ACUTE MESENTERIC ISCHEMIA

clinical presentation, therapeutic

approach
 Cokkinis (1921)
“occlusion of the mesenteric vessels is regarded as one of
those conditions of which the diagnosis is impossible, the
prognosis hopeless, and the treatment almost useless.”

 ACS (2006)
“acute mesenteric ischemia is an uncommon life-
threatening clinical entity that ultimately leads to death
unless it is diagnosed and treated appropriately”
Outcomes After Surgery
20011
30 day mortality
Embolic 59%
Thrombotic 62%
20022
30 day mortality 32%
1 year mortality 57%
3 year mortality 68%
20033
Peri-op mortality 62%
20034
Peri-op mortality 15%
20055
Peri-op mortality 35%
1
Ann Surg 2001;233(6):801-808
2
J Vasc Surg 2002;35:445-52
3
Ann Vasc Surg 2003;17:72-79
4
Vasc Endovasc Surg 2003;37:245-252
5
W J Surg 2005;29:645-648
 Accordingly, the index of
suspicion for this disease should
be high whenever a patient
presents with acute-onset severe
abdominal pain that is out of
proportion to the physical
findings.

 Once the diagnosis is made,

prompt intervention is required to
minimize morbidity and mortality.
 M.E. 57 year-old female patient

 Onset 12 hours earlier

 Mild right upper quadrant pain
 Nausea and vomiting
 Diarrhea

 Past medical history

 Obesity BMI=32kg/mp
 Sinus node disease
 Artificial pacemaker
 Grade I atrioventricular block
 Appendectomy
 Medication Preductal, Bisogamma, Propafenona
 Clinical examination revealed tenderness in the right upper
quadrant of the abdomen.

 Temperature was measured to be 37 degrees.

 Blood tests
 Leucocytosis of 16.0 x 109/L
 Glucose 212 mg/dL (65-110)
 Amylasemia 120 U/L (20-110)
 LDH 726 U/L
 Bilirubinemia 1.6 U/L (0.2-1.3)

 Urine
 Amyl-U 1200 U/L (32-641)

 Plain abdominal radiography

 normal

 Ultrasonography
 Edema of the pancreas
 Supposed diagnosis Mild Acute Pancreatitis

 Treatment
 As for acute pancreatitis
 No antibiotherapy

 Evolution
 Significant improvement
 General status
 Abdominal pain
 Soft abdomen
 No nausea, no vomiting
 Blood tests after 24 hours
 Leucocyte 12.7x109/ μL
 TBil 6.9 U/L (0.2-1.3)
 AST 88 U/L
 PLT 82,000 /μL
 48 hours after admission

 8 a.m.
 scleral jaundice
 ultrasonography nothing new
 blood tests
 TBil 9.9 U/L (0.2-1.3)
 AST 67 U/L
 LDH 1142 U/L (313-618)
 PLT 90,000 /μL
 Leucocyte 10.0x109/ μL
 6 p.m.
 altered general status
 abdominal examination mild tenderness
 ultrasonography intestinal gas distension
 supportive measures
 72 hours after admision

 Progressive deterioration of general condition

 Abdominal examination - upper quadrants
tenderness
 Blood tests – normal !!!
 Ultrasonography - immobile intestinal loops
 CT-scan arranged
 Operation

 Acute mesenteric ischemia

 Jejunoileal resection + right

colectomy

 Ileostomy and colostomy

 Only 45 cm of jejunum was

spared
 14 days later jejunocolic anastomosis

 p.o. course simple

 Short bowel syndrome

 One month 2-4 stools/day

 One year the patient was well

  The classic presentation for patients with embolic disease
of the mesenteric vessels and thrombotic mesenteric
occlusion is sudden-onset midabdominal pain that is
described as being out of proportion to the physical
findings.

 95% of patients presented with abdominal pain, 44% with

nausea, 35% with vomiting, and 35% with diarrhea; only
16% presented with blood per rectum.

 Park WM, Gloviczki P, Cherry KJ Jr, et al: Contemporary management of acute

mesenteric ischemia: factors associated with survival. J Vasc Surg 35:445, 2002
  Patients with MVT often present with various nonspecific abdominal
complaints; accordingly, this diagnosis may be especially challenging.
Common complaints include nausea, vomiting, diarrhea, abdominal
cramping, and nonlocalized abdominal pain.
 As a rule, these symptoms are not acute.
 A study of MVT patients found that 84% presented with abdominal pain. Of
those 84%, only 16% presented with peritoneal signs, whereas 68%
presented with vague abdominal pain. Other presenting symptoms included
diarrhea (42%), nausea and vomiting (32%), malaise (16%), and upper GI
bleeding (10%).

 Patients with NOMI present somewhat differently. The pain reported is

usually not as sudden as that noted with embolic or thrombotic
occlusion: it is generally more diffuse and tends to wax and wane
(unlike the pain associated with embolic or thrombotic disease, which
tends to get progressively worse).

