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| :''This article concerns ischemia of the small bowel. See [[ischemic colitis]] for ischemia of the large bowel'' | | <div style="-webkit-user-select: none;"> |
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| {{Infobox_Disease |
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| Name = Mesenteric ischemia |
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| Image = |
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| Caption = |
| | | <figure-inline>[[File:Siren.gif|link=Intestinal ischemia resident survival guide|41x41px]]</figure-inline>|| <br> || <br> |
| DiseasesDB = 29034 |
| | | [[Intestinal ischemia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| ICD10 = {{ICD10|K|55|9|k|55}} |
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| ICD9 = {{ICD9|557.9}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 001156 |
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| eMedicineSubj = radio |
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| eMedicineTopic = 2726|
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| }}
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| {{SI}}
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| {{CMG}}
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| {{EH}} | | {{Mesenteric ischemia}} |
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| '''Mesenteric ischemia''' (Mesenteric ischaemia - British English) is a medical condition in which inflammation and injury of the small intestine result from inadequate blood supply.<ref name="pmid10784596">{{cite journal |author=Brandt LJ, Boley SJ |title=AGA technical review on intestinal ischemia. American Gastrointestinal Association |journal=Gastroenterology |volume=118 |issue=5 |pages=954-68 |year=2000 |pmid=10784596|url=http://www.gastrojournal.org/article/PIIS0016508500701831/fulltext}}</ref><ref name="pmid10784595">{{cite journal |author=American Gastroenterological Association |title=American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia |journal=Gastroenterology |volume=118 |issue=5 |pages=951-3 |year=2000 |pmid=10784595|url=http://www.gastrojournal.org/article/PIIS001650850070182X/fulltext}} http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3069&nbr=2295</ref>. Causes of the reduced blood flow can include changes in the systemic circulation (e.g. [[hypotension|low blood pressure]]) or local factors such as [[vasoconstriction|constriction of blood vessels]] or a [[blood clot]]. It is more common in the elderly<ref name="pmid11432300">{{cite journal | author = Greenwald D, Brandt L, Reinus J | title = Ischemic bowel disease in the elderly. | journal = Gastroenterol Clin North Am | volume = 30 | issue = 2 | pages = 445-73 | year = 2001 | id = PMID 11432300}}</ref><ref name="pmid9146714">{{cite journal |author=McKinsey JF, Gewertz BL |title=Acute mesenteric ischemia |journal=Surg. Clin. North Am. |volume=77 |issue=2 |pages=307-18 |year=1997 |pmid=9146714}}</ref>. | | '''For patient information click [[Mesenteric ischemia (patient information)|here]]''' |
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| ==Diagnosis==
| | {{CMG}}; {{AE}}{{FT}} |
| It is important to differentiate [[ischemic colitis]], which often resolves on its own, from the more immediately life-threatening condition of acute mesenteric ischemia of the [[small bowel]].
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| === Differential Diagnosis ===
| | {{SK}} Intestinal ischemia; intestinal ischaemia; bowel ischemia; bowel ischaemia |
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| In alphabetical order. <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
| | ==[[Mesenteric ischemia overview|Overview]]== |
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| * [[Aortic Aneurysm]]
| | ==[[Mesenteric ischemia historical perspective|Historical Perspective]]== |
| * [[Atherosclerosis]]
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| * [[Atrial fibrillation]]
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| * [[Behcet's Syndrome]]
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| * [[Cardiac arrhythmia]]
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| * [[Cardiac thrombus]]
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| * [[Cirrhosis]]
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| * [[Coagulation disorder]]
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| * [[Congestive Heart Failure]]
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| * [[Dermatomyositis]]
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| * [[Drugs]]
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| * [[Endocarditis]]
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| * [[Hemorrhagic blood loss]]
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| * [[Henoch-Schonlein Purpura]]
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| * [[Hypercoagulable state]]
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| * [[Hypotension]]
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| * [[Hypovolemia]]
