Mesenteric Ischemia in Emergency Medicine 

  • Author: Daniel K Nishijima, MD; Chief Editor: David FM Brown, MD   more...
 
Updated: May 28, 2010
 

Background

Mesenteric ischemia is a relatively rare disorder seen in the emergency department (ED); however, it is an important diagnosis to make because of its high mortality rate. Vague and nonspecific clinical findings and limitations of diagnostic studies make the diagnosis a significant challenge. Moreover, delays in diagnosis lead to increased mortality rates. Despite recent advances in diagnosis and treatment, mortality rates continue to remain high.

Pneumatosis intestinalis is one of the few radiogrPneumatosis intestinalis is one of the few radiographic findings in patients with mesenteric ischemia.
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Pathophysiology

Mesenteric ischemia is caused by decreased intestinal blood flow that can be caused by a number of mechanisms. Decreased intestinal blood flow results in ischemia and subsequent reperfusion damage at the cellular level that may progress to the development of mucosal injury, tissue necrosis, and metabolic acidosis.

The blood supply to the intestine is derived predominantly from 3 major gastrointestinal arteries that arise from the abdominal aorta: the celiac axis, the superior mesenteric artery (SMA), and the inferior mesenteric artery (IMA). The intestine has significant collateral circulation at all levels that allows for some protection from ischemia and is able to compensate for approximately a 75% acute reduction in mesenteric blood flow for up to 12 hours, without substantial injury.[1]

The pathophysiology of intestinal ischemia can be divided into arterial and venous etiologies and acute and chronic ischemia. The vast majority of cases are secondary to arterial causes. All diseases and conditions that affect arteries, including atherosclerosis, arteritis, aneurysms, arterial infections, dissections, arterial emboli, and thrombosis, are reported to occur in the intestinal arteries.[2]

Acute mesenteric ischemia (AMI) can be further divided into embolic, thrombotic, or nonocclusive causes.[3]

  • Arterial embolism
    • Arterial embolism accounts for approximately one third of acute cases of acute mesenteric ischemia.
    • Emboli to the mesenteric arteries are usually from a dislodged cardiac thrombus.
    • The superior mesenteric artery (SMA) is most commonly affected, whereas the inferior mesenteric artery (IMA) is rarely affected due to its small caliber.[4]
  • Arterial thrombosis
    • Arterial thrombosis accounts for approximately one third of acute cases of acute mesenteric ischemia.
    • It is usually due to acute worsening of ischemia in patients who have preexisting atherosclerosis of the mesenteric arteries.
    • Thrombosis often involves at least 2 of the major splanchnic vessels.[5]
  • Nonocclusive etiology
    • Nonocclusive etiology accounts for approximately one third of acute cases of acute mesenteric ischemia.
    • The primary mechanism is severe and prolonged intestinal vasoconstriction.
    • The most common setting is severe systemic illness with systemic shock usually secondary to reduced cardiac output.[2]
    • Intestinal vasospasm has also been seen to occur in cocaine ingestion[6, 7] , ergot poisoning[8] , digoxin use, and with alpha-adrenergic agonists.
    • A small proportion of cases are from venous thrombosis, seen mostly in patients with hypercoagulable states.
    • Venous thrombosis of the visceral vessels may precipitate an acute ischemic event as compromised venous return leads to interstitial swelling of the bowel wall, with subsequent impedance of arterial flow and eventual tissue necrosis.[3]

Chronic mesenteric ischemia (CMI) usually results from long-standing atherosclerotic disease of 2 or more mesenteric vessels.[9] Other nonatheromatous causes of chronic mesenteric ischemia include the vasculitides such as Takayasu arteritis. Symptoms are caused by the gradual reduction in blood flow to the intestine that occurs during eating since total blood flow to the intestine can increase by 15% during meals.[10] Another rare cause of chronic mesenteric ischemia is due to celiac artery compression syndrome (CACS), which entails external compression of the celiac artery by the median arcuate ligament or the celiac ganglion.[11]

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Epidemiology

Frequency

United States

Acute mesenteric ischemia (AMI) is involved in up to 0.1% of all hospital admissions, although this number is likely to rise as the population ages.