 Morasch MD, Ebaugh JL, Chiou AC, et al: Mesenteric venous thrombosis: a changing
clinical entity. J Vasc Surg 34:680, 2001
 Risk factors provide essential clues for correct identification of these disease
processes.
 Patients with embolic occlusion of the mesenteric circulation typically have a history
of recent cardiac events (e.g.,myocardial infarction, atrial fibrillation, mural
thrombus, mitral valve disease, or left ventricular aneurysm) or previous embolic
disease.
 In Park’s study, 50% of the patients who presented with embolic occlusive disease had
atrial fibrillation
 Patients with acute mesenteric ischemia secondary to thrombotic occlusive disease
typically have other manifestations of diffuse atherosclerotic disease (e.g., CAD,
peripheral artery disease, and carotid stenosis).
 The risk factors for NOMI are slightly different.
 This condition usually occurs during severe low-flow states and represents extreme
mesenteric vasoconstriction. It is much more common among severely ill patients in an
intensive care unit who require vasopressors and among patients undergoing dialysis with
excessive fluid removal.
 The risk factors for MVT include a history of previous venous thrombosis or
pulmonary embolism, a known or suspected hypercoagulable state, oral
contraception, and estrogen supplementation. In a study of 31 patients who
presented with MVT at Northwestern University, 13 (42%) were diagnosed with a
hypercoagulable state, six (19%) had a history of previous thrombotic episodes, and
four (13%) had a history of cancer

 Park WM, Gloviczki P, Cherry KJ Jr, et al: Contemporary management of acute mesenteric ischemia: factors associated
with survival. J Vasc Surg 35:445, 2002
 Morasch MD, Ebaugh JL, Chiou AC, et al: Mesenteric venous thrombosis: a changing clinical entity. J Vasc Surg 34:680,
2001
 Clinical Presentation:
Laboratory

Limited clinical utility

 arterial lactate1
 amylase2

 CK, CK-BB3

 Serum phosphate4

 Other useless markers: LDH, PAF, TNF-α, AP,

AST/ALT, α-glutathione
1
Eur J Surg 1994;160:381-4
2
Br J Surg 1986;73:219-21
3
Dig Dis Sci 1991;36:1589-93
4
Br J Surg 1982;69:S52-3
 Investigative Studies

 Although there are no basic laboratory or radiographic studies that are

diagnostic for acute mesenteric ischemia, such studies can help confirm
the diagnosis when it is suspected on the basis of the history and the
physical examination.

 Mayo Clinic study

 98% of patients who presented with acute mesenteric ischemia were found to
have an elevation of the leukocyte count, and 50% were found to have counts
higher than 20,000/mmc.
 lactate is another nonspecific indicator of mesenteric bowel ischemia - 91% of
patients had elevated lactate levels, with 61% having levels higher than 3
mmol/L
 71% of patients presented with an elevated AST

 Park WM, Gloviczki P, Cherry KJ Jr, et al: Contemporary management of acute mesenteric ischemia: factors
associated with survival. J Vasc Surg 35:445, 2002
 Abdominal X-rays

 can neither establish nor exclude the

diagnosis of acute mesenteric ischemia

 may reveal signs that are consistent with

bowel ischemia. If obtained early,
abdominal plain films should show no
abnormalities.

 if obtained late in the presentation,

however, they may reveal edematous
bowel with thumbprinting. In severe
cases, abdominal plain films may reveal
gas in the bowel wall and the portal vein.
More commonly, however, they reveal a
pattern consistent with ileus or are
completely unremarkable.
 Duplex Ultrasonography

 limited role in the management of acute mesenteric ischemia, given

the acute nature of the presentation, the accompanying ileus with
excessive bowel gas and bowel edema (which hinders visualization
of the mesenteric vessels)

 capable of imaging stenotic and occlusive lesions at the origin of a

mesenteric vessel

 is of no value in detecting emboli beyond the proximal portion of

the vessel.

 similarly, it has no role in the diagnosis of NOMI.

Computed Tomography
Criteria
 pneumatosis
 venous gas
 SMA/celiac/IMA occlusion
w/distal disease
 arterial embolism
OR
 bowel wall thickening + one
of following:
 lack of bowel wall enhancement
 solid organ infarction
 venous thrombosis

Sensitivity: 100%
Specificity: 91% 1
Radiol 2003;229:91-98
 Angiography
 Gold Standard
 Anatomic delineation of
occlusion and collaterals

 Plan operative
revascularization

 Allow infusion of
therapeutic agents (lytics,
vasodilators)

1
Ann Surg 2001;233(6):801-808
 If diffuse bowel necrosis
exists and the bowel is
not salvageable, it is best
to close the abdomen
without attempting
further therapy.

 Approximately 50 cm of
viable bowel is required
to sustain life if the
ileocecal valve is present,
and 100 cm is preferable.

 Thompson JS, Langnas AN, Pinch LW, et al: Surgical

approach to short-bowel syndrome. Experience in a
population of 160 patients. Ann Surg 222:600, 1995
 Primary anastomosis or primary stomas ?

 Primary anastomoses, especially in the small intestine, can be performed if

brisk bleeding from the edges of the bowel wall is observed and the patient
is stable.

 Alternatively, long segments of marginal bowel left in situ may be stapled or

oversewn, with continuity established during a second-look procedure.

 After resection of the colon, creation of a stoma is generally indicated. An

important consideration is the patient’s hemodynamic status.

 If cardiac output is compromised or there is an ongoing requirement for

vasopressors and inotropic support, delay in intestinal reconstruction may
be safer, avoiding the risk for an anastomotic leak or dehiscence
 perioperative mortalities ranging from 32% to 69% and 5-year survival rates
ranging from 18% to 50%

 Park WM, Gloviczki P, Cherry KJ Jr, et al: Contemporary management of acute mesenteric
ischemia: factors associated with survival. J Vasc Surg 35:445, 2002
 Edwards MS, Cherr GS, Craven TE, et al: Acute occlusive mesenteric ischemia: surgical
management and outcomes. Ann Vasc Surg 17:72, 2003
 Klempnauer J, Grothues F, Bektas H, et al: Longterm results after surgery for acute mesenteric
ischemia. Surgery 121:239, 1997
 Conclusions

 Atipical presentation

 Early diagnosis and high index of suspicion

 Large resection is suitable when proximal jejunal

vascularisation is present

 Primary stomas are to be preferred

 Early reestablishment of bowel continuity is

desirable