eMedicine Specialties > Emergency Medicine > Cardiovascular

Mesenteric Ischemia: Differential Diagnoses & Workup

Author: Daniel K Nishijima, MD, Staff Physician, Department of Emergency Medicine, University of California Davis Medical Center
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
Contributor Information and Disclosures

Updated: Apr 8, 2009

Differential Diagnoses

Aneurysm, Abdominal
Myocardial Infarction
Appendicitis, Acute
Obstruction, Large Bowel
Cholangitis
Obstruction, Small Bowel
Cholecystitis and Biliary Colic
Pancreatitis
Cholelithiasis
Renal Calculi
Lactic Acidosis
Shock, Hypovolemic

Other Problems to Be Considered

Crohn disease colitis
Ulcerative colitis
Perforated viscus
Appendicitis
Pancreatitis
Diverticulitis
Volvulus
Bowel obstruction
Abdominal aortic aneurysm
Hepatobiliary disease

Workup

Laboratory Studies

  • No laboratory test sufficiently rules in or rules out the diagnosis of mesenteric ischemia. Laboratory findings in mesenteric ischemia are nonspecific and generally unreliable.
  • Of patients with acute mesenteric ischemia (AMI), 75% have a leukocytosis greater than 15,000 cells/mm3.
  • Elevated serum lactate level raises the suspicion of intestinal ischemia; however, elevation of lactate is often a late finding. One small study found that increased plasma lactate concentration had a sensitivity of 96% (24/25) for recognizing acute mesenteric ischemia in patients with abdominal complaints.21,22
  • Several studies have found that serum D-dimer may be used as an early marker for acute mesenteric ischemia, although it appears to be insensitive.23,24

Imaging Studies

  • The American Gastroenterological Association in 2000 released recommended algorithms for the diagnosis and management of mesenteric ischemia (see Media files 2-5).25 However, this was prior to improved data on multidetector computed tomography (CT) scans, which now have a greater role in the diagnosis of mesenteric ischemia.
Diagnosis and treatment of intestinal ischemia. S...

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.

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Diagnosis and treatment of intestinal ischemia. S...

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. S...

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.

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Diagnosis and treatment of intestinal ischemia. S...

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). ...

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.

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Management of chronic mesenteric ischemia (CMI). ...

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 indicat...

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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Management of colon ischemia. Solid lines indicat...

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.

  • Plain films
    • Plain abdominal radiographs are generally normal or nonspecific and therefore should not be used to rule out mesenteric ischemia. Thumbprinting, pneumatosis intestinalis, or portal venous gas raises the suspicion for mesenteric ischemia, though these are findings that are found later in the disease process.
    • Plain films are best used for rapid identification of intestinal obstruction or perforation and to hasten surgical intervention.
  • CT scan
    • Multidetector row CT has emerged as a valuable tool for the evaluation of mesenteric ischemia. Multidetector row CT and 3-dimensional imaging provide a detailed examination of small bowel and mesenteric vessels.26,27,28 Multiple studies have shown a sensitivity ranging from 96-100% and specificity ranging from 89-94%. Findings of acute mesenteric ischemia (AMI) included mesenteric arterial or venous thrombus, mesenteric venous gas, pneumatosis intestinalis, bowel-wall thickening, increased or decreased enhancement of the bowel wall, bowel dilatation, mesenteric or perienteric fat stranding, ascites, pneumoperitoneum, and solid organ infarction.29,30
    • CT scan of the abdomen is the diagnostic test of choice if suspicion for mesenteric venous thrombosis is high; sensitivities are greater than 90%.31 CT findings include a central lucency in the mesenteric vein, enlargement of the superior mesenteric vein, and a sharply defined vein wall with a rim of increased density.17
  • Angiography
    • For many years, angiography has been considered to be the criterion standard for the diagnosis of acute arterial occlusion with reported sensitivities 74-100% and specificity 100% in various studies.12,32,33,34,35,36,37  
    • Abrupt cutoff of the superior mesenteric artery (SMA) with the absence of collateral circulation is diagnostic, with nearly 100% sensitivity in acute embolic occlusion.38
    • Angiography has the added advantage of therapeutic options as well, including administration of intra-arterial thrombolytic agents for acute arterial thrombosis39 as well as intra-arterial papaverine infusion for all types of arterial ischemia.
    • The disadvantages of angiography are that it is highly invasive and is not suitable in critically ill patients, often is not readily available and may delay surgical management, and nephrotoxicity may occur due to the effects of intravenous contrast on the kidneys. Angiography also has a relatively high false-negative rate in patients presenting early in the course of the disease.25
    • Despite the disadvantages, if suspicion for AMI is high, the EP should aggressively pursue angiography as the diagnostic study of choice.
    • Prompt laparotomy is indicated in patients with suspected AMI in whom expeditious angiography is not available.
    • If suspicion of mesenteric venous thrombosis is high, such as in a patient with a history of hypercoagulable state, angiography is not indicated. CT scan of the abdomen is the diagnostic test of choice in this situation.
  • MRI
    • MRI has been evaluated for the diagnosis of chronic mesenteric ischemia (CMI) and has been shown to have accurate imaging of the mesenteric vasculature.40,41 However, in the acute setting, MRI does not have much benefit over CT imaging.
    • MRI should not be the initial test in the ED due to time constraints.
  • Ultrasonography
    • Duplex ultrasonography has shown promising results as a screening tool for the diagnosis of chronic mesenteric ischemia.42,43 However, the utility of these tests are largely dependent on operator training, bowel gas patterns, and patient body habitus.
    • For all practical purposes, ultrasonography should not be the initial diagnostic choice for the EP.44,45

Procedures

  • Nasogastric decompression: The placement of a nasogastric tube is diagnostically useful, both to evaluate the presence of blood, and therapeutically, to relieve distention secondary to ileus.
  • The placement of a central line may be useful in hemodynamically unstable patients.

More on Mesenteric Ischemia

Overview: Mesenteric Ischemia
Differential Diagnoses & Workup: Mesenteric Ischemia
Treatment & Medication: Mesenteric Ischemia
Follow-up: Mesenteric Ischemia
Multimedia: Mesenteric Ischemia
References
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Further Reading

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Keywords

acute mesenteric ischemia, AMI, chronic mesenteric ischemia, CMI, interruption of blood flow to small intestine, arterial mesenteric ischemia, venous mesenteric ischemia, superior mesenteric artery occlusion, nonocclusive infarction, inferior mesenteric artery occlusion, mesenteric venous thrombosis, arteritis

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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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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 and National Association of EMS Physicians
Disclosure: Intellicare Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

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, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, 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: Schering  Honoraria Speaking and teaching

 
 
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