Mesenteric Ischemia
Basics
Description
Description
- Decreased or occluded blood flow through the mesenteric vessels leading to ischemia or infarction of bowel
- Can be from arterial or venous blockage, or low flow states
- 1 in 1,000 of all ED presentations
- 1–2% of all admissions for abdominal pain:
- Most cases occur in patients >50 yr
- Mortality as high as 60–70%, particularly if diagnosis/presentation delayed >24 hr
Etiology
Etiology
- Acute mesenteric arterial embolism:
- 50% of cases of acute mesenteric ischemia
- Mean age 70 yr
- Emboli most commonly arise in left atria or ventricle, from a dysrhythmia, valvular lesions, or ventricular thrombus from a prior MI
- Typically lodge 3–10 cm distal to the origin of the superior mesenteric artery (SMA):
- Preserves blood flow to proximal small and large bowel
- Risk factors include dysrhythmia (especially atrial fibrillation), valvular heart disease, prior MI, aortic aneurysm, or dissection
- Mesenteric artery thrombus:
- SMA thrombus in 15% of cases of acute mesenteric ischemia
- Rare in other vessels
- Develops from plaque rupture of mesenteric atherosclerotic disease
- 50–80% may have longstanding intestinal angina (chronic mesenteric ischemia)
- Risk factors include age, atherosclerotic disease, HTN
- Mesenteric venous thrombosis:
- 5–15% of cases of acute mesenteric ischemia
- Subacute/indolent presentation
- 20–40% mortality
- Typically occurs in younger patients with underlying hypercoagulable state
- Risk factors include:
- Hypercoagulable state (lupus, protein C and S deficiency)
- Sickle cell disease
- Antithrombin III deficiency
- Malignancy (particularly portal)
- Pregnancy
- Sepsis
- Renal failure on dialysis
- Estrogen therapy
- Recent trauma or inflammatory conditions
- Nonocclusive mesenteric ischemia:
- 20–30% of cases of acute mesenteric ischemia
- Occurs in low cardiac output states with decreased mesenteric blood flow
- Risk factors include CHF, sepsis, hypotension, hypovolemia, diuretic use, recent surgery (especially cardiac), or recent vasopressor requirement
- Poorer survival rates
- Chronic mesenteric ischemia:
- “Intestinal angina”:
- Postprandial, diffuse abdominal pain occurring ∼1 hr after eating, lasts 1–2 hr
- Patients may develop food aversions and eat small meals to avoid pain
- “Intestinal angina”:
- Uncommon causes:
- Spontaneous mesenteric arterial dissection
- Median arcuate ligament syndrome – compression of the celiac axis or SMA by the arcuate ligament of the diaphragm
- Extrinsic compression from tumors
- Medications:
- Digitalis
- Ergotamine
- Cocaine
- Pseudoephedrine
- Vasopressin
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Citation
Schaider, Jeffrey J., et al., editors. "Mesenteric Ischemia." 5-Minute Emergency Consult, 6th ed., Lippincott Williams & Wilkins, 2020. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307593/0.1/Mesenteric_Ischemia.
Mesenteric Ischemia. In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307593/0.1/Mesenteric_Ischemia. Accessed December 10, 2024.
Mesenteric Ischemia. (2020). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (6th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307593/0.1/Mesenteric_Ischemia
Mesenteric Ischemia [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. [cited 2024 December 10]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307593/0.1/Mesenteric_Ischemia.
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