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[[File:Pneumatosis-intestinalis-2.jpgthumb|center|Case courtesy of <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/11782">rID: 11782</a>]
[[File:Pneumatosis-intestinalis-2.jpgthumb|center|Case courtesy of Radswiki, Radiopaedia.org, rID: 11782]]


==Pathophysiology==
==Pathophysiology==

Revision as of 15:29, 15 January 2018


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


Overview

Mesenteric ischemia is a type of intestinal ischemia primarily affecting the small intestine. It is one of the life-threatening gastrointestinal vascular emergencies which requires prompt surgical/medical intervention depending upon the underlying cause.

It can be divided into occlusive/non-occlusive, arterial or venous, localized/generalized and superficial or transmural.[1]


new [2] V new [3] (A) Grade 1. Normal. No vascular congestion is present, and both the villous architecture and muscular layer are preserved. (B) Grade 2. Villous architecture is preserved, with some mucosal congestion and dilated capillaries (black arrow). (C) Grade 3. Mucosa is congested (black arrow) with loss of superficial glandular architecture, but deep villous architecture is preserved. (D) Grade 4. The mucosa is completely involved, with loss of all superficial and deep glandular architecture, but the muscular layer is preserved. (E) Grade 5. There is total loss of glandular architecture, and the muscularis propria shows degeneration, fragmentation, and myocyte death, all indicative of transmural infarction (black arrow).

Overview

The anatomy and physiology of the small intestine plays a vital role in the develpoment of mesenteric ischemia. Intestinal muscosa has a high metabolic rate and accordingly a high blood flow requirement. The majority of blood supply of the intestine comes from the superior mesenteric artery, with a collateral blood supply from superior and inferior pancreaticoduodenal arteries (branches of the celiac artery) as well as the inferior mesenteric artery. The splanchnic circulation (arteries supplying the viscera) receives 15-35% of the cardiac output, making it sensitive to the effects of decreased perfusion. Mesenteric ischemia occurs when intestinal blood supply is compromised by more than 50% of the original blood flow. This can lead to disrutpion of mucosal barrier, allowing the release of bacterial toxins (present in the intestinal lumen) and vasoactive mediators which ultimately lead to complete necrosis (cell death) of the intestinal mucosa. This can further progress to depression in myocardial activity, sepsis, multiorgan failure, and without prompt intervention, even death.[4]


Case courtesy of Radswiki, Radiopaedia.org, rID: 11782
Case courtesy of Radswiki, Radiopaedia.org, rID: 11782

Pathophysiology

Pathogenesis

Intestinal damage occurs in response to ischemic insult.[5]

Following factors play a role in the development of mesenteric ischemia.

(a) Mesenteric vascular anatomy (General circulation)

(b) Collateral circulation

(c) Response of mesenteric vasculature to autonomic stimuli

(d) Vasoactive and humoral factors

(a) Mesenteric vascular anatomy and physiology:

The arterial supply of the intestine originates from three major arteries:[6][7][8]

  • Superior mesenteric artery (SMA)
    • Supplies the small intestine, proximal and mid colon upto the splenic flexure.
  • Inferior mesenteric artery (IMA)
    • Supplies hind gut starting from the splenic flexure to the rectum.
  • Celiac artery (CA)
    • Supplies the foregut, hepatobiliary system and spleen.
  • The venous system parallels the arterial branches and drains into the portal venous system.
  • The mesenteric circulation recevies approximately 25% of the resting and 35% of the postprandial cardiac output.
  • Mucosal and submucosal layers of the intestine receive 70% of the mesenteric blood flow, with the rest supplying the muscularis and serosal layers.

Commonly affected arteries:

  • Embolus can typically lodge into points of normal anatomic narrowing.
  • This makes superior mesenteric artery the most vulnerable site because of its relatively larger diameter (more blood flow) and low take off angle (more likely to from the aorta.
  • The majority of emboli lodge 3-10cm distal to the origin of superior mesenteric artery, classically sparing the proximal jejunum and colon.

