eMedicine Specialties > General Surgery > Abdomen

Mesenteric Artery Ischemia: Workup

Author: Deron J Tessier, MD, Staff Surgeon, Kaiser Permanente Medical Center, Fontana, CA
Contributor Information and Disclosures

Updated: Jul 8, 2009

Workup

Laboratory Studies

  • The following laboratory examinations should be ordered:
    • Prothrombin time
    • Activated partial thromboplastin time
    • Complete blood cell count, which may reveal a leukocytosis and/or hemoconcentration
    • Chemistry studies that may show acidosis, increased amylase levels, or increased lactate dehydrogenase levels
  • If a hypercoagulable state is suggested, additional laboratory studies such as tests for protein C and S deficiencies and antithrombin III deficiency can be ordered.

Imaging Studies

  • Obtain a chest radiograph.
  • Plain abdominal films can yield a presumptive diagnosis in 20-30% of patients. Late findings on plain films include intramural air and air in the portal venous system. If bowel perforation occurs, free air may be observed in the abdomen.
  • The computed tomography (CT) findings with specificity greater than 95% include SMA or superior mesenteric vein thrombosis, intestinal pneumatosis, portal venous gas, lack of bowel wall enhancement, and ischemia of other organs. Unlike embolic occlusions, thrombosis of the SMA generally occurs flush with the aortic origin of the vessel. Distended bowel, an absence of intestinal gas, a thickened bowel wall, and air-fluid levels are nonspecific findings.
  • Biplane aortography is the criterion standard for the diagnosis of mesenteric ischemia (see image below and Image 2). It can be used to confirm the presence and extent of occlusive disease. Anteroposterior views demonstrate collateral pathways, while lateral projections show the origins of visceral branches.


Aortogram showing narrowing of the superior mesen...

Aortogram showing narrowing of the superior mesenteric artery.

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Aortogram showing narrowing of the superior mesen...

Aortogram showing narrowing of the superior mesenteric artery.

  • Because arteriography can precipitate acute ischemia, ensure that the patient is well hydrated. Patients with thrombosis demonstrate complete lack of visualization of the SMA and its branches, while those with embolism to the SMA demonstrate filling of the proximal SMA only with a sharp cutoff of the artery.
  • If the case is not emergent, consider performing a dipyridamole-thallium scan to evaluate for coronary artery disease.

Other Tests

  • Obtain an ECG.

More on Mesenteric Artery Ischemia

Overview: Mesenteric Artery Ischemia
Workup: Mesenteric Artery Ischemia
Treatment: Mesenteric Artery Ischemia
Follow-up: Mesenteric Artery Ischemia
Multimedia: Mesenteric Artery Ischemia
References
Further Reading
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References

  1. Cappell MS. Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia. Gastroenterol Clin North Am. Dec 1998;27(4):827-60, vi. [Medline].

  2. Ha C, Magowan S, Accortt NA, et al. Risk of arterial thrombotic events in inflammatory bowel disease. Am J Gastroenterol. Jun 2009;104(6):1445-51. [Medline].

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

  4. Kougias P, Huynh TT, Lin PH. Clinical outcomes of mesenteric artery stenting versus surgical revascularization in chronic mesenteric ischemia. Int Angiol. Apr 2009;28(2):132-7. [Medline].

  5. Kim MY, Suh CH, Kim ST, et al. Magnetic resonance imaging of bowel ischemia induced by ligation of superior mesenteric artery and vein in a cat model. J Comput Assist Tomogr. Mar-Apr 2004;28(2):187-92. [Medline].

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

  7. Loffroy R, Steinmetz E, Guiu B, et al. Role for endovascular therapy in chronic mesenteric ischemia. Can J Gastroenterol. May 2009;23(5):365-73. [Medline].

  8. Penugonda N, Gardi D, Schreiber T. Percutaneous intervention of superior mesenteric artery stenosis in elderly patients. Clin Cardiol. May 2009;32(5):232-5. [Medline].

  9. Mitchell EL, Chang EY, Landry GJ, et al. Duplex criteria for native superior mesenteric artery stenosis overestimate stenosis in stented superior mesenteric arteries. J Vasc Surg. Feb 20 2009;[Medline].

  10. 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. 2006;202(6):859-67.

