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Key Features

Essentials of Diagnosis

  • Severe postprandial abdominal pain

  • Weight loss with a “fear of eating”

  • Acute mesenteric ischemia: severe abdominal pain yet minimal findings on physical examination

General Considerations

  • Acute visceral artery insufficiency results from

    • Embolic occlusion or primary thrombosis of at least one major mesenteric vessel

    • Nonocclusive mesenteric vascular insufficiency, which is generally seen in patients with low flow states, such as heart failure, or hypotension

  • In the chronic syndrome

    • There is adequate visceral perfusion at rest, but ischemia occurs with severe abdominal pain when flow demands increase with eating

    • At least two of the three major visceral vessels are affected before symptoms develop

  • Ischemic colitis

    • A variant of mesenteric ischemia

    • Usually occurs in the distribution of the inferior mesenteric artery

    • Clinical presentation is similar to inflammatory bowel disease

    • Can occur postoperatively, particularly after aortic aneurysm resection or aorto-femoral bypass for occlusive disease

Demographics

  • Patients with chronic intestinal ischemia are generally over age 45 years

Clinical Findings

Symptoms and Signs

  • Acute intestinal ischemia

    • Severe, steady epigastric and periumbilical pain

    • Minimal or no findings on physical examination

    • High white cell count

    • Lactic acidosis

    • Hypotension

    • Abdominal distention may aid in the diagnosis

  • Chronic intestinal ischemia

    • Evidence of atherosclerosis in other vascular beds

    • Epigastric or periumbilical postprandial pain lasting 1–3 hours

    • Weight loss

  • Ischemic colitis

    • Left lower quadrant pain and tenderness

    • Abdominal cramping

    • Mild diarrhea, often bloody

Differential Diagnosis

  • Peptic ulcer disease

  • Inflammatory bowel disease

  • Perforated abdominal abscess

  • Sepsis

  • Diverticulitis

Diagnosis

Laboratory Tests

  • Obtain complete blood count

  • Arterial blood gas if lactic acidosis is suspected

Imaging Studies

  • Contrast enhanced CT is highly accurate at determining the presence of ischemic intestine

  • CT angiography or magnetic resonance angiography can demonstrate narrowing of proximal visceral vessels in patients with acute or chronic intestinal ischemia

  • Angiography shows typical “pruned tree” appearance of distal visceral vascular bed in acute intestinal ischemia from a nonocclusive low flow state

  • Ultrasonography may show proximal obstructing lesions

Diagnostic Procedures

  • In patients with ischemic colitis, colonoscopy may reveal segmental ischemic changes, most often in the rectal sigmoid and splenic flexure where collateral circulation may be poor

Treatment

Medications

  • Vasodilators for nonocclusive mesenteric disease

  • Maintain blood pressure and perfusion in patients with ischemic colitis until collateral circulation becomes well established

Surgery

  • Acute intestinal ischemia

    • Immediate exploration to determine bowel viability

    • If the bowel remains viable, bypass using a prosthetic conduit can be done from the aorta to the celiac and the ...

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