(b) Collateral circulation:

The role of collateral circulation in the development of mesenteric ischemia is as follows:[9][10][11]

  • Intestines receive collateral blood supply at all levels from the superior and inferior pancreaticoduodenal arteries, branches of the celiac artery, which provides protection from ischemia.
  • These arteries can compensate for 75% reduction in mesenteric blood flow for upto 12 hours, without substanial injury.
  •  An extensive collateral circulation protects the intestines from transient periods of inadequate perfusion. However, prolonged reduction in splanchnic blood flow leads to vasoconstriction in the affected vascular bed, and eventually reduces collateral blood flow.  
  • The SMA and IMA communicate via the marginal artery of Drummond and the meandering mesenteric artery.
  • Collateralization between the IMA and systemic circulation occurs in the rectum as the superior rectal (hemorrhoidal) vessels merge with the middle rectal vessels from the internal iliac arteries.
  • The areas lacking this collateralization are prone towards ischemia.

(c) Factors regulating the mesenteric blood flow:

Mechansims that control the regulation of vascular tone of mesenteric circulation in response to periods of stress such as systemic hypotension or postprandial state.

Physiologically mesenteric circulation is affected by:[12][13]

  • Intrinsic regulatory system that includes metabolic and myogenic factors.
  • Extrinsic regulatory system that includes neural and humoral factors.

Intrinsic regulation:

  • Metabolic factors:
    • Reduction in blood supply to the mesentery causes adaptive changes in the splanchnic circulation.
    • A discrepancy between tissue oxyegn demand and supply raises the concentration of local metabolites such as hydrogen, potassium, carbon dioxide, and adenosine, resulting in vasodilation and hyperemia.
  • Myogenic factors:
    • Myogenic theory suggests that arteriolar tension receptors act to regulate vascular resistance in accordance with the transmural pressure.
    • An acute decrease in perfusion pressure is compensated for by a reduction in arteriolar wall tension, thereby maintaining splanchnic blood flow.

Extrinsic regulation:

  • Neural component:
    • The extrinsic neural component of splanchnic circulatory regulation comprises the alpha-activated vasoconstrictor fibers.
    • Intense activation of vasoconstrictor fibers through alpha-adrenergic stimulation results in vasoconstriction of small vessels and a decrease in mesenteric blood flow.
    • After periods of prolonged alpha-adrenergic vasoconstriction, blood flow increases, presumably through β-adrenergic stimulation, which acts as a protective response.
    • Although numerous types of neural stimulation (e.g. vagal, cholinergic, histaminergic, and sympathetic) can affect the blood supply of the gut, the adrenergic limb of the autonomic nervous system is the predominant neural influence on splanchnic circulation.
  • Humoral component:
    • Numerous endogenous and exogenous humoral factors affect the splanchnic circulation.
    • Norepinephrine and high doses of epinephrine produce intense vasoconstriction by stimulating the adrenergic receptors.
    • Other pharmacologic compounds that decrease splanchnic blood flow include:
      • Vasopressin
      • Phenylephrine
      • Digoxin
    • Low-dose dopamine causes splanchnic vasodilation, whereas higher doses lead to vasoconstriction by stimulating alpha adrenergic receptors.
    • Exogenous agents that increase mesenteric blood flow include:
      • Papaverine
      • Adenosine
      • Dobutamine
      • Fenoldopam
      • Sodium nitroprusside
    • In addition, numerous natural neurotransmitters can serve as splanchnic vasodilators, including acetylcholine, histamine, nitric oxide, leukotrienes, thromboxane analogues, glucagon, and a couple of gastrointestinal hormones.
Factors regulating mesenteric blood flow
Extrinsic reguatory system
Humoral (endogenous and exogenous) Neural component
Decrease blood flow Increase blood flow Decrease blood flow Increase blood flow
  • Epinephrine (high dose)
  • Norepinephrine (moderate to high dose)
  • Dopamine (high dose)
  • Phenylephrine
  • Vasopressin
  • Angiotensin
  • Digoxin
  • Epinephrine (low dose)
  • Norepinephrine (low dose)
  • Dopamine (low dose)
  • Dobutamine
  • Sodium nitroprusside
  • Papaverine
  • Nitric oxide
  • Acetylcholine
  • Histamine
  • Alpha-adrenergic receptors
  • Dopamenergic receptors
  • Beta adrenergic receptors
Intrinsic regulatory component
Decrease blood flow Increase blood flow
  • Arteriolar tension receptors
  • Hydrogen
  • Potasssium
  • Carbon dioxide
  • Adenosine

