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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 mesenteric 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

  • Chronic mesenteric ischemia

    • Also called intestinal angina

    • Occurs when increased flow demands during feeding are not met resulting in abdominal pain

    • Because of the rich collateral mesenteric network, at least two of the three major visceral vessels (celiac, superior mesenteric, inferior mesenteric arteries) are affected before symptoms develop

  • Ischemic colitis

    • A variant of mesenteric ischemia

    • Usually occurs in the distribution of the inferior mesenteric artery

    • The intestinal mucosa is the most sensitive to ischemia and will slough if under perfused


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

Clinical Findings

Symptoms and Signs

  • Acute mesenteric ischemia

    • Severe, steady diffuse abdominal pain with absence of focal tenderness or distention

    • Pain "out of proportion" to physical findings occurs because ischemia initially is mucosal and does not impact the peritoneum until transmural ischemia inflames the peritoneal lining

    • Abdominal distention may aid in the diagnosis

  • Chronic mesenteric 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

    • Rectal discharge will appear mucus-like or bloody and should prompt further evaluation

Differential Diagnosis

  • Peptic ulcer disease

  • Inflammatory bowel disease

  • Perforated abdominal abscess

  • Sepsis

  • Diverticulitis


Laboratory Tests

  • Acute mesenteric ischemia: high white blood cell count, lactic acidosis, hypotension

  • 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 mesenteric ischemia

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

  • Ultrasonography may show proximal obstructing lesions

Diagnostic Procedures

  • In patients with ischemic colitis, flexible sigmoidoscopy should be performed to assess the grade of ischemia that occurs most often in watershed areas such as the rectal sigmoid and splenic flexure




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