Lecture notes for medical students

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7. See notes for bibliography.

2. Learning Objectives
At the end of this session the learner will be able to
describe-
• Aetiology
• Clinical Features
• Management
Of Mesenteric Ischemia

3. Learning Objectives
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Controversies
11. Prevention
12. Guidelines
13. Take home messages

4. Introduction & History.
•

5. Introduction & History.
• Mesenteric ischemia is a rare, life-
threatening condition caused by inadequate
blood flow through the mesenteric vessels,
which results in ischemia and necrosis of
the intestinal wall.

6. Relevant Anatomy
•

7. Relevant Anatomy
• The celiac axis, the SMA, and the inferior
mesenteric artery (IMA) supply the foregut,
midgut, and hindgut, respectively.
• The superior mesenteric vessels are involved more
frequently than the inferior mesenteric vessels.
• Inferior mesenteric artery involvement is usually
clinically silent because of a rich collateral
circulation.
• Acute ischemia occurs in single vessel while in
chronic mesenteric ischemia disease is widespread
in all the vessels.

8. Relevant Anatomy
• If the main trunk of the SMA is involved,
the infarction usually covers an area from
just distal to the DJ fexure to the splenic
fexure.
• Usually, a branch of the main trunk is
implicated and the area of infarction is
smaller.

9. Aetiology
• Idiopathic
• Traumatic
• Infections /Infestation
• Neoplastic (Benign/Malignant)
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Autoimmune
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

10. Aetiology
• Idiopathic
• Traumatic
• Infections /Infestation
• Neoplastic (Benign/Malignant)
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Autoimmune
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

11. Aetiology of Aetiology
•

12. Aetiology of Aetiology
1. Embolism.
2. Arterial Thrombosis
3. Venous thrombosis
4. Non-occlusive mesenteric
ischaemia.

13. Aetiology of Aetiology
• Embolism.
– Atrial fbrillation,
– From the left ventricle after mural myocardial
infarction,
– Vegetations on mitral and aortic valves
associated with endocarditis
– Atheromatous plaque from an aortic aneurysm.
– Mycotic aneurysm,
– Thrombi formed at the site of atheromatous
plaques within the aorta or at the sites of
vascular aortic prosthetic grafts
•

14. Aetiology of Aetiology
• Arterial Thrombosis
– Atherosclerosis
– Vasculitides
• Thromboangitis obliterans
• Polyarteritis nodosa.
•

15. Aetiology of Aetiology
• Venous thrombosis
– Factor V leiden disorder
– Portal hypertension
– Portal pyaemia
– Sickle cell disease
– Oral contraceptive pill.
•

16. Aetiology of Aetiology
• Non-occlusive mesenteric ischaemia in
which the vessels are normal but fow is
critically reduced) may complicate critical
illness, possibly because of alterations in
splanchnic blood flow-
– Cardiac failure
– Septic shock
– Hypovolemia
– The use of potent vasopressors in critically ill
patients

17. Pathophysiology

18. Pathophysiology
• Damage to the affected bowel portion may
range from reversible ischemia to
transmural infarction with necrosis and
perforation.
• Tissue hypoxia, leads to initial bowel-wall
spasm .This leads to gut emptying by
vomiting or diarrhea.
• Mucosal sloughing may cause bleeding into
the gastrointestinal (GI) tract.

19. Pathophysiology
• As the ischemia persists, the mucosal
barrier becomes disrupted, and bacteria,
toxins, and vasoactive substances are
released into the systemic circulation (see
the image below). This can cause death
from septic shock, cardiac failure, or
multisystem organ failure before bowel
necrosis actually occurs.
• Transmural necrosis leads to perforation
peritonitis with much worse prognosis.

20. Classification

21. Classification
• Acute Mesenteric Ischemia
• Chronic Mesenteric Ischemia
• Mesenteric Venous Thrombosis

22. Clinical Features
•

23. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

24. Demography

25. Demography
• Incidence & Prevalence
• Geographical distribution.
• Race
• Age
• Sex
• Socioeconomic status
• Temporal behaviour

