Mesenteric ischemia natural history, complications and prognosis: Difference between revisions

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Latest revision as of 12:34, 14 April 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Overview

If left untreated, 99% of patients with mesenteric ischemia may progress to develop intestinal gangrene, septic shock and subsequent multiorgan failure. The progressive phases of mesenteric ischemia include a hyperactive phase, paralytic phase and a shock phase. The prognosis largely depends on prompt diagnosis and timely medical/surgical intervention depending on the underlying etiology. Poor prognostic factors include signs such as: tachypnea, tachycardia, hypotension and altered mental status. Common complications of mesenteric ischemia include: bowel infarction, perforation, sepsis, peritonitis, septic shock, and multiorgan failure.

Natural History

If left untreated, 99% of patients with mesenteric ischemia progress to develop intestinal gangrene, septic shock and subsequent multiorgan failure.
It can be divided into three phases:^[1]^[2]
- Hyperactive phase
- Paralytic phase
- Shock

Progressive phases of mesenteric ischemia include:

(a) Hyperactive phase:

Hyperactive phase is the phase of mesenteric ischemia in which the most common symptoms are excruciating abdominal pain and the passage of bloody stools.
Many patients get better and do not progress beyond this phase if treated in time.

(b) Paralytic phase:

Paralytic phase follows if ischemia continues.
In this phase, the abdominal pain becomes more widespread, the abdomen becomes tender to touch, and bowel motility decreases, resulting in abdominal bloating, no further bloody stools, and absent bowel sounds on exam.

(c) Shock phase:

Shock phase can develop as fluids start to leak through the damaged colon lining.
This can result in shock and metabolic acidosis with dehydration, low blood pressure, rapid heart rate, and confusion.
Patients who progress to this phase are often critically ill and require intensive care.

Prognosis

Mesenteric ischemia is difficult to diagnose.^[3]
The prognosis mostly depends on prompt diagnosis and timely medical/surgical intervention depending on the underlying etiology.^[4]
Generally, the prognosis is poor when there is delay in the treatment, ranging from 0% to 40%.^[5]
In case of occlusive type of acute mesenteric ischemia, mortality can be up to 90% without surgical intervention.^[6]^[7]

In embolic type of mesenteric arterial occlusion, there is improved outcome after surgical intervention, which is not the case in thrombotic and non-occlusive type of mesenteric ischemia.

Type of mesenteric ischemia	Survival rate	Mortality rate
Arterial embolism	41%	54%
Arterial thrombosis	38%	77%
Venous thrombosis	87%	32%

Venous thrombosis - 32% mortality
Arterial embolism - 54% mortality
Arterial thrombosis - 77% mortality
Non-occlusive ischemia - 70-90% mortality^[8]

Poor prognostic factors
Signs and symptoms	Signs of shock and dehydration: Tachypnea Tachycardia Fever Hypotension Foul smelling breath (from bowel necrosis) Altered mental status Signs of atherosclerosis: Xanthelasmas Peripheral artery disease Coronary artery disease
Laboratory findings	Metabolic acidosis Bandemia Elevated AST (aspartate transferase) Elevated blood urea nitrogen

Prognostic indicators of mesenteric ischemia:^[9]

Mannheim Peritonitis Index (MPI)
Platelet to lymphocyte ratio

Complications

Common complications of mesenteric ischemia include:

