This document summarizes the presentation, diagnosis, and treatment of mesenteric ischemia. It discusses the different classifications of mesenteric ischemia including arterial thrombosis, embolism, non-occlusive mesenteric ischemia, and venous thrombosis. Diagnosis involves imaging such as CT scan or angiography. Treatment depends on the severity and includes revascularization procedures, bowel resection, and management of complications like short bowel syndrome. Prompt diagnosis and revascularization within 12 hours of symptom onset leads to the best outcomes.

1. Presenter: R 蔡逸文

2.  Literature review.
 MEDLINE/PubMed
 MeSH term keyword: “mesenteric ischemia”,
“bowel ischemia”, and “bowel infarction”
 Exclusion: Isolated colonic ischemia and focal
segmental ischemia secondary to adhesions,
hernias or other forms of extrinsic compression.

3.  Classification system used to determine
strength of evidence

4.  Presentation and clinical diagnosis
 etiology
 Diagnosis
 Image
 Treatment
 Vascular procedure
 Damage control surgery
 prevention

5. Presentation and clinical diagnosis

6.  Acute abdominal pain is disproportionate to
the physical examination findings
 Early:
 Nausea, vomiting and initial forced evacuation
 Late if transmural infarction:
 Fever, bloody diarrhea and shock

7. Presentation and clinical diagnosis

8.  Arterial thrombosis
(TAMI): 25%
 Arterial Embolic
(EAMI): 45%
 Non-occlusive
(NOMI): 20%
 Venous thrombosis
(VAMI): 10%

9. CHARACTERISTICS
 The sudden onset of severe
pain
 spontaneous emptying of
the bowel (vomiting and
diarrhea)
 no significant physical
findings(40-80%)
RISK FACTOR
 Atrial fibrillation
 Rheumatic heart disease
 Myocardial infarction
 Prosthetic valve
 Ventricular aneurism

10. CHARACTERISTICS
 Acute episode, may be
recurrent
 Prodromal symptoms of
mesenteric angina
 postprandial abdominal pain
 Nausea
 weight loss
RISK FACTOR
 Atherosclerosis
 Dyslipidemia
 History of other vascular
events, previous vascular
surgery

11. CHARACTERISTICS
 Subacute abdominal pain
 Vague complaints
 Younger population
 Thromboembolic AMI in the
over 60s
 VAMI in the over 40s
RISK FACTOR
 Hypercoagulability states
 Abdominal trauma
 Acute pancreatitis
 Malignancy
 Nephrotic syndrome,
 portal hypertension or
cirrhosis or splenomegaly
 Oral contraceptives
 Pregnancy and the
puerperium

12. CHARACTERISTICS
 Critically ill, sedated and
artificially ventilated Vague
complaints
 Acute or insidious pain
(without defecation)
 Mesenteric hypoperfusion
secondary to circulatory
shock or vasoactive drugs
RISK FACTOR
 Shock, hypovolemia,
hypotension
 Digitalis
 Diuretics
 beta-blockers, alpha-
adrenergics
 Enteral nutrition,
 Critical care support

13. Presentation and clinical diagnosis

14.  Older age
 Bandemia, Elevated serum aspartate
aminotransferase, Increased blood urea nitrogen,
Metabolic acidosis
 Significant co-morbidities and poor
performance status
 Intestinal necrosis
 Increased elapsed time to laparotomy(24hr)
 When the colon was involved
Aliosmanoglu I et al. Int Surg. 2013
Huang HH, et al. Chin Med Assoc. 2005
Gupta PK et al. Surgery. 2011

15. Presentation and clinical diagnosis

16.  Multi-detector computerized tomography
scanning (MDCT) with intravenous contrast
(LOE: III)
 Percutaneous angiography for suspected
NOMI (LOE:III)

18. Pneumatosis intestinalis +
hepatic portal or portomesenteric venous gas
↑the likelihood of transmural bowel infarction
Lisa M. Ho, et al. American Journal of Roentgenology. 2007
Melanie S. Morris, et al .The American Journal of Surgery. 2008

19. Treatment

20.  Vasopressor drugs should be avoided in AMI.
 Minimal effect on the splanchnic circulation
 Dobutamine, low dose dopamine, or milrinone
 Cardiac glycosides should not be used as first
line treatment of atrial fibrillation/flutter in
AMI (LOE: IV).