  11. Schoots IG, Levi MM, Reekers JA. Thrombolytic therapy for acute superior mesenteric artery occlusion. J Vasc Interv Radiol. Mar 2005;16(3):317-29. [Medline].

  12. Bingol H, Zeybek N, Cingoz F, et al. Surgical therapy for acute superior mesenteric artery embolism. Am J Surg. Jul 2004;188(1):68-70. [Medline].

  13. Cooperman M, Martin EW Jr, Carey LC. Evaluation of ischemic intestine by Doppler ultrasound. Am J Surg. Jan 1980;139(1):73-7. [Medline].

  14. Eker A, Malzac B, Teboul J, Jourdan J. Mesenteric ischemia after coronary artery bypass grafting: should local continuous intra-arterial perfusion with papaverine be regarded as a treatment?. Eur J Cardiothorac Surg. Feb 1999;15(2):218-20. [Medline]. [Full Text].

  15. Hansen KJ, Wilson DB, Craven TE, et al. Mesenteric artery disease in the elderly. J Vasc Surg. Jul 2004;40(1):45-52. [Medline].

  16. 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].

  17. Mamode N, Pickford I, Leiberman P. Failure to improve outcome in acute mesenteric ischaemia: seven-year review. Eur J Surg. Mar 1999;165(3):203-8. [Medline].

  18. Milner R, Woo EY, Carpenter JP. Superior mesenteric artery angioplasty and stenting via a retrograde approach in a patient with bowel ischemia--a case report. Vasc Endovascular Surg. Jan-Feb 2004;38(1):89-91. [Medline].

  19. Nyman U, Ivancev K, Lindh M, Uher P. Endovascular treatment of chronic mesenteric ischemia: report of five cases. Cardiovasc Intervent Radiol. Jul-Aug 1998;21(4):305-13. [Medline].

  20. Redaelli CA, Schilling MK, Buchler MW. Intraoperative laser Doppler flowmetry: a predictor of ischemic injury in acute mesenteric infarction. Dig Surg. 1998;15(1):55-9. [Medline].

  21. Schoots IG, Koffeman GI, Legemate DA, et al. Systematic review of survival after acute mesenteric ischaemia according to disease aetiology. Br J Surg. Jan 2004;91(1):17-27. [Medline].

  22. Seidel SA, Bradshaw LA, Ladipo JK, et al. Noninvasive detection of ischemic bowel. J Vasc Surg. Aug 1999;30(2):309-19. [Medline].

  23. Yasuhara H. Acute mesenteric ischemia: the challenge of gastroenterology. Surg Today. 2005;35(3):185-95. [Medline].

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Further Reading

Related eMedicine topics:
Acute Mesenteric Ischemia
Chronic Mesenteric Ischemia
Mesenteric Artery Thrombosis
Mesenteric Ischemia
Mesenteric Venous Thrombosis

Clinical guidelines:
ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). American College of Cardiology Foundation - Medical Specialty Society
American Heart Association - Professional Association
Society for Cardiovascular Angiography and Interventions - Medical Specialty Society
Society for Vascular Medicine and Biology - Medical Specialty Society
Society for Vascular Surgery - Medical Specialty Society
Society of Interventional Radiology - Medical Specialty Society.  2005.  191 pages.  NGC:004740

Clinical trials:
Biomagnetic Signals of Intestinal Ischemia
Biomagnetic Signals of Intestinal Ischemia II (SQUID)

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Keywords

mesenteric artery ischemia, ischemia, mesenteric, mesenteric artery, mesentery, mesenteric ischemia, ischemic bowel, ischemic colitis, superior mesenteric artery, mesenteric thrombosis, intestinal angina, acute mesenteric ischemia, chronic mesenteric ischemia, thromboendarterectomy of the superior mesenteric artery, decreased blood supply to the small bowel, decreased blood supply to the large bowel, bowel infarction, bowel necrosis, mesenteric thromboendarterectomy, visceral atherosclerosis, acute thrombotic mesenteric artery ischemia, acute embolic mesenteric artery ischemia, visceral venous thrombosis, nonocclusive mesenteric ischemia, non-occlusive mesenteric ischemia

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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.

Medical Editor

Burt Cagir, MD, FACS, Assistant Professor of Surgery, State University of New York, Upstate Medical Center; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic
Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, and Society for Surgery of the Alimentary Tract
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael A Grosso, MD, Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital
Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, 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, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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