References

↑ Boley, SJ, Brandt, LJ, Veith, FJ. Ischemic disorders of the intestines. Curr Probl Surg 1978; 15:1.
↑ Hunter G, Guernsey J (1988). "Mesenteric ischemia". Med Clin North Am. 72 (5): 1091–115. PMID 3045452.
↑ Klempnauer J, Grothues F, Bektas H, Pichlmayr R (1997). "Long-term results after surgery for acute mesenteric ischemia". Surgery. 121 (3): 239–43. PMID 9068664.
↑ Meyer T, Klein P, Schweiger H, Lang W (1998). "[How can the prognosis of acute mesenteric artery ischemia be improved? Results of a retrospective analysis]". Zentralbl Chir. 123 (3): 230–4. PMID 9586181.
↑ Endean ED, Barnes SL, Kwolek CJ, Minion DJ, Schwarcz TH, Mentzer RM (2001). "Surgical management of thrombotic acute intestinal ischemia". Ann Surg. 233 (6): 801–8. PMC 1421323. PMID 11407335.
↑ Kärkkäinen, Jussi M.; Acosta, Stefan (2017). "Acute mesenteric ischemia (part I) – Incidence, etiologies, and how to improve early diagnosis". Best Practice & Research Clinical Gastroenterology. 31 (1): 15–25. doi:10.1016/j.bpg.2016.10.018. ISSN 1521-6918.
↑ Ryer EJ, Kalra M, Oderich GS, Duncan AA, Gloviczki P, Cha S; et al. (2012). "Revascularization for acute mesenteric ischemia". J Vasc Surg. 55 (6): 1682–9. doi:10.1016/j.jvs.2011.12.017. PMID 22503176.
↑ Salamone G, Raspanti C, Licari L, Falco N, Rotolo G, Augello G; et al. (2017). "Non-Occlusive Mesenteric Ischemia (NOMI) in Parkinson's disease: case report". G Chir. 38 (2): 71–76. PMC 5509387. PMID 28691670.
↑ Yılmaz EM, Cartı EB (2017). "Prognostic factors in acute mesenteric ischemia and evaluation with Mannheim Peritonitis Index and platelet-to-lymphocyte ratio". Ulus Travma Acil Cerrahi Derg. 23 (4): 301–305. doi:10.5505/tjtes.2016.00701. PMID 28762450.

[1] Boley, SJ, Brandt, LJ, Veith, FJ. Ischemic disorders of the intestines. Curr Probl Surg 1978; 15:1.

[2] Hunter G, Guernsey J (1988). "Mesenteric ischemia". Med Clin North Am. 72 (5): 1091–115. PMID 3045452.

[pmid9068664-3] Klempnauer J, Grothues F, Bektas H, Pichlmayr R (1997). "Long-term results after surgery for acute mesenteric ischemia". Surgery. 121 (3): 239–43. PMID 9068664.

[pmid9586181-4] Meyer T, Klein P, Schweiger H, Lang W (1998). "[How can the prognosis of acute mesenteric artery ischemia be improved? Results of a retrospective analysis]". Zentralbl Chir. 123 (3): 230–4. PMID 9586181.

[pmid11407335-5] Endean ED, Barnes SL, Kwolek CJ, Minion DJ, Schwarcz TH, Mentzer RM (2001). "Surgical management of thrombotic acute intestinal ischemia". Ann Surg. 233 (6): 801–8. PMC 1421323. PMID 11407335.

[KärkkäinenAcosta2017-6] Kärkkäinen, Jussi M.; Acosta, Stefan (2017). "Acute mesenteric ischemia (part I) – Incidence, etiologies, and how to improve early diagnosis". Best Practice & Research Clinical Gastroenterology. 31 (1): 15–25. doi:10.1016/j.bpg.2016.10.018. ISSN 1521-6918.

[pmid22503176-7] Ryer EJ, Kalra M, Oderich GS, Duncan AA, Gloviczki P, Cha S; et al. (2012). "Revascularization for acute mesenteric ischemia". J Vasc Surg. 55 (6): 1682–9. doi:10.1016/j.jvs.2011.12.017. PMID 22503176.

[pmid28691670-8] Salamone G, Raspanti C, Licari L, Falco N, Rotolo G, Augello G; et al. (2017). "Non-Occlusive Mesenteric Ischemia (NOMI) in Parkinson's disease: case report". G Chir. 38 (2): 71–76. PMC 5509387. PMID 28691670.

[pmid28762450-9] Yılmaz EM, Cartı EB (2017). "Prognostic factors in acute mesenteric ischemia and evaluation with Mannheim Peritonitis Index and platelet-to-lymphocyte ratio". Ulus Travma Acil Cerrahi Derg. 23 (4): 301–305. doi:10.5505/tjtes.2016.00701. PMID 28762450.

