Diagnosis and Non-Surgical Management of Mesenteric Ischemia
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Introduction
Mesenteric ischemia is an uncommon but serious disease. It was reported by Conner in 1933, who postulated that patients with chronic abdominal pain may have actually suffered from repeated intestinal angina.1 Mesenteric ischemia can be either acute or chronic. Acute mesenteric ischemia (AMI) is further subdivided into occlusive and nonocclusive mesenteric ischemia. Occlusive mesenteric ischemia is thrombotic or embolic in origin. Approximately 80% of cases of AMI are occlusive in etiology, with arterial emboli or thromboses in 65% of the cases. Nonocclusive mesenteric ischemia is due to arterial hypoperfusion, most commonly a result of primary splanchnic vasoconstriction and low-flow states. Chronic mesenteric ischemia (CMI) refers to episodic or constant intestinal hypoperfusion, which usually develops in patients with atherosclerotic vascular disease. CMI is being diagnosed in an increasing number of individuals, possibly the result of an aging population. We briefly describe a patient with mesenteric ischemia and further discuss the diagnosis and endovascular management options.
Case
An 83-year-old, African-American female with a history of type 2 diabetes mellitus type, hypertension, gastroesophageal reflux disease and hyperthyroidism presented with post-prandial abdominal pain for approximately three months. The pain was dull and achy in character, which predominantly started in the epigastric region radiating to her left shoulder. She had significant weight loss of about 50 pounds, anorexia over the past 8 months and nausea for about 3 to 4 months. She did not experience significant vomiting or constipation. However, she complained of increased flatulence. She had no previous history of hepatitis, pancreatitis, or gastric or duodenal ulcers. There was no known history of cholelithiasis or cholecystitis. The patient also complained of increased peristalsis soon after she eats, with occasional diarrhea. She worked all her life as a farmer, denied smoking or drinking alcohol, however, dips snuff. She had never traveled outside the United States and denied any exposure to tuberculosis.
On physical examination, her vital signs were stable. Her temperature was 36.8, blood pressure was 140/60, regular heart rate was 84, and respiratory rate was 18. She was thin and cachectic-looking, with no obvious distress. There was no scleral icterus noted. Her cardiac examination revealed a regular rhythm with a 2/6 ejection systolic murmur heard at the murmur left sternal border. Her lungs were clear to auscultation. Her abdomen was soft, non-distended with no mass palpated. She had mild tenderness at her epigastric region with no guarding, rigidity or rebound. She had normal bowel sounds in all four quadrants with no bruits. Blood work showed a hemoglobin of 9.0 g/dl and hematocrit of 27. Her white blood cell count (WBC) and platelets were within normal range. Her metabolic panel showed sodium to be 136 mEq/l, potassium 2.8 mEq/l, chloride 99 mEq/l, and HCO3 27 mEq/l. Her renal function was normal. Her liver panel showed albumin 2.9 g/dL, total bilirubin 0.6 mg/dL, direct bilirubin 0.2 mg/dL, SGOT 16 U/L, SGPT 4 U/L, alkaline phosphatase 77 U/L. Her serum amylase and lipase levels were elevated in the range of 689 U/L and 668 U/L, respectively.
She underwent an acute abdominal series that was non-diagnostic with heavy vascular calcification, and non-specific bowel gas pattern. Gas was visualized in the colon. There were no dilated loops seen to suggest obstruction. Because of the clinical presentation and elevated amylase and lipase, the patient was admitted to the hospital with a diagnosis of pancreatitis for further management. The patient underwent a computed tomography (CT) of her abdomen. Contiguous axial images of the abdomen and pelvis were obtained after administration of intravenous and oral contrast. It showed severe atherosclerotic disease of the abdominal aorta and the origin of the superior mesenteric artery (SMA) appeared to be severely stenotic and possibly occluded proximally. The distal branches of the superior mesenteric artery appeared to be patent. Computed tomographic angiography (CTA) was done the following day to further evaluate the abdominal aorta and mesenteric arteries. CTA showed a 2 cm segmental occlusion of the proximal SMA with calcific plaque at the ostium. The distal SMA was reconstituted by way of inferior mesenteric artery (IMA) collaterals. The IMA was a large artery with an ostial stenosis estimated at 70%. Subtotal occlusion of the celiac artery (CA) at the ostium was also identified.
Mesenteric angina was diagnosed and with persisting abdominal pain, the patient underwent a mesenteric angiogram, which confirmed the findings of the CTA. The patient underwent a successful angioplasty and stenting of the SMA. Her proximal lesion was initially dilated with a 2.5 mm x 30 mm Voyager balloon (Guidant Corp., Santa Clara, California), followed by a 4.0 mm x 30 mm Aviator balloon (Cordis Corporation, Miami, Florida). Due to suboptimal results of the balloon angioplasty, a 5.0 mm x 18 mm Genesis stent (Cordis) was placed in the ostial and proximal portion of the SMA. Post procedure pictures showed good flow into SMA with less than 10% residual stenosis. The patient was able to tolerate oral intake well without any abdominal pain, and her amylase and lipase levels normalized. She was discharged home under stable conditions and is being followed up as an outpatient.