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| * [[Myocardial Infarction]]
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| * [[Neoplasm]]
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| * [[Peritonitis]]
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| * [[Polyarteritis Nodosa]]
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| * [[Polycythemia Vera]]
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| * [[Progressive systemic sclerosis]]
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| * [[Reiter's Syndrome]]
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| * [[Rheumatoid Arthritis]]
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| * [[Sepsis]]
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| * [[Shock]]
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| * [[Sjogren's Syndrome]]
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| * [[Systemic Lupus Erythematosus]]
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| * [[Trauma]]
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| * [[Valvular heart disease|Valvular Disease]]
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| * [[Vasculitis]]
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| * [[Wegener's Granulomatosis]]
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| ===Signs and symptoms=== | | ==[[Mesenteric ischemia classification|Classification]]== |
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| Three progressive phases of [[ischemic colitis]] have been described:<ref>Boley, SJ, Brandt, LJ, Veith, FJ. Ischemic disorders of the intestines. Curr Probl Surg 1978; 15:1.</ref><ref>{{cite journal | author = Hunter G, Guernsey J | title = Mesenteric ischemia. | journal = Med Clin North Am | volume = 72 | issue = 5 | pages = 1091-115 | year = 1988 | id = PMID 3045452}}</ref>
| | ==[[Mesenteric ischemia pathophysiology|Pathophysiology]]== |
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| *A ''hyperactive'' phase occurs first, in which the primary symptoms are severe [[abdominal pain]] and the passage of bloody stools. Many patients get better and do not progress beyond this phase.
| | ==[[Mesenteric ischemia causes|Causes]]== |
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| *A ''paralytic'' phase can follow if ischemia continues; in this phase, the [[abdominal pain]] becomes more widespread, the belly becomes more tender to the touch, and bowel [[motility]] decreases, resulting in abdominal bloating, no further bloody stools, and absent bowel sounds on exam.
| | ==[[Mesenteric ischemia differential diagnosis|Differentiating Mesenteric Ischemia from Other Diseases]]== |
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| *Finally, a ''[[shock]]'' phase can develop as fluids start to leak through the damaged colon lining. This can result in [[Shock (medical)|shock]] and [[metabolic acidosis]] with [[dehydration]], [[hypotension|low blood pressure]], [[tachycardia|rapid heart rate]], and confusion. Patients who progress to this phase are often critically ill and require [[intensive care]].
| | ==[[Mesenteric ischemia epidemiology and demographics|Epidemiology and Demographics]]== |
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| Symptoms of mesenteric ischemia vary and can be acute (especially if embolic)<ref name="pmid15159262">{{cite journal |author=Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD |title=Acute mesenteric ischemia: a clinical review |journal=Arch. Intern. Med. |volume=164 |issue=10 |pages=1054-62 |year=2004 |pmid=15159262 | doi=10.1001/archinte.164.10.1054}}</ref>, subacute, or chronic<ref name="pmid2691119">{{cite journal |author=Font VE, Hermann RE, Longworth DL |title=Chronic mesenteric venous thrombosis: difficult diagnosis and therapy |journal=Cleveland Clinic journal of medicine |volume=56 |issue=8 |pages=823-8 |year=1989 |pmid=2691119}}</ref>.
| | ==[[Mesenteric ischemia risk factors|Risk Factors]]== |
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| Case series report prevalence of clinical findings and provide the best available, yet biased, estimate of the sensitivity of clinical findings<ref name="pmid2321134">{{cite journal |author=Levy PJ, Krausz MM, Manny J |title=Acute mesenteric ischemia: improved results--a retrospective analysis of ninety-two patients |journal=Surgery |volume=107 |issue=4 |pages=372-80 |year=1990 |pmid=2321134}}</ref><ref name="pmid11877691">{{cite journal |author=Park WM, Gloviczki P, Cherry KJ, Hallett JW, Bower TC, Panneton JM, Schleck C, Ilstrup D, Harmsen WS, Noel AA |title=Contemporary management of acute mesenteric ischemia: Factors associated with survival |journal=J. Vasc. Surg. |volume=35 |issue=3 |pages=445-52 |year=2002 |pmid=11877691|doi=10.1067/mva.2002.120373 }}</ref>. In a series of 58 patients with mesenteric ischemia due to mixed causes<ref name="pmid11877691">.</ref>:
| | ==[[Mesenteric ischemia natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| * [[abdominal pain]] was present in 95% (median of 24 hours duration). The other three patients presented with shock and [[metabolic acidosis]].
