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{{Mesenteric ischemia}}
{{Mesenteric ischemia}}


{{CMG}} {{AE}} {{FT}}
{{CMG}}; {{AE}}{{FT}}
 
==Overview==
==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==
==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==
==Prognosis==
* Mesenteric ischemia is difficult to diagnose.
* [[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 timley 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>
* 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>
* 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, mortality can be upto 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>
* 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 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.
* 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"
{| class="wikitable"
!Type of mesenteric ischemia
!Type of mesenteric ischemia
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!Mortality rate
!Mortality rate
|-
|-
|Arterial embolism
|[[Artery|Arterial]] [[embolism]]
|41%
|41%
|54%
|54%
Line 43: Line 58:
* [[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>
* [[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"
{| class="wikitable"
! colspan="4" |Poor prognostic factors
! colspan="2" |Poor prognostic factors
|-
|-
|Signs and symptoms
|'''Signs and symptoms'''
|Signs of shock
|Signs of shock and dehydration:
* Tachypnea
* [[Tachypnea]]
* Tachycardia
* [[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
|'''Laboratory findings'''
|
* Metabolic acidosis
* Bandemia
* Elevated AST (aspartate transferase)
* Elevated blood urea nitrogen
|
|
|-
|
|
|
|
|
* [[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==
==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==
==References==
Line 76: Line 98:


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Latest revision as of 12:34, 14 April 2021

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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

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:

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]
Type of mesenteric ischemia Survival rate Mortality rate
Arterial embolism 41% 54%
Arterial thrombosis 38% 77%
Venous thrombosis 87% 32%
Poor prognostic factors
Signs and symptoms Signs of shock and dehydration:

Signs of atherosclerosis:

Laboratory findings

Prognostic indicators of mesenteric ischemia:[9]

Complications

References

  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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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