1. Conner L. A discussion of the role of arterial thrombosis in the visceral disease of middle life, based upon analogies form coronary thrombosis. Am J Med Sci 1933;185:13.
2. Reinus JF, Brandt LJ, Boley SJ. Ischemic diseases of the bowel. Gastroenterol Clin North Am 1990;19:319–343.
3. Rosenblum JD, Boyle CM, Schwartz LB. The mesenteric circulation. Anatomy and physiology. Surg Clin North Am 1997;77:289–306.
4. Poole JW, Sammartano RJ, Boley SJ. Hemodynamic basis of the pain of chronic mesenteric ischemia. Am J Surg 1987;153:171–176.
5. Ghosn PB, Rabbat AG, Trudel J, et al. Celiac compression syndrome. Can J Surg 1982;25:377-9.
6. Dunbar JD, Molnar W, Beman FF, Marable SA. Compression of the celiac trunk and abdominal angina. Am J Roentgenol Radium Ther Nucl Med 1965;95:731–744.
7. Patel A, Kaleya RN, Sammartano RJ. Pathophysiology of mesenteric ischemia. Surg Clin North Am 1992;72:31–41.
8. McKinsey JF, Gewertz BL. Acute mesenteric ischemia. Surg Clin North Am 1997;77:307–318.
9. Hollier LH, Bernatz PE, Pairolero PC, et al. Surgical management of chronic intestinal ischemia: A reappraisal. Surgery 1981;90:940-6.
10. Cappell MS. Intestinal (mesenteric) vasculopathy. I. Acute superior mesenteric arteriopathy and venopathy. Gastroenterol Clin North Am 1998;27:783–825, vi.
11. Rhee RY, Gloviczki P. Mesenteric venous thrombosis. Surg Clin North Am 1997;77:327–338.
12. Thomas DP, Roberts HR. Hypercoagulability in venous and arterial thrombosis. Ann Intern Med 1997;126:638–644.
13. Wilcox MG, Howard TJ, Plaskon LA, et al. Current theories of pathogenesis and treatment of nonocclusive mesenteric ischemia. Dig Dis Sci 1995;40:709–716.
14. Garofalo M, Borioni R, Nardi P, et al. Early diagnosis of acute mesenteric ischemia after cardiopulmonary bypass. J Cardiovasc Surg (Torino) 2002;43:455–459.
15. Bassiouny HS. Nonocclusive mesenteric ischemia. Surg Clin North Am 1997;77:319–326.
16. Endress C, Gray DG, Wollschlaeger G. Bowel ischemia and perforation after cocaine use. AJR Am J Roentgenol 1992;159:73–75.
17. Glenister KM, Corke CF. Infarcted intestine: A diagnostic void. ANZ J Surg 2004;74:260–265.
18. Lange H, Jackel R. Usefulness of plasma lactate concentration in the diagnosis of acute abdominal disease. Eur J Surg 1994;160:381–384.
19. Jamieson WG, Marchuk S, Rowsom J, Durand D. The early diagnosis of massive acute intestinal ischaemia. Br J Surg 1982;69 Suppl:S52–3.
20. Fried MW, Murthy UK, Hassig SR, et al. Creatine kinase isoenzymes in the diagnosis of intestinal infarction. Dig Dis Sci 1991;36:1589–1593.
21. Calman C, Hershey FB, Skaggs JO, Spencer A. Serum lactic dehydrogenase in the diagnosis of the acute surgical abdomen. Surgery 1958;44:43–52.
22. Niewold TA, Meinen M, van der Meulen J. Plasma intestinal fatty acid binding protein (I-FABP) concentrations increase following intestinal ischemia in pigs. Res Vet Sci 2004;77:89–91.
23. Khurana S, Corbally MT, Manning F, et al. Glutathione S-transferase: A potential new marker of intestinal ischemia. J Pediatr Surg 2002;37:1543–1548.
24. Kanda T, Fujii H, Tani T, et al. Intestinal fatty acid-binding protein is a useful diagnostic marker for mesenteric infarction in humans. Gastroenterology 1996;110:339–343.
25. Laghi A, Iannaccone R, Catalano C, Passariello R. Multislice spiral computed tomography angiography of mesenteric arteries. Lancet 2001;358:638–639.
26. Greenwald DA, Brandt LJ, Reinus JF. Ischemic bowel disease in the elderly. Gastroenterol Clin North Am 2001;30:445–473.
