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Chronic Mesenteric Ischemia
Article Last Updated: Oct 10, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Deron J Tessier, MD, Staff Surgeon, Kaiser Permanente Medical Center, Fontana, CA
Deron J Tessier is a member of the following medical societies: American College of Surgeons and American Medical Association
Coauthor(s):
Russell A Williams, MBBS, Program Director, Professor, Department of Surgery, University of California Medical Center at Irvine
Editors: Mounzer Al Al Samman, MD, Department of Internal Medicine, Division of Gastroenterology, Assistant Professor, Texas Tech University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; BS Anand, MD, Department of Internal Medicine, Division of Gastroenterology, Professor, Baylor University College of Medicine; Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine; Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Author and Editor Disclosure
Synonyms and related keywords:
chronic visceral ischemia, postprandial abdominal pain, atherosclerotic plaque, thrombus, superior mesenteric artery, atherosclerosis, visceral atherosclerosis, thromboendarterectomy, malnutrition, malnourishment, coronary artery disease, CAD, transaortic visceral thromboendarterectomy, aortovisceral bypass
Background
Antonio Hodgson first described mesenteric ischemia (see Media file 1) in the latter part of the 15th century. During the middle of the 19th century, the medical profession became more interested in this condition. By the turn of the 20th century, many review articles and texts were produced describing the recent advances in both the characterization and treatment of mesenteric ischemia. In 1901, Schnitzler described a patient with a long history of postprandial abdominal pain. He was found to have an atherosclerotic plaque with an overlying thrombus of the superior mesenteric artery. Schnitzler concluded that if a patient could develop pain in his or her lower extremities secondary to atherosclerosis, the assumption that a patient could present with postprandial pain due to narrowing of the mesenteric vessels would be reasonable. By the middle of the 20th century, Dunphy hypothesized that mesenteric ischemia was a manifestation of visceral atherosclerosis. In 1958, Shaw and Maynard described the first thromboendarterectomy of the superior mesenteric artery for the treatment of both acute and chronic mesenteric ischemia. Several other surgical procedures have since been attempted, ranging from reimplantation of the visceral branch into the adjacent aorta to using an autogenous vein graft. In 1972, Stoney and Wylie introduced transaortic visceral thromboendarterectomy and aortovisceral bypass, which have proven to be very effective techniques.
Pathophysiology
In more than 95% of patients, the cause of mesenteric ischemia is diffuse atherosclerotic disease, which decreases the flow of blood to the bowel. As the atherosclerotic disease progresses, symptoms worsen. Usually, all 3 major mesenteric arteries are occluded or narrowed.
The pathophysiologic mechanism by which ischemia produces pain is still not completely understood.
Frequency
United States
Chronic mesenteric ischemia is a rare diagnosis. No reports of the actual incidence have been published. Moawad searched 20 years of literature and found only 330 cases. Because many cases are not reported, the true prevalence could be much higher. Autopsy studies support this theory, with findings of stenosis in up to 30% of selected patients with a history of abdominal pain.
International
No differences in frequency are reported in various regions of the world.
Mortality/Morbidity
- Chronic mesenteric ischemia by itself does not represent an important cause of mortality.
- Complications, which include acute thrombosis or embolus, are significant causes of increased mortality and are the main reason to revascularize these patients.
- Patients with chronic mesenteric ischemia often present with malnutrition secondary to their fear of postprandial abdominal pain. These patients may have a prolonged hospital course due to their chronic malnourished state.
Sex
- Some studies show an increased prevalence in females compared with males, while other studies show equal distribution.
Age
- The average age at presentation is 60 years.
History
- Patients typically present with a history of the following:
- Weight loss
- Postprandial pain, generally epigastric or periumbilical
- Fear of eating
- History of vascular disease involving other organs such as myocardial infarction (MI), cerebral vascular disease, or peripheral vascular disease
- Other nonspecific symptoms include the following:
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Flatulence
Physical
Upon physical examination, the following may be found:
- Signs of malnutrition
- Pain disproportionate to examination findings
- Usually diffuse mild abdominal tenderness
- No rebound or guarding
- Abdominal bruit
- Signs of peripheral vascular disease, such as carotid bruits, decreased pulses, and ischemic feet
Causes
Factors that predispose to atherosclerosis are associated with increased risk for chronic mesenteric ischemia. These include the following:
- Smoking
- Hypertension
- Diabetes mellitus
- Hypercholesterolemia (although patients may present with hypocholesterolemia because of their chronic malnourished state)
Acute Mesenteric Ischemia
Biliary Colic
Biliary Obstruction
Cholangitis
Cholecystitis
Diverticulitis
Duodenal Ulcers
Gastric Cancer
Gastric Ulcers
Gastritis, Acute
Gastritis, Chronic
Hiatal Hernia
Pancreatitis, Chronic
Pyelonephritis, Chronic
Other Problems to be Considered
Small bowel obstruction
Lab Studies
- CBC count may demonstrate anemia, leukopenia, or lymphopenia secondary to chronic malnourishment.
