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Abdominal Angina Workup

  • Author: Faisal Aziz, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Apr 22, 2016
 

Laboratory Studies

No laboratory tests are diagnostic. Usually, nutritional parameters are suggestive of malnutrition. If malignancy or gastric ulcer disease is suspected, consider obtaining appropriate laboratory and other diagnostic studies.

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Imaging Studies

Mesenteric angiography is the classic criterion standard diagnostic study. Because the vessels emerge from the anterior wall of the aorta, the ostia are visualized only on a lateral view (see the first image below). A prominent meandering mesenteric artery (see the second image below) is another clue.

Lateral aortogram shows abrupt cutoffs at origin oLateral aortogram shows abrupt cutoffs at origin of visceral vessels and tapered occlusion of distal aorta. Because these vessels originate from anterior surface of the aorta, stenoses and occlusions are not observed clearly on standard anteroposterior views.
Arteriogram illustrates meandering mesenteric arteArteriogram illustrates meandering mesenteric artery. Appearance of meandering mesenteric artery such as this one supports diagnosis of chronic mesenteric ischemia.

Duplex ultrasonography is emerging as a useful screening modality in this setting. It currently is most useful in cases where the diagnosis is suspected.[7, 8]

Indices that are studied include the following:

  • Peak systolic flow - This is increased if a stenosis is present
  • Normal vasodilatory response in response to eating - This is lost, especially in the superior mesenteric artery (SMA)

Computed tomography angiography (CTA) of the aorta and mesenteric arteries is now considered an alternative to mesenteric angiography by most authorities.

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Other Tests

Because most of these patients have generalized vascular disease, it is prudent to carry out a cardiovascular evaluation before performing surgery.

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Contributor Information and Disclosures
Author

Faisal Aziz, MD Assistant Professor of Surgery, Divsion of Vascular and Endovascular Surgery, Department of Surgery, Pennsylvania State University College of Medicine

Faisal Aziz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Anthony J Comerota, MD, FACS, FACC, FRACS Director of Jobst Vascular Institute, Program Director of General Vascular Surgery Residency, Toledo Hospital; Director of Jobst (ProMedica) Vascular Laboratories; Adjunct Professor of Surgery, Department of Surgery, University of Michigan Medical School

Anthony J Comerota, MD, FACS, FACC, FRACS is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Society for Vascular Surgery, Society of University Surgeons, American Stroke Association, American Venous Forum, Eastern Vascular Society, Society for Clinical Vascular Surgery

Disclosure: Received honoraria from BMS for speaking and teaching; Received consulting fee from BMS for consulting; Received grant/research funds from BMS for research studies; Received honoraria from Covidien for speaking and teaching; Received consulting fee from Covidien for consulting; Received honoraria from Otsuka for speaking and teaching; Received honoraria from Sanofi/Aventis for speaking and teaching; Received consulting fee from Sanofi/Aventis for consulting; Received grant/research funds from Sa.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: Received none from RFA Medical for director; Received none from MRC Biotec for director.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Marc D Basson, MD, PhD, MBA, FACS Associate Dean for Medicine, Professor of Surgery and Basic Science, University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

Acknowledgements

We wish to thank Carol EH Scott-Conner, MD, PhD, and Beth Ballinger, MD, for their previous contributions to this article.

References
  1. Tyson RL. Diagnosis and treatment of abdominal angina. Nurse Pract. 2010 Nov. 35(11):16-22; quiz 22-3. [Medline].

  2. Moschetta M, Stabile Ianora AA, Pedote P, et al. Prognostic value of multidetector computed tomography in bowel infarction. Radiol Med. 2009 Aug. 114(5):780-91. [Medline].

  3. Sarac TP, Altinel O, Kashyap V, Bena J, Lyden S, Sruvastava S, et al. Endovascular treatment of stenotic and occluded visceral arteries for chronic mesenteric ischemia. J Vasc Surg. 2008 Mar. 47(3):485-91. [Medline].

  4. Sundermeyer A, Zapenko A, Moysidis T, Luther B, Kröger K. Endovascular treatment of chronic mesenteric ischemia. Interv Med Appl Sci. 2014 Sep. 6 (3):118-24. [Medline].

  5. Cai W, Li X, Shu C, Qiu J, Fang K, Li M, et al. Comparison of clinical outcomes of endovascular versus open revascularization for chronic mesenteric ischemia: a meta-analysis. Ann Vasc Surg. 2015 Jul. 29 (5):934-40. [Medline].

  6. Fields JM, Dean AJ. Systemic causes of abdominal pain. Emerg Med Clin North Am. 2011 May. 29(2):195-210, vii. [Medline].

  7. Danse EM, Kartheuser A, Paterson HM, et al. Color Doppler sonography of small bowel wall changes in 21 consecutive cases of acute mesenteric ischemia. JBR-BTR. 2009 Jul-Aug. 92(4):202-6. [Medline].

  8. Pellerito JS, Revzin MV, Tsang JC, et al. Doppler sonographic criteria for the diagnosis of inferior mesenteric artery stenosis. J Ultrasound Med. 2009 May. 28(5):641-50. [Medline].

  9. Cunningham CG, Reilly LM, Rapp JH, Schneider PA, Stoney RJ. Chronic visceral ischemia. Three decades of progress. Ann Surg. 1991 Sep. 214(3):276-87; discussion 287-8. [Medline]. [Full Text].

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

  11. Schermerhorn ML, Giles KA, Hamdan AD, et al. Mesenteric revascularization: management and outcomes in the United States, 1988-2006. J Vasc Surg. 2009 Aug. 50(2):341-348.e1. [Medline]. [Full Text].

  12. Aksu C, Demirpolat G, Oran I, et al. Stent implantation in chronic mesenteric ischemia. Acta Radiol. 2009 Jul. 50(6):610-6. [Medline].

  13. Oderich GS, Erdoes LS, Lesar C, Mendes BC, Gloviczki P, Cha S, et al. Comparison of covered stents versus bare metal stents for treatment of chronic atherosclerotic mesenteric arterial disease. J Vasc Surg. 2013 Nov. 58(5):1316-23. [Medline].

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Superior mesenteric artery and inferior mesenteric artery share collateral circulation near splenic flexure of colon. When dilated, this vessel is termed meandering mesenteric artery. As seen on angiography, this is sign of chronic mesenteric ischemia.
Pancreaticoduodenal arcades are collateral pathways between celiac artery and superior mesenteric artery.
Lateral aortogram shows abrupt cutoffs at origin of visceral vessels and tapered occlusion of distal aorta. Because these vessels originate from anterior surface of the aorta, stenoses and occlusions are not observed clearly on standard anteroposterior views.
Arteriogram illustrates meandering mesenteric artery. Appearance of meandering mesenteric artery such as this one supports diagnosis of chronic mesenteric ischemia.
Celiac artery is exposed at its origin in preparation for antegrade bypass.
Superior mesenteric artery and several branches are exposed for antegrade bypass.
Antegrade bypass from aorta to superior mesenteric artery (SMA) and celiac artery (SMA anastomosis is shown) using Dacron graft.
Completed retrograde bypass to superior mesenteric artery using expanded polytetrafluoroethylene graft material. Image courtesy of Jamal Hoballah, MD, University of Iowa College of Medicine.
Possible incision for trapdoor aortotomy. Plaque at orifices of visceral vessels is removed after trapdoor incision is lifted. When satisfactory endarterectomy has been achieved, trapdoor is sutured shut.
Completion duplex ultrasonographic study shows excellent flow at distal anastomosis.
Upper gastrointestinal series (barium swallow) shows ulcer.
 
 
 
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