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| * [[nausea]] in 44%
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| * [[vomiting]] in 35%
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| * [[diarrhea]] in 35%
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| * [[heart rate]] > 100 in 33%
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| * 'blood per rectum' in 16% (not stated if this number also included [[occult blood]] - presumably not)
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| * [[constipation]] 7%
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| In the absence of adequate quantitative studies to guide diagnosis, various heuristics help guide diagnosis:
| | ==Diagnosis== |
| * Mesenteric ischemia "''should be suspected when individuals, especially those at high risk for acute mesenteric ischemia, develop severe and persisting abdominal pain that is disproportionate to their abdominal findings''"<ref name="pmid10784595">.</ref>
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| * Regarding mesenteric arterial thrombosis or embolism: "''...early symptoms are present and are relative mild in 50% of cases for three to four days before medical attention is sought''"<ref name="isbn019517545X">Cope's Early Diagnosis of the Acute Abdomen by Zachary Cope and William Silen (2005) - Oxford University Press, USA ISBN 019517545X</ref>.
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| * Regarding mesenteric arterial thrombosis or embolism: "''Any patient with an arrhythmia such as auricular fibrillation who complains of abdominal pain is hghly suspected of having embolization to the superior mesenteric artery until proved otherwise''"<ref name="isbn019517545X">.</ref>.
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| * Regarding nonocclusive intestinal ischemia: "''Any patient who takes digitalis and diuretics and who complains of abdominal pain must be considered to have nonocclusive ischemia until proved otherwise''"<ref name="isbn019517545X">.</ref>.
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| ===Blood tests===
| | [[Mesenteric ischemia guidelines for diagnosis|Guidelines for Diagnosis]] | [[Mesenteric ischemia history and symptoms|History and Symptoms]] | [[Mesenteric ischemia physical examination|Physical Examination]] | [[Mesenteric ischemia laboratory findings|Laboratory Findings]] | [[Mesenteric ischemia x ray|X Ray]] | [[Mesenteric ischemia CT|CT]] | [[Mesenteric ischemia MRA|MRA]] | [[Mesenteric ischemia ultrasound|Ultrasound]] | [[Mesenteric ischemia other imaging findings|Other Imaging Findings]] | [[Mesenteric ischemia other diagnostic studies|Other Diagnostic Studies]] |
| In a series of 58 patients with mesenteric ischemia due to mixed causes<ref name="pmid11877691">.</ref>:
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| * [[White blood cell count]] >10.5 in 98% (probably an overestimate as only tested in 81% of patients)
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| * [[Lactic acid]] elevated 91% (probably an overestimate as only tested in 57% of patients)
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| ===Plain x-ray=== | | ==Treatment== |
| Plain [[X-ray]]s are often normal or show non-specific findings.<ref>{{cite journal | author = Smerud M, Johnson C, Stephens D | title = Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases. | journal = AJR Am J Roentgenol | volume = 154 | issue = 1 | pages = 99-103 | year = 1990 | id = PMID 2104734}}</ref>.
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| * Bowel wall thickening
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| * Submucosal focal mural thickening or thumbprinting
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| * Dilated bowel loops
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| * [http://www.radswiki.net/main/index.php?title=Pneumatosis Pneumatosis]
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| * Mesenteric or [http://www.radswiki.net/main/index.php?title=Portal_venous_gas portal venous gas]
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| ===Computed tomography===
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| [[Computed tomography]] (CT scan) is often used.<ref name="pmid3336673">{{cite journal | author = Alpern M, Glazer G, Francis I | title = Ischemic or infarcted bowel: CT findings. | journal = Radiology | volume = 166 | issue = 1 Pt 1 | pages = 149-52 | year = 1988 | id = PMID 3336673}}</ref><ref>{{cite journal | author = Taourel P, Deneuville M, Pradel J, Régent D, Bruel J | title = Acute mesenteric ischemia: diagnosis with contrast-enhanced CT. | journal = Radiology | volume = 199 | issue = 3 | pages = 632-6 | year = 1996 | id = PMID 8637978|doi=10.1148/rg.243035084|url=http://radiology.rsnajnls.org/cgi/reprint/199/3/632.pdf}}</ref> The accuracy of the [[Computed tomography|CT scan]] depends on whether a small bowel obstruction (SBO) is present <ref name="pmid15835585">{{cite journal |author=Staunton M, Malone DE |title=Can acute mesenteric ischemia be ruled out using computed tomography? Critically appraised topic |journal=Canadian Association of Radiologists journal = Journal l'Association canadienne des radiologistes |volume=56 |issue=1 |pages=9-12 |year=2005 |pmid=15835585 | url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=16596241&site=ehost-live}}</ref>.