Areas prone to ischemia:

Areas prone to ischemia Blood supply
  • Splenic flexure
End arteries of superior mesenteric artery
  • Rectosigmoid junction
End arteries of inferior mesenteric artery
  • The watershed areas that lack collateralization are as follows:
  • Splenic flexure
    • Supplied by the end arteries of SMA with no collateral circulation.
  • Rectosigmoid junction

Supplied by the end arteries of IMA with no collateral circulation.

Mechanism of ischemia:

The sequence of events that take place in the small intestine subsequent to decreased blood flow:

 
 
 
Ischemic insult
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Decreased delivery of oxygen and nutrients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disruption in cellular metabolism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tissue injury due to hypoxia and reperfusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Full thickness necrosis of the bowel
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perforation of the bowel wall
 
 
 
 
  • Mesenteric ischemia occurs when the blood supply to mesentery is reduced leading to disruption of cellular metabolism owing to oxygen and nutrient deficiency.
  • In the first 4 hours following ischemia, necrosis of the mucosal villi occurs.
  • Persistent ischemia for more than 6 hours results in transmural, mural or mucosal infarction, ultimately leading to bowel perforation.
  • Prolonged ischemia leads to progressive vasoconstriction of the mesenetric vessels which raises the pressure in them resulting in lowering the collateral flow.
  • This is followed by vasodilation, trying to restore blood flow to the area of ischemic insult which causes reperfusion injury.
  • Reperfusion injury causes release of oxygen free radicals, toxic byproducts of ischemic injury and neutrophil activation.

 The pathophysiology of mesenteric ischemia can be explained on the basis of etiology:[14][15]

  • Acute mesenteric arterial embolism: Attributes to 50% cases of mesenteric ischemia.
  • Mesenteric embolus can oringinate from the left atrium, associated with cardiac arrythmias such as atrial fibrillation.
  • Recent myocardial infarction resulting in segmental wall motion abnormality leading to poor ejaction fraction and embolus formation.
  • Infective endocarditis: vegetations on the cardiac valves resulting in turbulence in blood flow predisposing to formation of emboli into the blood stream.
  • Acute mesenteric arterial thrombosis:
  • 25% cases of mesenteric ischemia result from mesenteric arterial thrombosis.
  • Most likely due to underlying atherosclerosis(plaque formation) leading to stenosis.
  • An underlying plaque(fatty streak) in the superior mesenteric artery leads to critical stenosis over the years forming collaterals.
  • It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
  • [Pathogen name] is usually transmitted via the [transmission route] route to the human host.
  • Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.
  • [Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
  • The progression to [disease name] usually involves the [molecular pathway].
  • The pathophysiology of [disease/malignancy] depends on the histological subtype.

Genetics

  • [Disease name] is transmitted in [mode of genetic transmission] pattern.
  • Genes involved in the pathogenesis of [disease name] include [gene1], [gene2], and [gene3].
  • The development of [disease name] is the result of multiple genetic mutations.

Associated Conditions

Gross Pathology

  • Gross pathology shows following changes:
    • Early stage of ischemia: Intestinal wall in congested.
    • Late stage of ischemia: Edematous, friable and hemorrhagic bowel wall.

Microscopic Pathology

  • On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

The goal of surgical intervention for AMI consists of:

Re-establishment blood supply to the ischemic bowel. Resection of all non-viable areas. preservation of all possible bowel. Intestinal viability is the maximum vital element influencing outcome in sufferers with AMI. Non-feasible gut, if unrecognized, effects in multi-machine organ dysfunction and in the end demise. activate laparotomy lets in for direct assessment of bowel viability.