Mortality/Morbidity

  • Mortality rates are high and range from 60-100% depending on the source of obstruction.[3] Early and aggressive diagnosis and treatment has been shown to significantly decrease the mortality rate if the diagnosis is made prior to the development of peritonitis.[12]
  • One report of 21 patients with superior mesenteric artery (SMA) embolus, intestinal viability was achieved in 100% of patients before diagnosis if the duration of symptoms was less than 12 hours, in 56% if it was between 12 and 24 hours, and in only 18% if symptoms were more than 24 hours in duration.[13]
  • Another study found that, even at hospital centers with angiography available 24 hours, mortality rates still were approximately 70%.[14]

Sex

No sex predilection exists.

Age

Mesenteric ischemia is generally a disease of the older population, with the typical age of onset being older than 60 years; however, with risk factors and other predisposing factors, it may be seen in younger patients.

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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  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine 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.

References

  1. Boley SJ. Circulatory responses to acute reduction of superior mesenteric arterial flow. Physiologist. 1969;12:180.

  2. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL. ACC/AHA 2005 Practice 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): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. Mar 21 2006;113(11):e463-654. [Medline].

  3. Chang RW, Chang JB, Longo WE. Update in management of mesenteric ischemia. World J Gastroenterol. May 28 2006;12(20):3243-7. [Medline].

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

  5. Boley SJ, Brandt LJ, Sammartano RJ. History of mesenteric ischemia. The evolution of a diagnosis and management. Surg Clin North Am. Apr 1997;77(2):275-88. [Medline].

  6. Endress C, Gray DG, Wollschlaeger G. Bowel ischemia and perforation after cocaine use. AJR Am J Roentgenol. Jul 1992;159(1):73-5. [Medline].

  7. Sudhakar CB, Al-Hakeem M, MacArthur JD, Sumpio BE. Mesenteric ischemia secondary to cocaine abuse: case reports and literature review. Am J Gastroenterol. Jun 1997;92(6):1053-4. [Medline].

  8. Liu JJ, Ardolf JC. Sumatriptan-associated mesenteric ischemia. Ann Intern Med. Apr 4 2000;132(7):597. [Medline].

  9. Moawad J, Gewertz BL. Chronic mesenteric ischemia. Clinical presentation and diagnosis. Surg Clin North Am. Apr 1997;77(2):357-69. [Medline].

  10. Chang JB, Stein TA. Mesenteric ischemia: acute and chronic. Ann Vasc Surg. May 2003;17(3):323-8. [Medline].

  11. Bech FR. Celiac artery compression syndromes. Surg Clin N Am. 1997.;77:409-424,. [Medline].

  12. Boley SJ, Sprayregen S, Veith FJ, Siegelman SS. An aggressive roentgenologic and surgical approach to acute mesenteric ischemia. Surg Annu. 1973;5:355-78. [Medline].

  13. Boley SJ, Sprayregan S, Siegelman SS, Veith FJ. Initial results from an aggressive roentgenological and surgical approach to acute mesenteric ischemia. Surgery. Dec 1977;82(6):848-55. [Medline].

  14. Nonthasoot B, Tullavardhana T, Sirichindakul B, Suphapol J, Nivatvongs S. Acute mesenteric ischemia: still high mortality rate in the era of 24-hour availability of angiography. J Med Assoc Thai. Sep 2005;88 Suppl 4:S46-50. [Medline].

  15. Sanchez LD, Tracy JA, Berkoff D, Pedrosa I. Ischemic colitis in marathon runners: a case-based review. J Emerg Med. Apr 2006;30(3):321-6. [Medline].

  16. Agaoglu N, Türkyilmaz S, Ovali E, Uçar F, Agaoglu C. Prevalence of prothrombotic abnormalities in patients with acute mesenteric ischemia. World J Surg. Sep 2005;29(9):1135-8. [Medline].

  17. Kumar S, Sarr MG, Kamath PS. Mesenteric venous thrombosis. N Engl J Med. Dec 6 2001;345(23):1683-8. [Medline].

  18. Abdu RA, Zakhour BJ, Dallis DJ. Mesenteric venous thrombosis--1911 to 1984. Surgery. Apr 1987;101(4):383-8. [Medline].