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| '''SBO absent'''
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| * prevalence of mesenteric ischemia 23%
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| * [[sensitivity (tests)|sensitivity]] 64%
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| * [[specificity (tests)|specificity]] 92%
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| * [[positive predictive value]] (at prevalence of 23%) 79%
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| * [[negative predictive value]] (at prevalence of 23%) 95%
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| '''SBO present'''
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| * prevalence of mesenteric ischemia 62%
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| * [[sensitivity (tests)|sensitivity]] 83%
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| * [[specificity (tests)|specificity]] 93%
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| * [[positive predictive value]] (at prevalence of 62%) 93%
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| * [[negative predictive value]] (at prevalence of 62%) 61%
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| Findings on [[Computed tomography|CT scan]] include:
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| * Mesenteric edema<ref name="pmid3336673"/>
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| * Bowel dilatation<ref name="pmid3336673"/>
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| * Bowel wall thickening<ref name="pmid3336673"/>
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| * Intramural gas<ref name="pmid3336673"/>
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| * Mesenteric stranding<ref name="pmid15143223">{{cite journal |author=Pereira JM, Sirlin CB, Pinto PS, Jeffrey RB, Stella DL, Casola G |title=Disproportionate fat stranding: a helpful CT sign in patients with acute abdominal pain |journal=Radiographics : a review publication of the Radiological Society of North America, Inc |volume=24 |issue=3 |pages=703–15 |year=2004 |pmid=15143223 |doi=10.1148/rg.243035084}}</ref>
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| ==Treatment==
| | [[Mesenteric ischemia guidelines for treatment|Guidelines for Treatment]] | [[Mesenteric ischemia medical therapy|Medical Therapy]] | [[Mesenteric ischemia surgery|Surgery]] | [[Mesenteric ischemia primary prevention|Primary Prevention]] | [[Mesenteric ischemia secondary prevention|Secondary Prevention]] | [[Mesenteric ischemia cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Mesenteric ischemia future or investigational therapies|Future or Investigational Therapies]] |
| "Surgical revascularisation remains the treatment of choice for mesenteric ischaemia, but thrombolytic medical treatment and vascular interventional radiological techniques have a growing role" <ref name="pmid12816826">{{cite journal |author=Sreenarasimhaiah J |title=Diagnosis and management of intestinal ischaemic disorders |journal=BMJ |volume=326 |issue=7403 |pages=1372-6 |year=2003 |pmid=12816826 | doi=10.1136/bmj.326.7403.1372}}</ref>.
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| ==Prognosis== | | ==Case Studies== |
| The prognosis depends on prompt diagnosis (less than 12-24 hours and before [[gangrene]])<ref name="pmid10784596">.</ref> and the the underlying cause<ref name="pmid">{{cite journal |author=Schoots IG, Koffeman GI, Legemate DA, Levi M, van Gulik TM |title=Systematic review of survival after acute mesenteric ischaemia according to disease aetiology |journal=The British journal of surgery |volume=91 |issue=1 |pages=17-27 |year=2004 |pmid=14716789}}</ref>:
| | [[Mesenteric ischemia case study one|Case #1]] |
| * [[venous thrombosis]] - 32% mortality
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| * [[arterial embolism]] - 54% mortality
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| * [[arterial thrombosis]] - 77% mortality
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| * [[non-occlusive ischemia]] - 73% mortality
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| ==References== | | ==Related Chapters== |
| <references/>
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| | ''This article concerns ischemia of the small bowel. See [[ischemic colitis]] for ischemia of the large bowel'' |
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| {{Symptoms and signs}} | | {{Symptoms and signs}} |
| {{SIB}}
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| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
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