After preliminary resuscitation, midline laparotomy should be done observed by means of assessment of all areas of the gut with choices for resection of all surely necrotic areas. In instances of uncertainty, intraoperative Doppler can be beneficial, as the presence of Doppler indicators over distal branches of SMA allows bowel conservation, heading off lengthy-time period disability. The SMA is without problems palpated with the aid of setting palms at the back of the basis of the mesentery. The SMA is recognized as a firm tubular shape, which may additionally or might not have a palpable pulse. in any other case, the SMA can also be reached via following the middle colic artery where it enters the SMA at the mesentery. Direct sharp dissection, exposing the artery from its surrounding mesenteric tissue, is needed for correct exposure to carry out revascularization. In instances of diagnostic uncertainties, arteriogram is the study of preference. it is able to be executed intraoperatively mainly in hybrid suites.

References

  1. Corcos O, Nuzzo A (2013). "Gastro-intestinal vascular emergencies". Best Pract Res Clin Gastroenterol. 27 (5): 709–25. doi:10.1016/j.bpg.2013.08.006. PMID 24160929.
  2. Dunphy, J. E. (1936). Abdominal pain of vascular origin. The American Journal of the Medical Sciences, 192(1), 109-113.
  3. Oderich, Gustavo (2014). Mesenteric vascular disease : current therapy. New York: Springer. ISBN 9781493918461.
  4. Rosenblum JD, Boyle CM, Schwartz LB (1997). "The mesenteric circulation. Anatomy and physiology". Surg Clin North Am. 77 (2): 289–306. PMID 9146713.
  5. Sánchez-Fernández P, Mier y Díaz J, Blanco-Benavides R (2000). "[Acute mesenteric ischemia. Profile of an aggressive disease]". Rev Gastroenterol Mex. 65 (3): 134–40. PMID 11464607.
  6. Kumar S, Sarr MG, Kamath PS (2001). "Mesenteric venous thrombosis". N Engl J Med. 345 (23): 1683–8. doi:10.1056/NEJMra010076. PMID 11759648.
  7. Ha C, Magowan S, Accortt NA, Chen J, Stone CD (2009). "Risk of arterial thrombotic events in inflammatory bowel disease". Am J Gastroenterol. 104 (6): 1445–51. doi:10.1038/ajg.2009.81. PMID 19491858.
  8. Granger DN, Richardson PD, Kvietys PR, Mortillaro NA (1980). "Intestinal blood flow". Gastroenterology. 78 (4): 837–63. PMID 6101568.
  9. McKinsey JF, Gewertz BL (1997). "Acute mesenteric ischemia". Surg Clin North Am. 77 (2): 307–18. PMID 9146714.
  10. Walker TG (2009). "Mesenteric vasculature and collateral pathways". Semin Intervent Radiol. 26 (3): 167–74. doi:10.1055/s-0029-1225663. PMC 3036491. PMID 21326561.
  11. Fisher DF, Fry WJ (1987). "Collateral mesenteric circulation". Surg Gynecol Obstet. 164 (5): 487–92. PMID 3554567.
  12. Hansen MB, Dresner LS, Wait RB (1998). "Profile of neurohumoral agents on mesenteric and intestinal blood flow in health and disease". Physiol Res. 47 (5): 307–27. PMID 10052599.
  13. Schoenberg MH, Beger HG (1993). "Reperfusion injury after intestinal ischemia". Crit Care Med. 21 (9): 1376–86. PMID 8370303.
  14. Acosta S (2015). "Mesenteric ischemia". Curr Opin Crit Care. 21 (2): 171–8. doi:10.1097/MCC.0000000000000189. PMID 25689121.
  15. Acosta S, Ogren M, Sternby NH, Bergqvist D, Björck M (2005). "Clinical implications for the management of acute thromboembolic occlusion of the superior mesenteric artery: autopsy findings in 213 patients". Ann Surg. 241 (3): 516–22. PMC 1356992. PMID 15729076.