26. Demography
• Incidence & Prevalence-

27. Demography
Incidence & Prevalence-
• 0.1% of all hospital admissions

28. Demography
• Geographical distribution.

29. Demography
Geographical distribution-
• NIL

30. Demography
• Race.

31. Demography
Race- Nil

32. Demography
• Age

33. Demography
Age- Above 60 years of age.

34. Demography
• Sex

35. Demography
Sex- Nil

36. Demography
• Socioeconomic status

37. Demography
Socioeconomic status- Nil

38. Demography
• Temporal behaviour

39. Demography
Temporal behaviour- Likely to increase as
population of elderly increases.

40. Symptoms

41. Symptoms
• Sudden onset of severe abdominal pain in a
patient with atrial fbrillation or
atherosclerosis.
• The pain is typically in the central abdomen
and is out of all proportion to the physical
fndings.
• Persistent vomiting and defecation occur
early, with the subsequent passage of
altered blood

42. Signs
• Local Examination

43. Signs
• Abdominal tenderness may be mild
initially, with rigidity being a late feature.
• Shock, with features of both hypovolaemia
and sepsis, rapidly ensues.

44. Prognosis

45. Prognosis
• Mortility is high 80-90 %
• Survivors of resection surgery suffer short
bowel syndrome.

46. Complications

47. Complications
• Bowel necrosis necessitating bowel
resection
• Sepsis and septic shock
• Multiple organ dysfunction syndrome
(MODS)
• Death

48. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology
– Germ line Testing and Molecular Analysis
• Diagnostic Laparotomy.

49. Investigations
• Laboratory Studies
–

50. Investigations
• Laboratory Studies
– Neutrophil leukocytosis,
– Severe metabolic acidosis
– Raised blood lactate.
•

51. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

52. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

53. Investigations
• Imaging studies: Plain X-Ray
– Pneumatosis intestinalis (ie, submucosal gas),
– Thumbprinting of the bowel wall
– Portal vein gas
• Angiography

54. Investigations
• Imaging studies CECT
– Bowel wall enhancement absent or reduced
– Free fuid in the abdomen.
– Gas may be present within the intestinal wall
and occasionally in the mesenteric and portal
vein, a late and ominous sign.
• CT Angiography
• MRI and MRA

55. Differential Diagnosis

56. Differential Diagnosis
• Abdominal Abscess
• Abdominal Angina
• Abdominal Aortic Aneurysm
• Acute Abdomen and Pregnancy
• Acute Cholecystitis and Biliary Colic
• Acute Intermittent Porphyria
• Acute Pancreatitis
• Acute Pyelonephritis
• Aortic Dissection
• Appendicitis
• Bacterial Pneumonia
• Bacterial Sepsis
• Biliary Disease
• Biliary Obstruction
• Boerhaave Syndrome
• Cholangitis
• Acute Cholecystitis
• Diverticulitis
• Ectopic Pregnancy
• Esophageal Rupture
• Gallstones (Cholelithiasis)
• Gastric Volvulus
• Helicobacter Pylri Infection
• Hypovolemic Shock
• Postoperative Ileus
• Intestinal Perforation
• Lactic Acidosis
• Large-Bowel Obstruction
• Multiple Organ Dysfunction
Syndrome in Sepsis
• Myocardial Infarction
• Nephrolithiasis
• Pneumothorax Imaging
• Septic Shock
• Small-Bowel Obstruction
• Testicular Torsion Imaging

57. Management

58. Non Operative Therapy

59. Non Operative Therapy
• Acute mesenteric arterial embolism- Papaverine
infusion, embolectomy, and intra-arterial
thrombolysis
• Acute mesenteric arterial thrombosis-
Papaverine infusion
• Nonocclusive mesenteric ischemia - Papaverine
infusion.
• Mesenteric venous thrombosis- Anticoagulation
with heparin or warfarin, either alone or in
combination with surgery; immediate
heparinization should be started even when
surgical intervention is indicated

60. Operative Therapy

61. Operative Therapy
• Embolus -An immediate laparotomy with
embolectomy or revascularisation of the
SMA by vascular bypass may be considered
in early cases of arterial ischaemia,
followed by postoperative anticoagulation
• Resection of gangrenous bowel.
• Relook laparotomy
• Small bowel transplantation

62. Operative Therapy
• Acute mesenteric arterial thrombosis -
arterial reconstruction, either through
aortosuperior mesenteric arterial bypass
grafting or through reimplantation of the
superior mesenteric artery (SMA) into the
aorta.
•

63. Chronic Small Intestinal Ischaemia
• Chronic small intestinal ischaemia almost
invariably results from atherosclerosis.
• Patients classically present with symptoms
of severe central abdominal pain that comes
on within 30–60 minutes of eating
(mesenteric angina).
• Weight loss and diarrhoea