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[2]

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[4]

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[9]

@@ Line 2: / Line 2: @@
 {{Mesenteric ischemia}}
-{{CMG}} {{AE}} {{FT}}
+{{CMG}}; {{AE}}{{FT}}
 ==Overview==
+If left untreated, 99% of patients with [[Mesenteric ischemia|mesenteric]] ischemia may progress to develop [[Intestine|intestinal]] [[gangrene]], [[Sepsis|septic]] [[shock]] and subsequent [[Multiple organ dysfunction syndrome|multiorgan]] failure. The progressive phases of mesenteric ischemia include a [[hyperactive]] phase, [[paralytic]] phase and a [[shock]] phase. The [[prognosis]] largely depends on prompt [[diagnosis]] and timely [[Medicine|medical]]/surgical intervention depending on the underlying etiology. Poor prognostic factors include signs such as: [[tachypnea]], [[tachycardia]], [[hypotension]] and [[altered mental status]]. Common complications of [[Mesenteric ischemia|mesenteric]] ischemia include: [[bowel infarction]], [[perforation]], [[sepsis]], [[peritonitis]], [[Sepsis|septic shock]], and [[multiple organ dysfunction syndrome|multiorgan failure]].
 ==Natural History==
-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>
+*If left untreated, 99% of patients with [[Mesenteric ischemia|mesenteric]] ischemia progress to develop [[Intestine|intestinal]] [[gangrene]], [[Sepsis|septic]] [[shock]] and subsequent [[Multiple organ dysfunction syndrome|multiorgan]] failure.
+*It can be divided into three phases:<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>
+**[[Hyperactive]] phase
+**[[Paralytic]] phase
+**[[Shock]]
-*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.
+==== Progressive phases of [[mesenteric ischemia]] include: ====
-*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.
+===== ''(a) Hyperactive'' phase: =====
+* Hyperactive phase is the phase of mesenteric ischemia in which the most common symptoms are excruciating [[abdominal pain]] and the passage of bloody stools.
+* Many patients get better and do not progress beyond this phase if treated in time.
-*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]].
+===== ''(b) Paralytic'' phase: =====
+* Paralytic phase follows if ischemia continues.
+* In this phase, the [[abdominal pain]] becomes more widespread, the abdomen becomes tender to touch, and bowel [[motility]] decreases, resulting in abdominal bloating, no further bloody stools, and absent bowel sounds on exam.
+===== (c) Shock phase: =====
+*''[[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]].
 ==Prognosis==
-In the case of chronic mesenteric ischemia, the outlook after a successful surgery is good. However, if appropriate lifestyle changes (such as a healthy diet and exercise) are not made, any problems with artherosclerosis will generally get worse over time.  Persons with acute mesenteric ischemia usually do poorly, since death of the intestine often occurs before surgery is done. However, when diagnosed and treated right away, patients with acute mesenteric ischemia can be treated successfully.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|Mesenteric]] ischemia is difficult to diagnose.<ref name="pmid9068664">{{cite journal| author=Klempnauer J, Grothues F, Bektas H, Pichlmayr R| title=Long-term results after surgery for acute mesenteric ischemia. | journal=Surgery | year= 1997 | volume= 121 | issue= 3 | pages= 239-43 | pmid=9068664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9068664  }} </ref>
+* The [[prognosis]] mostly depends on prompt [[diagnosis]] and timely [[Medicine|medical]]/surgical intervention depending on the underlying etiology.<ref name="pmid9586181">{{cite journal| author=Meyer T, Klein P, Schweiger H, Lang W| title=[How can the prognosis of acute mesenteric artery ischemia be improved? Results of a retrospective analysis]. | journal=Zentralbl Chir | year= 1998 | volume= 123 | issue= 3 | pages= 230-4 | pmid=9586181 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9586181  }} </ref>