21. Treatment

22.  Open embolectomy
 Endovascular embolectomy
 percutaneous mechanical aspiration or
thrombolysis
 percutaneous transluminal angioplasty (PTA) with
or without stenting

23.  Endovascular procedure
 PTA and stenting
 Percutaneous aspiration thrombectomy, local
fibrinolysis or intra-arterial drug perfusion
 Retrograde open mesenteric stenting
 After resection of ischemic bowel
 Failed percutaneous treatment

24.  Bypass procedures
 Antegrade bypass from supraceliac aorta to
superior mesenteric trunk
 Retrograde bypass from the infra-renal aorta and
iliac arteries

25.  Correcting the underlying cause
 Improving mesenteric perfusion by direct
infusion of vasodilators.
 Prostaglandin E1 (alprostadil): 20 mcg bolus
followed by 60–80 mcg/24 h infusion;
 papaverine (30–60 mg/h)
 Infarcted bowel resection(LOE: III)

26.  Systemic anticoagulation (LOE: III)
 Vascular
 Failed medical therapy
 Transjugular intrahepatic portosystemic shunting
(TIPS) with mechanical aspiration thrombectomy
and direct thrombolysis
 Percutaneous transhepatic thrombolysis
 Indirect thrombolysis via the SMA

27. Treatment

28.  Immediate surgery if comorbidities and
clinical condition make curative treatment
possible (LOE: III)
 Patients considered unsalvageable should
have palliative care (LOE: IV)

29. Treatment

30.  Laparotomy with resection of ischemic bowel
(and no anastomosis or stoma)
 open thrombectomy (if indicated)
 A temporary abdominal closure via a negative
pressure wound therapy
 ICU and continue resuscitation
 scheduled ‘second-look’ procedure within 48 h
(LOE: III)

31. Treatment

32.  Reassessed after adequate fluid resuscitation
and revascularization.
 Intra-operative assessment:
 Doppler ultrasound of the vascular arcade,
fluorescein angiography, indocyanine
angiography
 A second-look procedure for the doubts of
viability of the bowel(LOE: IV).

33. Treatment

34.  Restoration of bowel continuity following
extensive resection (LOE: III).
 Improve functional results
 May avoid the need for long termTPN

35.  Short bowel syndrome often occurs when
residual small bowel length <200 cm
 The following minimum remaining intestinal
lengths must be respected :
 100 cm for terminal jejunostomy (colon removed)
 65 cm for jejunocolic anastomosis (colon retained)
 35 cm for jejunoileal anastomosis with retention
of the ileocecal region.
Messing B, et al. Gastroenterology.1999

36.  In the elderly patients and in those with
significant co-morbidities
 Significant risk of resection
 In younger patients
 Long term parenteral nutrition
 The option of subsequent intestinal
transplantation

37. Treatment

38.  Anastomosis should be avoided in patients
with shock or multiple organ dysfunction.
(LOE: III)
 Stoma avoid risks of anastomotic failure and
permit easy examination of the bowel by
inspection or endoscopy

39. Treatment

40.  Access bowel viability after revascularization
and resuscitation
 possible progression of bowel ischemia?
 If doubt about the viability of the bowel,
resection of it (LOE: IV).
 Bowel anastomosis(LOE: III).
 Close the wound

41. Treatment

42.  Symptoms >24hr=> Mortality increases
dramatically
 Symptoms <12hr=> lowest mortality
 Gut viability 100% when <12h
56% when 12~24hr
18% when >24hr
Aliosmanoglu I et al. Int Surg. 2013
Lobo Martinez E , et al. Rev Esp Enferm Dig. 1993

43.  Revascularization performed within 12 h from
the onset of symptoms. (LOE: III)
 Resection of non-viable bowel should be
performed without delay. (LOE: III)

44. Treatment

45.  ~60%TAMI have previous symptoms of
chronic mesenteric ischemia
 ~30% EAMI have inadequately treated atrial
fibrillation at presentation
Edwards MS, et al. AnnVasc Surg. 2003
Edwards MS, et al. AnnVasc Surg. 2003

46.  Elective revascularization for patients with
proven CMI (LOE: IV)
 Anticoagulants or antiplatelet therapy and
statin therapy for patients with mesenteric
artery thrombosis (LOE: IV).
 High risk of coronary thrombosis
Bj ¨ ornsson S, et al. J Gastrointest Surg 2013
Cho JS, et al. JVasc Surg. 2002

47.  Life-long anticoagulation, unless
contraindicated, for EAMI, prevent
recurrence (LOE: IV).
 A minimum of 6 months of anticoagulation
and survey for thrombophilia or
hypercoagulability forVAMI. (LOE: III).
Klempnauer J, Surgery. 1997
Daniel G. et al. N Engl J Med 2016
Acosta S, et al. Br J Surg 2008;

48.  History, physical examination
 prompt diagnosis should be achieved and
revascularization performed within 12 h from
the onset of symptoms.
 Resection of non-viable bowel should be
performed without delay

49. Presentation and clinical diagnosis

50.  Routine laboratory tests reflect disease
progression in AMI (LOE: III).
 Leukocytosis, metabolic acidosis with high anion gap
 High level of Lactate, amylase, AST(GOT), lactate
dehydrogenase(LDH) and creatine
phosphokinase(CPK)
 A normal serum lactate level does not exclude
AMI and not be used for diagnosis (LOE: III).