  19. Harward TR, Green D, Bergan JJ, Rizzo RJ, Yao JS. Mesenteric venous thrombosis. J Vasc Surg. Feb 1989;9(2):328-33. [Medline].

  20. Tseng YC, Tseng CK, Chou JW, Lai HC, Hsu CH, Cheng KS, et al. A rare cause of mesenteric ischemia: celiac axis compression syndrome. Intern Med. 2007;46:1187-1190. [Medline].

  21. Lange H, Jackel R. Usefulness of plasma lactate concentration in the diagnosis of acute abdominal disease. Eur J Surg. Jun-Jul 1994;160(6-7):381-4. [Medline].

  22. Lange H, Toivola A. Warning signals in acute abdominal disorders. Lactate is the best marker of mesenteric ischemia. Lakartidningen. 1997;May 14; 94(20):1893-6. [Medline].

  23. Kurt Y, Akin ML, Demirbas S, Uluutku AH, Gulderen M, Avsar K. D-dimer in the early diagnosis of acute mesenteric ischemia secondary to arterial occlusion in rats. Eur Surg Res. Jul-Aug 2005;37(4):216-9. [Medline].

  24. Altinyollar H, Boyabatli M, Berberoglu U. D-dimer as a marker for early diagnosis of acute mesenteric ischemia. Thromb Res. 2006;117(4):463-7. [Medline].

  25. American Gastroenterological Association medical position statement: Guidelines on intestinal ischemia. Gastroenterology. 2000;118:951-953. [Medline].

  26. Horton KM, Fishman EK. Multi-detector row CT of mesenteric ischemia: can it be done?. Radiographics. Nov-Dec 2001;21(6):1463-73. [Medline].

  27. Cikrit DF, Harris VJ, Hemmer CG, Kopecky KK, Dalsing MC, Hyre CE. Comparison of spiral CT scan and arteriography for evaluation of renal and visceral arteries. Ann Vasc Surg. Mar 1996;10(2):109-16. [Medline].

  28. Zeman RK, Silverman PM, Vieco PT, Costello P. CT angiography. AJR Am J Roentgenol. Nov 1995;165(5):1079-88. [Medline].

  29. Kirkpatrick ID, Kroeker MA, Greenberg HM. Biphasic CT with mesenteric CT angiography in the evaluation of acute mesenteric ischemia: initial experience. Radiology. Oct 2003;229(1):91-8. [Medline].

  30. Wiesner W. Is multidetector computerized tomography currently the primary diagnostic method of choice in diagnostic imaging of acute intestinal ischemia? [in German]. Schweiz Rundsch Med Prax. Jul 30 2003;92(31-32):1315-7. [Medline].

  31. Vogelzang RL, Gore RM, Anschuetz SL, Blei AT. Thrombosis of the splanchnic veins: CT diagnosis. AJR Am J Roentgenol. Jan 1988;150(1):93-6. [Medline].

  32. Clark RA, Gallant TE. Acute mesenteric ischemia: angiographic spectrum. AJR Am J Roentgenol. Mar 1984;142(3):555-62. [Medline].

  33. Naitove A, Weismann RE. Primary mesenteric venous thrombosis. Ann Surg. Apr 1965;161:516-23. [Medline].

  34. Kaufman SL, Harrington DP, Siegelman SS. Superior mesenteric artery embolization: an angiographic emergency. Radiology. Sep 1977;124(3):625-30. [Medline].

  35. Bottger T, Scahafer W, Weber W, Junginger T. Value of preoperative diagnosis in mesenteric vascular occlusion: a prospective study [in German]. Langenbecks Arch Chir. 1990;375:278-282. [Medline].

  36. Boos S. [Angiography of the mesenteric artery 1976 to 1991. A change in the indications during mesenteric circulatory disorders?]. Radiologe. Apr 1992;32(4):154-7. [Medline].

  37. Czerny M, Trubel W, Claeys L, Scheuba C, Huk I, Prager M. [Acute mesenteric ischemia]. Zentralbl Chir. 1997;122(7):538-44. [Medline].

