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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 ischemia results from

    • Occlusive mesenteric arterial disease, either embolic occlusion or primary thrombosis of at least one major mesenteric artery

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

  • In chronic mesenteric ischemia

    • Also called intestinal angina

    • 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 must be 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 mesenteric ischemia

    • Visceral arterial embolism: acute severe, steady, diffuse epigastric and periumbilical pain

    • In contrast, with primary visceral arterial thrombosis, patients often have antecedent history of chronic mesenteric ischemia

    • Minimal or no findings “pain out of proportion” on physical examination

    • Hypotension

    • 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 due to fear of eating limiting food intake

    • Dehydration leading to hypotension and acute thrombosis in severe cases

  • Ischemic colitis

    • Left lower quadrant pain and tenderness

    • Abdominal cramping

    • Mild diarrhea (non-bloody or bloody)

    • Rectal discharge will appear mucus-like or bloody

Differential Diagnosis

  • Peptic ulcer disease

  • Inflammatory bowel disease

  • Perforated abdominal abscess

  • Sepsis

  • Diverticulitis

DIAGNOSIS

Laboratory Tests

  • Leukocytosis

  • Arterial blood gas if lactic acidosis is suspected

Imaging Studies

  • Contrast-enhanced CT is 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 of the mesenteric vessels may show proximal obstructing lesions

Diagnostic Procedures

  • In patients with ischemic colitis, flexible sigmoidoscopy may reveal segmental ischemic changes, most often in the rectal sigmoid and splenic flexure

TREATMENT

  • Acute mesenteric ischemia

    • Immediate ...

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