- Chemistries may show electrolyte abnormalities from malnutrition, vomiting, or diarrhea.
- Urinalysis should be performed to rule out stones or infection.
- Liver function tests may show hypoalbuminemia from malnutrition.
- If a patient presents with steatorrhea, send stool fat for examination.
- Preoperative considerations include the following;
- CBC count
- Chemistries
- Prothrombin time (PT)
- Activated partial thromboplastin time (aPTT)
- International normalized ratio (INR)
Imaging Studies
- Perform chest radiography to rule out pneumonia (see Media file 2).
- Perform dipyridamole-thallium scanning if coronary artery disease is a suspected comorbidity.
- Arteriography is the criterion standard and will show occlusion (see Media file 4) of 2 visceral branches of the aorta, with severe stenosis of the remaining visceral branch, usually the celiac or superior mesenteric artery. Look for a dilated meandering artery (see Media file 3), which indicates well-developed collateral flow.
- Mesenteric duplex ultrasonography is a noninvasive method of analyzing flow through the vessels. Unfortunately, intraperitoneal gas, respiratory movements, obesity, and any previous abdominal surgeries limit results.
- MRI is under investigation as a future diagnostic tool.
- Preoperative studies include the following:
- Chest radiography
- Dipyridamole-thallium scanning
- Arteriography
Other Tests
- Perform ECG to rule out cardiac disease.
Histologic Findings
Transected mesenteric vessels show diffuse atherosclerosis. The histological findings from the bowel include atrophy of the tips of the villi, which leads to loss of the absorptive surface in the small bowel. The loss of the absorptive surface in conjunction with the patient's fear of eating results in the malnourished state commonly seen in persons with this condition.
Medical Care
- Because of the high rate of thrombosis, medical management as a sole treatment is warranted only in patients whose risk with surgery outweighs the benefits.
- Some patients may find short-term relief with nitrate therapy; however, this treatment is not curative.
- Medical management includes anticoagulation therapy with warfarin.
- Once a diagnostic arteriogram is obtained and surgery is deemed appropriate, start intra-arterial papaverine to reduce the risk of arterial spasm.
Surgical Care
- After the diagnosis is made by arteriography, patients should undergo surgery because of the risk of continued weight loss, acute infarction, perforation, sepsis, and death.
- Stenting of visceral vessels has been reported with some success and may be an alternative to surgery. One study suggests that stenting may result in equivalent patency rates to that of surgical correction; however, symptomatic improvement may not be as good. Another study suggests that the long-term outcome may be equal to that of surgery.
- Preoperative considerations include the following:
- Because of the long period of malnutrition, patients should receive parenteral nutrition prior to surgery.
- Cross and match 2 units of blood.
- Prepare the patient's bowel the night prior to surgery, and arrange for the patient to ingest nothing by mouth past midnight.
- Obtain informed consent.
- To decrease the risk of vasospasm, intra-arterial papaverine may be started at the time of the angiogram.
- Surgical correction includes (1) transaortic endarterectomy of the celiac or superior mesenteric artery, (2) retrograde bypass from the external iliac artery, and (3) anterograde bypass, which provides the best orientation of the graft to the aorta. Mesenteric artery reimplantation has been performed but is not widely recommended because of the technical difficulties of the procedure.
Consultations
- Because of the high rate of coronary artery disease in these patients, consultation with a cardiologist is warranted to evaluate potential risks associated with surgery.
Diet
- Because chronic mesenteric ischemia is a complication of diffuse atherosclerosis of the arterial tree, these patients should maintain a low-fat diet, similar to that of patients with cardiac disease.
- Some patients report increased postprandial pain after eating large or fatty meals. Therefore, the diet should be appropriately altered to include small, multiple meals or low-fat meals.
Activity
- Encourage regular exercise, as in patients with cardiac disease.
Drugs used in chronic mesenteric ischemia include heparin and warfarin for anticoagulation and intra-arterial papaverine as a vasodilator.
Drug Category: Anticoagulants
Prevent an acute thrombotic/embolic event.
