toxicity
Documented hypersensitivity; presence of active hemorrhage, potential hemorrhage, and hemorrhagic disorders; severe thrombocytopenia
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Some preparations contain benzyl alcohol as a preservative and, when used in large amounts, are associated with fetal toxicity (gasping syndrome); preservative-free heparin is recommended in neonates; heparin should be used with caution in patients in shock or with severe hypotension
Vasodilators
Used during arteriogram to decrease vasospasm in occluded arteries, with the objective of improving blood flow.
Papaverine (Genabid)
Benzylisoquinoline-derivative with direct nonspecific relaxant effect on vascular, cardiac, and other smooth muscle.
Adult
30-60 mg/h IV
Pediatric
Not established
May decrease effectiveness of levodopa
Documented hypersensitivity; complete AV heart block
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in angina, recent MI, recent stroke glaucoma
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 |
| « Previous Page | Next Page » |
References
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Further Reading
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