64. Chronic Small Intestinal Ischaemia
• Treatment
– Selective visceral angiography, with
stenting/angioplasty
– Bypass surgery
– Smoking cessation
– Anticoagulation.
•

65. Guidelines
• https://wjes.biomedcentral.com/articles/10.1
186/s13017-017-0150-5

66. Take home messages

67. Take home messages
• Acute mesenteric ischemia may be caused
by an arterial embolism, thrombosis, non-
occlusive disease, or venous thrombosis.
• Patients present with abdominal pain out of
proportion to the abdominal examination.
Peritonitis, sepsis, and hematochezia are
concerning for bowel infarction.
• Computed tomography (CT) with
angiography of the abdomen and pelvis
• Management is blood flow to the intestines,
as well as resection of any nonviable bowel.

68. MCQ
•

69. MCQ
• Following are true of chronic mesentric
ischemia except
A. Food fear
B. Profound weight loss
C. Normal barium studies
D. Positive stool occult blood

70. MCQ
• Following are true of chronic mesentric
ischemia except
A. Food fear
B. Profound weight loss
C. Normal barium studies
D. Positive stool occult blood

71. MCQ
• Most common cause of mesenteric
ischemia? (AIIMS Nov 08)
A. Embolism
B. Non-occlusive ischemia
C. Arterial thrombosis
D. Venous thrombosis

72. MCQ
• Most common cause of mesenteric
ischemia? (AIIMS Nov 08)
A. Embolism
B. Non-occlusive ischemia
C. Arterial thrombosis
D. Venous thrombosis

73. MCQ
• Etiology of strangulating hernia are all except:
(LB24th/1279) (AZIMS 91)
A. Volvulus
B. Mesenteric vascular occlusion
C. Intussusception
D. Gallstone ulcers

74. MCQ
• Etiology of strangulating hernia are all except:
(LB24th/1279) (AZIMS 91)
A. Volvulus
B. Mesenteric vascular occlusion
C. Intussusception
D. Gallstone ulcers

75. MCQ
• Strangulated intestinal onstruction not seen in
A. Mesenteric vascular occlusion
B. Gall stone ileus
C. Volvulus
D. Intussuception (AIIMS-1991)

76. MCQ
• Strangulated intestinal onstruction not seen in
A. Mesenteric vascular occlusion
B. Gall stone ileus
C. Volvulus
D. Intussuception (AIIMS-1991)

77. MCQ
• True about mesenteric vein thrombosis---
3.76aaaII (PG103)
A. Peritoneal signss always present
B. Thrombobectomy is always done
C. Heparin is given
D. Surgery can lead to short bowel synd.

78. MCQ
• True about mesenteric vein thrombosis---
3.76aaaII (PG103)
A. Peritoneal signss always present
B. Thrombobectomy is always done
C. Heparin is given
D. Surgery can lead to short bowel synd.

79. MCQ
• An elderly male with history of IHD and cerebrovascular
disease presented with abdominal pain, and bloody stools,
likely diagnosis will be---3.80aaaII (AlIMS 97)
A. Ulcerative colitis
B. Crohns
C. Acute mesentric ischaemia
D. Malignancy

80. MCQ
• An elderly male with history of IHD and cerebrovascular
disease presented with abdominal pain, and bloody stools,
likely diagnosis will be---3.80aaaII (AlIMS 97)
A. Ulcerative colitis
B. Crohns
C. Acute mesentric ischaemia
D. Malignancy

81. MCQ
• Most common cause of acute mesenteric ischemia is:
A. Arterial thrombosis
B. Venous thrombosis
C. Embolism
D. Non occlusive disease

82. MCQ
• Most common cause of acute mesenteric ischemia is:
A. Arterial thrombosis
B. Venous thrombosis
C. Embolism
D. Non occlusive disease

83. MCQ
• Following are complaints of a pt. with h/o ischemic heart
disease, acute abdominal pain, tenderness, distension of
abdomen, absent bowel sound, maroon coloured blood in
stool. Diagnosis is ----aiims pgmee questions - dec., 1997 /
14.11
A. Mesentric ischemia
B. Colon carcinoma
C. Ulcerative colitis
D. Crohn's disease

84. MCQ
• Following are complaints of a pt. with h/o ischemic heart
disease, acute abdominal pain, tenderness, distension of
abdomen, absent bowel sound, maroon coloured blood in
stool. Diagnosis is ----aiims pgmee questions - dec., 1997 /
14.11
A. Mesentric ischemia
B. Colon carcinoma
C. Ulcerative colitis
D. Crohn's disease

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