Template:WH Template:WS

Risk Factors

Common Risk Factors

The following conditions pose a signifiacnt risk towards the development of mesenteric ischemia either by interrupting the blood flow through the artery or vein supplying the small intestine (e.g.thromboemboli) or by reducing the blood supply (e.g. vasoconstriction). Also, there are certain life-style related risk factors which predominantly cause mesenteric ischemia in the older age group. [1][2][3]

Risk factors
Occlusive Embolic Atrial fibrillation
Cardiac arrhythmia
Valvular heart disease
Infective endocarditis
Recent myocardial infarction
Ventricular aneurysm
Aortic atherosclerosis
Thrombotic Advanced age
Low cardiac output states
Peripheral arterial disease
Traumatic injury
Inherited thrombophilia-
Acquired thrombophilia- malignancy, oral contraceptives intake.
Non-occlusive Heart failure
Aortic insufficiency
Septic shock
Vasoconstrictive drugs:
Cocaine abuse or ergot poisoning
Hemodialysis
Other causes Lifestyle related risk factors:
  • High cholesterol levels
  • History of smoking
  • Immobility
  • Recent surgery

Less common risk factors:

  • Fibromuscular dysplasia
  • Beta receptor blocking agents
  • Hepatitis
  • Common risk factors in the development of mesenteric ischemia include:
    • Occlusive causes
      • Embolic causes:[1]
      • Atrial fibrillation
      • Cardiac arrhythmias
      • Valvular heart diseases
      • Infective endocarditis
      • Recent myocardial infarction
      • Ventricular aneurysm
      • Aortic atherosclerosis
      • Aortic aneurysm
    • Thrombotic causes:[2]
      • Advanced age
      • Low cardiac output states
      • Traumatic injury
      • Peripheral artery disease
  • Non-occlusive causes:[3]

Less Common Risk Factors

  • Less common risk factors in the development of mesenteric ischemia include:
    • Fibromuscular dysplasia
    • Hepatitis
    • Beta recpetor blocking agents
    • Polyarteritis nodosa

Causes

Narrowing of the arteries that supply blood to the intestine causes mesenteric ischemia. The arteries that supply blood to the intestines run directly from the aorta. Mesenteric ischemia is often seen in people who have hardening of the arteries in other parts of the body (for example, those with coronary artery disease or peripheral vascular disease). The condition is more common in smokers and in patients with high blood pressure or blood cholesterol. Mesenteric ischemia may also be caused by an embolus that suddenly blocks one of the mesenteric arteries. The emboli usually come from the heart or aorta. These clots are more commonly seen in patients with arrhythmias, such as atrial fibrillation. They can be broadly classified into four categories:[4]

Classification based on etiology
Etiology Cause Incidence Examples
Occlusive causes Aterial embolism 50-70%
Arterial thrombosis 15-25%
Venous thrombosis 5%
  • Right-sided heart failure
  • Previous deep venous thrombosis (20-40% risk)
  • Primary clotting disorder
  • Pancreatitis
  • Polycythemia
  • Sickle cell anemia
  • Recent abdominal surgery or infection
  • visceral infections, perforated viscus
  • resulting bowel wall edema, as well as the increased outflow resistance secondary to venous thrombosis and increased blood viscosity, can impede arterial inflow, leading to submucosal hemorrhage, venous capillary congestion, and bowel infarction.
Non-Occlusive causes Non-occlusive ischemia 20-30%
  • Low cardiac output states(most commom cause)
  • Hypovolemia
  • Vasoconstrictive drugs (Digoxin, alpha-adrernergic agonists)
  • Septic schock
  • Aortic insufficiency
  • Cocaine abuse or ergot poisoning

History and symptoms

Overview

Mesenteric ischemia is not an isloated entity but a group of diseases, including mesenteric artery thromboembolic occlusion, meseenteric vein thrombosis and non occlusive, that impair the blood supply to the small intestine, leading to development of same clinical features. However, they can differentiate based on preexisting comorbidities.[5]

Symptoms

In order to diagnose the condition promptly, a special attention towards the history and symptoms should be given.[6][7]

Symptoms of mesenteric ischemia vary and can be acute (especially if embolic)[8], subacute, or chronic[9].

Case series report prevalence of clinical findings and provide the best available, yet biased, estimate of the sensitivity of clinical findings[10][11]. In a series of 58 patients with mesenteric ischemia due to mixed causes[11]:

History

  • The majority of patients with [disease name] are asymptomatic.