  38. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology. May 2000;118(5):954-68. [Medline].

  39. Savassi-Rocha PR, Veloso LF. Treatment of superior mesenteric artery embolism with a fibrinolytic agent: case report and literature review. Hepatogastroenterology. Sep-Oct 2002;49(47):1307-10. [Medline].

  40. Lauenstein TC, Ajaj W, Narin B, Göhde SC, Kröger K, Debatin JF. MR imaging of apparent small-bowel perfusion for diagnosing mesenteric ischemia: feasibility study. Radiology. Feb 2005;234(2):569-75. [Medline].

  41. Heiss SG, Li KC. Magnetic resonance angiography of mesenteric arteries. A review. Invest Radiol. Sep 1998;33(9):670-81. [Medline].

  42. Bowersox JC, Zwolak RM, Walsh DB, Schneider JR, Musson A, LaBombard FE. Duplex ultrasonography in the diagnosis of celiac and mesenteric artery occlusive disease. J Vasc Surg. Dec 1991;14(6):780-6; discussion 786-8. [Medline].

  43. Moneta GL, Yeager RA, Dalman R, Antonovic R, Hall LD, Porter JM. Duplex ultrasound criteria for diagnosis of splanchnic artery stenosis or occlusion. J Vasc Surg. Oct 1991;14(4):511-8; discussion 518-20. [Medline].

  44. Zwolak RM. Can duplex ultrasound replace arteriography in screening for mesenteric ischemia?. Semin Vasc Surg. Dec 1999;12(4):252-60. [Medline].

  45. Char D, Hines G. Chronic mesenteric ischemia: diagnosis and treatment. Heart Dis. Jul-Aug 2001;3(4):231-5. [Medline].

  46. Tambyraja AL. Management of acute mesenteric ischaemia: recommended strategy is misleading. BMJ. Aug 16 2003;327(7411):396; author reply 396. [Medline].

  47. Ward D, Vernava AM, Kaminski DL, Ure T, Peterson G, Garvin P. Improved outcome by identification of high-risk nonocclusive mesenteric ischemia, aggressive reexploration, and delayed anastomosis. Am J Surg. Dec 1995;170(6):577-80; discussion 580-1. [Medline].

  48. Grieshop RJ, Dalsing MC, Cikrit DF, Lalka SG, Sawchuk AP. Acute mesenteric venous thrombosis. Revisited in a time of diagnostic clarity. Am Surg. Sep 1991;57(9):573-7; discussion 578. [Medline].

  49. Jona J, Cummins GM, Head HB, Govostis MC. Recurrent primary mesenteric venous thrombosis. JAMA. Mar 4 1974;227(9):1033-5. [Medline].

  50. Silva JA, White CJ, Collins TJ, Jenkins JS, Andry ME, Reilly JP. Endovascular therapy for chronic mesenteric ischemia. J Am Coll Cardiol. Mar 7 2006;47(5):944-50. [Medline].

  51. Brown DJ, Schermerhorn ML, Powell RJ, Fillinger MF, Rzucidlo EM, Walsh DB. Mesenteric stenting for chronic mesenteric ischemia. J Vasc Surg. Aug 2005;42(2):268-74. [Medline].

  52. Landis MS, Rajan DK, Simons ME, Hayeems EB, Kachura JR, Sniderman KW. Percutaneous management of chronic mesenteric ischemia: outcomes after intervention. J Vasc Interv Radiol. Oct 2005;16(10):1319-25. [Medline].

  53. Sreenarasimhaiah J. Diagnosis and management of intestinal ischaemic disorders. BMJ. Jun 21 2003;326(7403):1372-6. [Medline].

  54. Huang HH, Chang YC, Yen DH, Kao WF, Chen JD, Wang LM. Clinical factors and outcomes in patients with acute mesenteric ischemia in the emergency department. J Chin Med Assoc. Jul 2005;68(7):299-306. [Medline].

  55. Fink S, Chaudhuri TK, Davis HH. Acute mesenteric ischemia and malpractice claims. South Med J. Feb 2000;93(2):210-4. [Medline].

 
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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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