| Drug Name | Warfarin (Coumadin) |
|---|
| Description | Anticoagulant that interferes with epoxide reductase, preventing production of vitamin K–dependent factors II, VII, IX, X, and protein C and S. Because protein C and S are the first factors to be inhibited, a prothrombic effect occurs during initial few days after instituting warfarin. Start patients on heparin first and then switch to warfarin when the PT, aPTT, and INR are therapeutic. Duration of action is 2-5 d. |
|---|
| Adult Dose | 5 mg/d PO initially for 2-4 d; adjust dose to desired PT/INR |
|---|
| Pediatric Dose | 0.05-0.34 mg/kg/d PO; adjust dose according to desired INR; infants may require doses at or near high end of this range |
|---|
| Contraindications | Documented hypersensitivity, severe liver or kidney disease, open wounds or GI ulcers |
|---|
| Interactions | Drugs that may decrease anticoagulant effects include griseofulvin, carbamazepine, glutethimide, estrogens, nafcillin, phenytoin, rifampin, barbiturates, cholestyramine, colestipol, vitamin K, spironolactone, oral contraceptives, and sucralfate
Medications that may increase anticoagulant effects include oral antibiotics, phenylbutazone, salicylates, sulfonamides, chloral hydrate, clofibrate, diazoxide, anabolic steroids, ketoconazole, ethacrynic acid, miconazole, nalidixic acid, sulfonylureas, allopurinol, chloramphenicol, cimetidine, disulfiram, metronidazole, phenylbutazone, phenytoin, propoxyphene, sulfonamides, gemfibrozil, acetaminophen, and sulindac |
|---|
| Pregnancy | X - Contraindicated in pregnancy
|
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| Precautions | Do not switch brands after achieving therapeutic response; caution in active tuberculosis or diabetes; patients with protein C or S deficiency are at risk of developing skin necrosis |
|---|
| Drug Name | Heparin |
|---|
| Description | Sulfated mucopolysaccharide. Anticoagulant effect is related to ability to activate plasma antithrombin. Main role of heparin in these patients is to prevent thrombus propagation. |
|---|
| Adult Dose | 80 U/kg loading dose IV followed by 18 U/kg/h; adjust dose to appropriate aPTT level |
|---|
| Pediatric Dose | 50 U/kg loading dose IV followed by 25 U/kg/h |
|---|
| Contraindications | Documented hypersensitivity; presence of active hemorrhage, potential hemorrhage, and hemorrhagic disorders; severe thrombocytopenia |
|---|
| Interactions | Digoxin, nicotine, tetracycline, and antihistamines may decrease effects; NSAIDs, ASA, dextran, dipyridamole, and hydroxychloroquine may increase heparin toxicity |
|---|
| Pregnancy | C - Safety for use during pregnancy has not been established.
|
|---|
| Precautions | Some preparations contain benzyl alcohol as a preservative and, when used in large amounts, are associated with fetal toxicity (gasping syndrome); preservative-free heparin is recommended in neonates; heparin should be used with caution in patients in shock or with severe hypotension |
|---|
Drug Category: Vasodilators
Used during arteriogram to decrease vasospasm in occluded arteries, with the objective of improving blood flow.
| Drug Name | Papaverine (Genabid) |
|---|
| Description | Benzylisoquinoline-derivative with direct nonspecific relaxant effect on vascular, cardiac, and other smooth muscle. |
|---|
| Adult Dose | 30-60 mg/h IV |
|---|
| Pediatric Dose | Not established |
|---|
| Contraindications | Documented hypersensitivity; complete AV heart block |
|---|
| Interactions | May decrease effectiveness of levodopa |
|---|
| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Caution in angina, recent MI, recent stroke glaucoma |
|---|
Further Inpatient Care
- Postoperative care includes the following:
- Ambulate early because of the high rate of postoperative ileus.
- Monitor blood pressure to prevent hypotension, which can induce ischemia.
Further Outpatient Care
- Monitor the PT and INR.
- Routine visceral duplex ultrasonography is recommended every 4-6 months.
Complications
- The risk of MI is increased but can be reduced with the following steps:
- Identify patients at risk preoperatively.
- Place a Swan-Ganz catheter perioperatively.
- Inform the anesthesiologist when cross-clamping the aorta, so that myocardial protective maneuvers are used.
- Acute renal failure can be prevented with the following steps:
- Adequately hydrate the patient before and during surgery.
- Administer mannitol before cross-clamping the aorta.
- Monitor BUN and creatinine levels in the preoperative and postoperative periods.
Prognosis
- The mortality rate associated with visceral reconstruction is approximately 4-6%.
- A 2004 study from the Wake Forest School of Medicine found the following:
- The symptom-free survival rate for hospital survivors is 57% at 70 months.
- Primary and primary-assisted patency rates are 81% and 89%, respectively
- Patients with acute-on-chronic mesenteric ischemia had significantly higher perioperative mortality rates (54% vs 10%) than those with chronic symptoms alone.
Patient Education
Medical/Legal Pitfalls
- Failure to have a high enough index of suspicion for the disease is the major medical pitfall. Many emergency department physicians and surgeons overlook placing this diagnosis on their differential. This can be disastrous.
- Failure to treat the disorder as aggressively as it deserves is also a pitfall. Once the diagnosis is considered, a complete workup, including an angiogram, should be performed.
The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor, Yale D Podnos, MD, MPH, to the development and writing of this article.
| Media file 1:
Angiogram of a patient with chronic mesenteric ischemia. Notice the diffuse occlusive disease. |
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Media type: X-RAY
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| Media file 2:
Radiograph showing a tortuous, dilated, meandering artery. |
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Media type: X-RAY
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| Media file 4:
Chronic aortic occlusion (Leriche syndrome) with acute embolic occlusion of the superior mesenteric artery. |
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Media type: X-RAY
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Chronic Mesenteric Ischemia excerpt Article Last Updated: Oct 10, 2006
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