Mesenteric Ischemia in Emergency Medicine Clinical Presentation

  • Author: Daniel K Nishijima, MD; Chief Editor: David FM Brown, MD   more...
 
Updated: May 1, 2012
 

History

  • The clinical presentation is largely dependent on the underlying etiology, with acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI) presenting very differently.
  • The classic picture of a patient with acute mesenteric ischemia involves severe abdominal pain with a paucity of abdominal examination findings and a history of risk factors.
  • Because the pathologic process is ischemia, the pain is initially visceral in nature and generally poorly localized.
  • Acute pain may occur if ischemia is due to embolic disease, however a gradual onset of pain is more common in the overall spectrum of mesenteric ischemia.
  • The pain is usually severe and may occasionally be refractory to opioid analgesics.
  • Prior episodes of a similar pain, often related to meals (intestinal angina), may be reported.
  • Abdominal pain may be absent in 15-25% of cases; associated GI symptoms are common and caution must be taken to not be misled.
  • Nausea and vomiting are frequent, and diarrhea may occur in as many as 50% of patients with mesenteric ischemia.
  • The classic triad of superior mesenteric artery (SMA) embolism includes GI emptying, abdominal pain, and underlying cardiac disease.
  • Chronic mesenteric ischemia typically causes postprandial abdominal pain and weight loss that results in chronic dull pain as the obstructive process worsens.
  • Patients with chronic mesenteric ischemia may also report sitophobia (fear of eating).
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Physical

  • The sine qua non of mesenteric ischemia is a relatively normal abdominal examination in the face of severe abdominal pain.
  • Advanced ischemia may be signified by increasing abdominal distention, ileus, frank peritonitis, and shock.
  • Theoretically, before the onset of significant mucosal injury, blood in the GI tract should be absent early in the disease process.
  • Melena or hematochezia occurs in 15% of cases, and occult blood is detected in approximately 50% of patients.[12]
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Causes

  • Acute arterial embolus: Embolic lesions are usually secondary to conditions that predispose the patient to embolus formation such as atrial fibrillation, ventricular aneurysm, and valvular disease.[3]
  • Acute arterial thrombosis
    • Acute arterial thrombosis usually occurs following a superimposed insult in patients with preexisting atherosclerosis.
    • Other causes include aortic aneurysm, aortic dissection, and arteritis.
  • Nonocclusive ischemia
    • The causes of nonocclusive mesenteric ischemia include all of the causes of splanchnic vasoconstriction including hypovolemia, cardiac shock, sepsis, alpha-agonism, ergots, cocaine, and digitalis.
    • Case reports exist of marathon runners developing ischemic colitis following a marathon that resolved in most runners with supportive treatment.[15]
  • Mesenteric venous thrombosis
    • Approximately 75% of patients with mesenteric venous thrombosis have an underlying hypercoagulable state[16] or other risk factors including portal hypertension, intra-abdominal sepsis, cirrhosis, pancreatitis, malignancy, and trauma.
    • Oral contraceptive use accounts for 9-18% of the episodes of mesenteric venous thrombosis in young women.[17, 18, 19]
  • Mechanical compression: Case reports have documented the etiology of celiac artery compression syndrome (CACS) as a cause of mesenteric ischemia due to external compression of the celiac artery usually by the median arcuate ligament or the celiac ganglion.[11, 20]
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Contributor Information and Disclosures
Author

Daniel K Nishijima, MD  Staff Physician, Department of Emergency Medicine, University of California Davis Medical Center

Daniel K Nishijima, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Mark Su, MD, FACEP, FACMT  Consulting Staff and Director of Fellowship in Medical Toxicology, Department of Emergency Medicine, North Shore University Hospital; Consulting Staff, North Shore University Hospital

Mark Su, MD, FACEP, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert M McNamara, MD, FAAEM  Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Gary Setnik, MD  Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Pneumatosis intestinalis is one of the few radiographic findings in patients with mesenteric ischemia.
Diagnosis and treatment of intestinal ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternate management plan. DVT, deep vein thrombosis; SMA, superior mesenteric artery. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
Diagnosis and treatment of intestinal ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternate management plan. DVT, deep vein thrombosis; SMA, superior mesenteric artery. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
Management of chronic mesenteric ischemia (CMI). Solid lines indicate accepted management plan; dashed lines indicate alternative management plan. MRA, magnetic resonance angiography; CT, computerized tomography. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
Management of colon ischemia. Solid lines indicate accepted management plan; dashed lines indicate alternative management plan. BE, barium enema; NPO, nothing by mouth; PLC, protein-losing colopathy; IBD, inflammatory bowel disease. Adapted from Gastroenterology. 2000 May; 118(5): 954-68.
 
 
 
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