OR

  • The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].
  • Symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. 

History

Patients with [disease name]] may have a positive history of:

  • [History finding 1]
  • [History finding 2]
  • [History finding 3]

Common Symptoms

Common symptoms of [disease] include:

  • [Symptom 1]
  • [Symptom 2]
  • [Symptom 3]

Less Common Symptoms

Less common symptoms of [disease name] include

  • [Symptom 1]
  • [Symptom 2]
  • [Symptom 3]

References

  1. 1.0 1.1 Fitzgerald T, Kim D, Karakozis S, Alam H, Provido H, Kirkpatrick J (2000). "Visceral ischemia after cardiopulmonary bypass". Am Surg. 66 (7): 623–6. PMID 10917470.
  2. 2.0 2.1 Martinelli I, Mannucci PM, De Stefano V, Taioli E, Rossi V, Crosti F; et al. (1998). "Different risks of thrombosis in four coagulation defects associated with inherited thrombophilia: a study of 150 families". Blood. 92 (7): 2353–8. PMID 9746774.
  3. 3.0 3.1 Acosta S, Ogren M, Sternby NH, Bergqvist D, Björck M (2006). "Fatal nonocclusive mesenteric ischaemia: population-based incidence and risk factors". J Intern Med. 259 (3): 305–13. doi:10.1111/j.1365-2796.2006.01613.x. PMID 16476108.
  4. Reinus JF, Brandt LJ, Boley SJ (1990). "Ischemic diseases of the bowel". Gastroenterol Clin North Am. 19 (2): 319–43. PMID 2194948.
  5. Yasuhara H (2005). "Acute mesenteric ischemia: the challenge of gastroenterology". Surg Today. 35 (3): 185–95. doi:10.1007/s00595-004-2924-0. PMID 15772787.
  6. 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.
  7. Stone JR, Wilkins LR (2015). "Acute mesenteric ischemia". Tech Vasc Interv Radiol. 18 (1): 24–30. doi:10.1053/j.tvir.2014.12.004. PMID 25814200.
  8. Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD (2004). "Acute mesenteric ischemia: a clinical review". Arch. Intern. Med. 164 (10): 1054–62. doi:10.1001/archinte.164.10.1054. PMID 15159262.
  9. Font VE, Hermann RE, Longworth DL (1989). "Chronic mesenteric venous thrombosis: difficult diagnosis and therapy". Cleveland Clinic journal of medicine. 56 (8): 823–8. PMID 2691119.
  10. Levy PJ, Krausz MM, Manny J (1990). "Acute mesenteric ischemia: improved results--a retrospective analysis of ninety-two patients". Surgery. 107 (4): 372–80. PMID 2321134.
  11. 11.0 11.1 Park WM, Gloviczki P, Cherry KJ, Hallett JW, Bower TC, Panneton JM, Schleck C, Ilstrup D, Harmsen WS, Noel AA (2002). "Contemporary management of acute mesenteric ischemia: Factors associated with survival". J. Vasc. Surg. 35 (3): 445–52. doi:10.1067/mva.2002.120373. PMID 11877691.

Template:WH Template:WS The above studies ultimately led to the aggressive roentgenologic and surgical approach to acute mesenteric ischemia we proposed in 1973.15 The cornerstones of that protocol are the earlier and more liberal use of angiography in patients at risk and the infusion of papaverine through the angiographic catheter as part of the treatment of both occlusive and nonocclusive mesenteric arterial insufficiency (Figs. 1 and 2). Utilizing the protocol based on these principles, we and Clark and Gallant20 were able to lower the mortality rate to 50% or less while preserving all or most of the intestines in the majority of patients. In a subsequent study of SMA embolus,9 we observed that in patients in whom there was a “doctor delay” of less than 12 hours before starting the protocol and when the management followed the protocol, there was a 67% survival—a realistic therapeutic goal.

