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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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| | | <figure-inline>[[File:Siren.gif|link=Intestinal ischemia resident survival guide|41x41px]]</figure-inline>|| <br> || <br> |
| | | [[Intestinal ischemia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
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| {{Infobox_Disease |
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| Name = Mesenteric ischemia |
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| Image = |
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| Caption = |
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| DiseasesDB = 29034 |
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| 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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| {{Mesenteric ischemia}} | | {{Mesenteric ischemia}} |
| {{CMG}}
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| | '''For patient information click [[Mesenteric ischemia (patient information)|here]]''' |
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| | {{CMG}}; {{AE}}{{FT}} |
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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>.
| | {{SK}} Intestinal ischemia; intestinal ischaemia; bowel ischemia; bowel ischaemia |
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| ==Diagnosis== | | ==[[Mesenteric ischemia overview|Overview]]== |
| 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 === | | ==[[Mesenteric ischemia historical perspective|Historical Perspective]]== |
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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 classification|Classification]]== |
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| * [[Aortic Aneurysm]]
| | ==[[Mesenteric ischemia pathophysiology|Pathophysiology]]== |
| * [[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 causes|Causes]]== |
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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 differential diagnosis|Differentiating Mesenteric Ischemia from Other Diseases]]== |
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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 epidemiology and demographics|Epidemiology and Demographics]]== |
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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 risk factors|Risk Factors]]== |
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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 natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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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>.
| | ==Diagnosis== |
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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 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]] |
| * [[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:
| | ==Treatment== |
| * 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===
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| 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===
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| 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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| * The CT and MR imaging findings represent a combination of those seen at plain radiography, barium studies, and angiography (vascular occlusion).
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| * CT and/or MR imaging may be helpful in determining the primary cause of bowel ischemia as well as allowing direct evaluation of the bowel wall, adjacent mesentery, and vascular structures.
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| * The '''most common CT finding in bowel ischemia is bowel wall thickening''' (nonspecific finding). The thickened bowel wall is sometimes associated with the [[target sign]], alternating layers of high and low attenuation within the thickened bowel wall, which results from submucosal edema or hemorrhage.
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| * '''Absent or poor enhancement of the bowel wall is the most specific finding for bowel ischemia.'''
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| * Other CT findings of bowel ischemia reported in the literature include arterial occlusion, mesenteric or portal vein thrombosis, bowel dilatation, engorgement of mesenteric veins and mesenteric edema, intramural gas (intestinal pneumatosis), mesenteric or portal venous gas, lack of bowel wall enhancement, and infarction of other abdominal organs (eg, liver, spleen, or kidneys).
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| ** Bowel dilatation reflects the interruption of peristaltic activity in ischemic segments. It is a common but nonspecific finding in bowel ischemia.
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| ** Engorgement of mesenteric veins reflects venous congestion secondary to stasis.
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| ** Owing to the edema that accompanies bowel ischemia, the mesenteric fat may be abnormally increased in attenuation.
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| ** Intramural gas is a less common but more specific CT sign of ischemic bowel disease. The intramural gas is caused by dissection of luminal gas into the bowel wall across the compromised mucosa.
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| ** Mesenteric or portal venous gas is an even less common CT manifestation of ischemic bowel disease and represents the propagation of intramural gas into the mesenteric venous system. Free intraperitoneal gas is an ominous CT sign in ischemic bowel disease because it indicates perforation of an infarcted bowel segment.
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| '''Patient #1: CT images of patient with ischemic bowel demonstrates pneumatosis and portal venous gas'''
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| <gallery>
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| Image:
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| Bowel-infarction-CT-01.jpg
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| Bowel-infarction-CT-02.jpg
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| Bowel-infarction-CT-03.jpg
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| </gallery>
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| '''Patient #2: CT images demonstrate mesenteric ischemia with marked atherosclerosis of arteries'''
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| Mesenteric ischemia 101.jpg
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| Mesenteric ischemia 102.jpg
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| Mesenteric ischemia 103.jpg
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| Mesenteric ischemia 104.jpg | | [[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]] |
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| | ==Case Studies== |
| | [[Mesenteric ischemia case study one|Case #1]] |
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| Mesenteric ischemia 105.jpg
| | ==Related Chapters== |
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| Mesenteric ischemia 106.jpg
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| </gallery>
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| ==Treatment== | |
| "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==
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| 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>:
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| * [[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==
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| <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}} |
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| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
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