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

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Revision as of 16:37, 12 January 2018

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 subsequently multiorgan failure.

Natural History

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

Progressive phases of ischemic colitis include:

(a) Hyperactive phase:

Hyperactive phase is that phase of mesenteric ischemia 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.

(b) Paralytic phase: 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.

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 upto 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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@@ Line 14: / Line 14: @@
 **[[Shock]]
+==== Progressive phases of [[ischemic colitis]] include: ====
+===== ''(a) Hyperactive'' phase: =====
-Progressive phases of [[ischemic colitis]] have been described:
+* Hyperactive phase is that phase of mesenteric ischemia in which the primary symptoms are severe [[abdominal pain]] and the passage of bloody stools.
-*''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.
+* Many patients get better and do not progress beyond this phase.
-*''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.
+''(b) Paralytic'' phase: 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.
 *''[[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]].