Mesenteric Venous Thrombosis

Before the recognition of nonocclusive mesenteric ischemia, mesenteric venous thrombosis was thought to be the principal cause of acute mesenteric ischemia. Cokkinis, in 1926,21 reported that 60% of his patients with acute mesenteric infarction had venous thrombosis. By 1963, Jackson40 found that only 25% of his series had venous thrombosis, and in our institution the incidence had fallen to 10% by 1973 and to less than 5% by 1983.85

Although Klein46 and others had earlier described the varying clinical course that mesenteric venous thrombosis could take and differentiated the entities of arterial and venous occlusion, it was Donaldson and Stout25 and Warren and Eberhard84 who focused attention on mesenteric venous thrombosis as a distinct entity in 1935.

In the 1950s, 25% to 55% of cases of mesenteric venous thrombosis were thought to be of the “agnogenic” or “primary” type, developing de novo in the absence of any precipitating factors. Since then, the identification of the hypercoagulable states seen with oral contraceptives61 and antithrombin III,35 protein S, or protein C34 deficiencies has reduced the number of cases with no identifiable contributing disorders to less than 20%.

During the past 25 years, advances in imaging techniques have greatly increased our ability to diagnose mesenteric venous thrombosis before operation. Angiographic diagnosis in 1980,77 ultrasonographic identification in 1979,81 and diagnosis by CT in 198463 and by MRI in 19903 confirmed the early observations by Cokkinis21 that superior mesenteric venous thrombosis can follow a very benign course, and made possible added therapeutic options in the management of this condition.

By 1950, resection followed by immediate postoperative heparin administration57 had been established as the standard treatment. The first successful thrombectomy of the SMV was performed by Fontaine et al30 in 1953, but few of these operations have been reported since.38,53 Papaverine infusion into the SMA has more recently been employed in selected cases. An individualized approach to patients with mesenteric venous thrombosis incorporating newer diagnostic and therapeutic techniques was proposed by Boley et al in 1992.10 During the past 25 years, our ability to diagnose has paralleled advances in imaging techniques.

Chronic Mesenteric Ischemia

The earliest report of chronic intestinal ischemia was by Councilman in 1894.24 He reported three cases of chronic occlusion of the SMA associated with abdominal pain. In 1901, Schnitzler67 described a patient with long-standing postprandial pain who went on to develop an acute thrombosis and intestinal infarction. Despite these reports, the concept of chronic mesenteric ischemia remained controversial because at autopsy some patients had evidence of stenosis or occlusion of all three splanchnic arteries but had had no abdominal symptoms. In 1936, Dunphy26 reconfirmed the entity when he described premonitory symptoms of postprandial pain, weight loss, and altered intestinal motility in 7 of 12 patients dying of intestinal infarction. In 1957, Mikkelson55 coined the term “intestinal angina” to describe this symptom complex. Chronic mesenteric ischemia has always been a difficult diagnosis to prove. Recently, functional testing of the body's ability to increase intestinal blood flow after a test meal has helped refine our diagnostic accuracy.8

In 1958 Shaw and Maynard70 performed the first successful endarterectomy for chronic mesenteric ischemia. Technically more successful procedures, such as Dacron bypass grafting from the infrarenal aorta to the SMA, were described in 1962 by Morris et al,56 and antegrade aortovisceral bypass and transaortic visceral thromboendarterectomy were described in 1966 by Stoney and Wylie.75 More recently, balloon dilatation of stenoses of both the celiac artery and SMA has been successfully performed.31

References

 
 
 
 
 
 
 
 
 
 
 
 
 
 
A01
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
B01
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
C01
 
 
 
 
 
 
 
 
 
 
 
 
 
 
C02
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D01
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Overview

Surgery may be needed to treat mesenteric ischemia. Surgery for chronic mesenteric artery ischemia involves removing the blockage and reconnecting the arteries to the aorta. A bypass around the blockage is another procedure. It is usually done with a plastic tube graft. An alternative to surgery is a stent. It may be inserted to enlarge the blockage in the mesenteric artery or deliver medicine directly to the affected area. This is a new technique and it should only be done by experienced health care providers. The outcome is usually better with surgery. Surgical revascularisation remains the treatment of choice for mesenteric ischemia, but thrombolytic medical treatment and vascular interventional radiological techniques have a growing role [1].

Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[2]

Nonocclusive Intestinal Ischemia Treatment (DO NOT EDIT)[3]

Class I
"1. Treatment of the underlying shock state is the most important initial step in treatment of nonocclusive intestinal ischemia. (Level of Evidence: C)"
"2. Laparotomy and resection of nonviable bowel is indicated in patients with nonocclusive intestinal ischemia who have persistent symptoms despite treatment. (Level of Evidence: B) "
Class IIa
"1. Transcatheter administration of vasodilator medications into the area of vasospasm is indicated in patients with nonocclusive intestinal ischemia who do not respond to systemic supportive treatment and in patients with intestinal ischemia due to cocaine or ergot poisoning. (Level of Evidence: B)"

Acute Obstructive Intestinal Ischemia (DO NOT EDIT)[3]

Class I
"1. Surgical treatment of acute obstructive intestinal ischemia includes revascularization, resection of necrotic bowel, and, when appropriate, a “second look” operation 24 to 48 hours after the revascularization. (Level of Evidence: B)"

Endovascular Treatment (DO NOT EDIT)[3]

Class IIb
"1. Percutaneous interventions (including transcatheter lytic therapy, balloon angioplasty, and stenting) are appropriate in selected patients with acute intestinal ischemia caused by arterial obstructions. Patients so treated may still require laparotomy. (Level of Evidence: C)"

Chronic Intestinal Ischemia Surgical Treatment (DO NOT EDIT)[3]

Class I
"1. Surgical treatment of chronic intestinal ischemia is indicated in patients with chronic intestinal ischemia. (Level of Evidence: B)"
Class IIb
"1. Revascularization of asymptomatic intestinal arterial obstructions may be considered for patients undergoing aortic/renal artery surgery for other indications. (Level of Evidence: B)"
Class III (No Benefit)
"1. Surgical revascularization is not indicated for patients with asymptomatic intestinal arterial obstructions, except in patients undergoing aortic/renal artery surgery for other indications. (Level of Evidence: B)"

Chronic Intestinal Ischemia Interventional Treatment (DO NOT EDIT)[3]

Class I
"1. Percutaneous endovascular treatment of intestinal arterial stenosis is indicated in patients with chronic intestinal ischemia. (Level of Evidence: B) "

References

  1. Sreenarasimhaiah J (2003). "Diagnosis and management of intestinal ischaemic disorders". BMJ. 326 (7403): 1372–6. doi:10.1136/bmj.326.7403.1372. PMID 12816826.
  2. Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L; et al. (2013). "Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 61 (14): 1555–70. doi:10.1016/j.jacc.2013.01.004. PMC 4492473. PMID 23473760.
  3. 3.0 3.1 3.2 3.3 3.4 Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B (2006). "ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation". Circulation. 113 (11): e463–654. doi:10.1161/CIRCULATIONAHA.106.174526. PMID 16549646. Retrieved 2012-10-09. Unknown parameter |month= ignored (help)


Surgery Latest Feham is annoyed

  • The goals of surgical therapy are as follows:
    • Re-establishment blood supply to the ischemic bowel
    • Resection of all non-viable areas of the bowel
    • Preservation of the viable bowel
  • Intestinal viability is defined as the maximum vital element influencing outcome in patients with AMI.
  • Non-viable bowel, if unrecognized, can cause multi-organ failure and lead to the death eventually.
  • Laparotomy allows to determine the viability of the bowel.
  • After preliminary resuscitation, midline laparotomy should be done observed by means of assessment of all areas of the gut with choices for resection of all surely necrotic areas. In instances of uncertainty, intraoperative Doppler can be beneficial.

Medical therapy:

  The important factors in the treatment of acute mesenteric ischemia are summarized in Fig. . The  for  open surgical   an endovascular    of  key . First and  is the  and severity of bowel ischemic,    of the occlusive lesion, and   is  of the  availability and the  of an

  of  of acute mesenteric ischemia are summarized in Fig. . The  for  open surgical   an endovascular    of  key . First and  is the  and severity of bowel ischemic,    of the occlusive lesion, and   is  of the  availability and the  of an