+* Generally, the [[prognosis]] is poor when there is delay in the treatment, ranging from 0% to 40%.<ref name="pmid11407335">{{cite journal| author=Endean ED, Barnes SL, Kwolek CJ, Minion DJ, Schwarcz TH, Mentzer RM| title=Surgical management of thrombotic acute intestinal ischemia. | journal=Ann Surg | year= 2001 | volume= 233 | issue= 6 | pages= 801-8 | pmid=11407335 | doi= | pmc=1421323 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11407335  }} </ref>
+* In case of occlusive type of acute [[Mesenteric ischemia|mesenteric]] ischemia, mortality can be up to 90% without surgical intervention.<ref name="KärkkäinenAcosta2017">{{cite journal|last1=Kärkkäinen|first1=Jussi M.|last2=Acosta|first2=Stefan|title=Acute mesenteric ischemia (part I) – Incidence, etiologies, and how to improve early diagnosis|journal=Best Practice & Research Clinical Gastroenterology|volume=31|issue=1|year=2017|pages=15–25|issn=15216918|doi=10.1016/j.bpg.2016.10.018}}</ref><ref name="pmid22503176">{{cite journal| author=Ryer EJ, Kalra M, Oderich GS, Duncan AA, Gloviczki P, Cha S et al.| title=Revascularization for acute mesenteric ischemia. | journal=J Vasc Surg | year= 2012 | volume= 55 | issue= 6 | pages= 1682-9 | pmid=22503176 | doi=10.1016/j.jvs.2011.12.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22503176  }} </ref>
+* In [[Embolism|embolic]] type of [[Mesenteric ischemia|mesenteric]] [[Artery|arterial]] occlusion, there is improved outcome after surgical intervention, which is not the case in [[Thrombosis|thrombotic]] and non-occlusive type of [[Mesenteric ischemia|mesenteric]] ischemia.
+{| class="wikitable"
+!Type of mesenteric ischemia
+!Survival rate
+!Mortality rate
+|-
+|[[Artery|Arterial]] [[embolism]]
+|41%
+|54%
+|-
+|[[Arterial thrombosis]]
+|38%
+|77%
+|-
+|[[Venous thrombosis]]
+|87%
+|32%
+|}
 * [[Venous thrombosis]] - 32% mortality
 * [[Arterial embolism]] - 54% mortality
 * [[Arterial thrombosis]] - 77% mortality
 * [[Non-occlusive ischemia]] - 70-90% mortality<ref name="pmid28691670">{{cite journal| author=Salamone G, Raspanti C, Licari L, Falco N, Rotolo G, Augello G et al.| title=Non-Occlusive Mesenteric Ischemia (NOMI) in Parkinson's disease: case report. | journal=G Chir | year= 2017 | volume= 38 | issue= 2 | pages= 71-76 | pmid=28691670 | doi= | pmc=5509387 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28691670  }} </ref>
+{| class="wikitable"
+! colspan="2" |Poor prognostic factors
+|-
+|'''Signs and symptoms'''
+|Signs of shock and dehydration:
+* [[Tachypnea]]
+* [[Tachycardia]]
+* [[Fever]]
+* [[Hypotension]]
+* Foul smelling breath (from bowel necrosis)
+* [[Altered mental status]]
+Signs of [[atherosclerosis]]:
+* Xanthelasmas
+* [[Peripheral arterial disease|Peripheral artery disease]]
+* [[Coronary heart disease|Coronary artery disease]]
+|-
+|'''Laboratory findings'''
+|
+* [[Metabolic acidosis|Metabolic]] acidosis
+* [[Bandemia]]
+* Elevated AST ([[aspartate]] [[transferase]])
+* Elevated [[blood]] [[urea]] nitrogen
+|}
+'''Prognostic indicators of mesenteric ischemia:'''<ref name="pmid28762450">{{cite journal| author=Yılmaz EM, Cartı EB| title=Prognostic factors in acute mesenteric ischemia and evaluation with Mannheim Peritonitis Index and platelet-to-lymphocyte ratio. | journal=Ulus Travma Acil Cerrahi Derg | year= 2017 | volume= 23 | issue= 4 | pages= 301-305 | pmid=28762450 | doi=10.5505/tjtes.2016.00701 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28762450  }} </ref>
+* [[Mannheim's Peritoneal index score (MPI)|Mannheim]] Peritonitis Index (MPI)
+* [[Platelet]] to [[lymphocyte]] ratio
 ==Complications==
-Tissue death from lack of blood flow ([[infarction]]) in the intestines is the most serious complication of mesenteric artery ischemia. Surgery may be needed to remove the dead portion.
+*Common complications of [[Mesenteric ischemia|mesenteric]] ischemia include:
+**[[Bowel infarction]]
+**[[Perforation]]
+**[[Sepsis]]
+**[[Peritonitis]]
+**[[Sepsis|Septic shock]]
+**[[Multiple organ dysfunction syndrome|Multiorgan failure]]
 ==References==
@@ Line 29: / Line 98: @@
 [[Category:Needs content]]
+[[Category:Up-To-Date]]