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Potentially life-threatening emergency
Acute mesenteric ischemia
Other Resources UpToDate PubMed
Potentially life-threatening emergency

Acute mesenteric ischemia

Contributors: Sara Manning MD, Michael W. Winter MD, Paritosh Prasad MD, John T. Finnell MD
Other Resources UpToDate PubMed

Synopsis

Emergent Care / Stabilization:
For patients presenting with hemodynamic instability of peritoneal signs:
  • Resuscitate with intravenous (IV) fluids and vasopressors as needed.
  • Initiate empiric antibiotics with enteric coverage.
  • Engage consultants early, including general and vascular surgery.
  • Interventional radiology may also play an important role in treatment for some etiologies of mesenteric ischemia.
Diagnosis Overview:
Acute mesenteric ischemia is a sudden interruption or severe reduction in blood flow to the bowel leading to ischemia, necrosis, and ultimately perforation. It is a medical emergency requiring emergent intervention to restore perfusion, often requiring a multidisciplinary approach. Mesenteric ischemia can result from several distinct pathologic entities including embolic disease, arterial thrombosis, mesenteric vein thrombosis, and lack of perfusion due to low flow states or nonocclusive mesenteric ischemia (NOMI).

Embolic disease most commonly affects the superior mesenteric artery (SMA), largely due to anatomic factors. The SMA branches off the aorta at a 45 degree angle, and rapidly tapers, providing a funnel-like shape that traps emboli. The SMA serves a large area of the bowel from the duodenum through the first two-thirds of the transverse colon, producing profound injury in the setting of acute loss of perfusion.

Mesenteric ischemia is relatively rare with an incidence of roughly 5-8 per 100 000 per year. The incidence of mesenteric ischemia increases significantly with age, with a median age at presentation of 67 years. While advancements in treatment strategies have made significant improvements in the mortality of mesenteric ischemia, it remains high at approximately 50%. As with overall incidence, mortality increases significantly with age.

Patient presentation is characterized by the sudden onset of severe abdominal pain with a benign abdominal examination, often referred to as "pain out of proportion to exam." Many patients will develop vomiting and diarrhea. Bloody diarrhea due to bowel necrosis is a late finding. In occlusive disease, symptoms progress rapidly over hours to days. Those with thrombotic disease may report weeks to months of preceding symptoms suggestive of chronic mesenteric ischemia. These can include abdominal pain worsened after eating (so-called "intestinal angina"), fear of eating, and weight loss. Nonocclusive mesenteric ischemia is often observed in the setting of critical illness. Worsening acidosis, hemodynamic instability, feeding intolerance, diarrhea, and abdominal distention are all worrisome signs.

Risk factors for mesenteric ischemia reflect the pathophysiologic mechanisms for each variant: SMA embolism, SMA thrombosis, mesenteric vein thrombosis, and NOMI. Commonly associated conditions include underlying cardiac disease (ie, atrial fibrillation, congestive heart failure with reduced ejection fraction, valvular disorders), hypertension, diabetes, hyperlipidemia, smoking, and hypercoagulable states. More rarely, those who have undergone recent endovascular aortic repair are at increased risk.

Codes

ICD10CM:
K55.9 – Vascular disorder of intestine, unspecified

SNOMEDCT:
91489000 – Acute vascular insufficiency of intestine

Look For

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Intestinal malrotation (particularly sigmoid volvulus in the elderly)
  • Ruptured aortic aneurysm (see Abdominal aortic aneurysm)
  • Acute coronary syndrome
  • Pericarditis
  • Chronic mesenteric ischemia
  • Peptic ulcer disease
  • Gastroesophageal reflux disease
  • Gastritis
  • Bowel obstruction (see Large bowel obstruction, Small bowel obstruction)
  • Infectious colitis (eg, Amebic colitis, Clostridioides difficile colitis)
  • Inflammatory bowel disease (eg, Crohn disease, Ulcerative colitis)
  • Malignancy
  • Acute pancreatitis
  • Choledocholithiasis
  • Biliary calculus
  • Acute cholecystitis
  • Constipation (see Chronic constipation, Drug-induced constipation)
  • Hepatitis (eg, Hepatitis A virus infection, Hepatitis B virus infection, Hepatitis C virus infection)
  • Esophageal motility disorder
  • Vasculitis

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Reviewed:03/27/2023
Last Updated:04/03/2023
Copyright © 2024 VisualDx®. All rights reserved.
Potentially life-threatening emergency
Acute mesenteric ischemia
Imaging Studies image of Acute mesenteric ischemia - imageId=8357340. Click to open in gallery.  caption: '<span>Enhanced CT scan of the abdomen showing low attenuation wall thickening throughout the small bowel with mesenteric edema and decrease in wall enhancement. These findings are consistent with diffuse extensive ischemia of the small bowel.</span>'
Enhanced CT scan of the abdomen showing low attenuation wall thickening throughout the small bowel with mesenteric edema and decrease in wall enhancement. These findings are consistent with diffuse extensive ischemia of the small bowel.
Copyright © 2024 VisualDx®. All rights reserved.