27. Giovagnorio F, Picarelli A, Di Giovambattista F, Mastracchio A. Evaluation with Doppler sonography of mesenteric blood flow in celiac disease. AJR Am J Roentgenol 1998;171:629–632.
28. van Oostayen JA, Wasser MN, Griffioen G, et al. Diagnosis of Crohn's ileitis and monitoring of disease activity: Value of Doppler ultrasound of superior mesenteric artery flow. Am J Gastroenterol 1998;93:88–91.
29. Roobottom CA, Dubbins PA. Significant disease of the celiac and superior mesenteric arteries in asymptomatic patients: Predictive value of Doppler sonography. AJR Am J Roentgenol 1993;161:985–988.
30. Iwao T, Toyonaga A, Shigemori H, et al. Echo-Doppler measurements of portal vein and superior mesenteric artery blood flow in humans: Inter- and intra-observer short-term reproducibility. J Gastroenterol Hepatol 1996;11:40–46.
31. http://www.acc.org/clinical/guidelines/pad/index.pdf.
32. Taourel PG, Deneuville M, Pradel JA, et al. Acute mesenteric ischemia: Diagnosis with contrast-enhanced CT. Radiology 1996;199:632–636.
33. Kernagis LY, Levine MS, Jacobs JE. Pneumatosis intestinalis in patients with ischemia: Correlation of CT findings with viability of the bowel. AJR Am J Roentgenol 2003;180:733–736.
34. Laissy JP, Trillaud H, Douek P. MR angiography: Noninvasive vascular imaging of the abdomen. Abdom Imaging 2002;27:488–506.
35. Hagspiel KD, Leung DA, Angle JF, et al. MR angiography of the mesenteric vasculature. Radiol Clin North Am 2002;40:867–886.
36. Horton KM, Fishman EK. The current status of multidetector row CT and three-dimensional imaging of the small bowel. Radiol Clin North Am 2003;41:199–212.
37. Kim AY, Ha HK. Evaluation of suspected mesenteric ischemia: Efficacy of radiologic studies. Radiol Clin North Am 2003;41:327–342.
38. Bakal CW, Sprayregen S, Wolf EL. Radiology in intestinal ischemia. Angiographic diagnosis and management. Surg Clin North Am 1992;72:125–141.
39. Boley SJ, Brandt LJ, Sammartano RJ. History of mesenteric ischemia. The evolution of a diagnosis and management. Surg Clin North Am 1997;77:275–288.
40. Cleveland TJ, Nawaz S, Gaines PA. Mesenteric arterial ischaemia: Diagnosis and therapeutic options. Vasc Med 2002;7:311–321.
41. Cunningham CG, Reilly LM, Rapp JH, et al. Chronic visceral ischemia. Three decades of progress. Ann Surg 1991;214:276–288.
42. Johnston KW, Lindsay TF, Walker PM, Kalman PG. Mesenteric arterial bypass grafts: early and late results and suggested surgical approach for chronic and acute mesenteric ischemia. Surgery 1995;118:1–7.
43. Kihara TK, Blebea J, Anderson KM, et al. Risk factors and outcomes following revascularization for chronic mesenteric ischemia. Ann Vasc Surg 1999;13:37–44.
44. Cho JS, Carr JA, Jacobsen G, et al. Long-term outcome after mesenteric artery reconstruction: A 37-year experience. J Vasc Surg 2002;35:453–460.
45. AbuRahma AF, Stone PA, Bates MC, Welch CA. Angioplasty/stenting of the superior mesenteric artery and celiac trunk: Early and late outcomes. J Endovasc Ther 2003;10:1046–1053.
46. Allen RC, Martin GH, Rees CR, et al. Mesenteric angioplasty in the treatment of chronic intestinal ischemia. J Vasc Surg 1996;24:415–423.
47. Sheeran SR, Murphy TP, Khwaja A, et al. Stent placement for treatment of mesenteric artery stenoses or occlusions. J Vasc Interv Radiol 1999;10:861–867.
48. Maspes F, Mazzetti di Pietralata G, Gandini R, et al. Percutaneous transluminal angioplasty in the treatment of chronic mesenteric ischemia: Results and 3 years of follow-up in 23 patients. Abdom Imaging 1998;23:358–363.
49. Brown DJ, Schermerhorn ML, Powell RJ, et al. Mesenteric stenting for chronic mesenteric ischemia. J Vasc Surg 2005;42:268–274.
50. Rivitz SM, Geller SC, Hahn C, Waltman AC. Treatment of acute mesenteric venous thrombosis with transjugular intramesenteric urokinase infusion. J Vasc Interv Radiol 1995;6:219–228.
51. Simo G, Echenagusia AJ, Camunez F, et al. Superior mesenteric arterial embolism: Local fibrinolytic treatment with urokinase. Radiology 1997;204:775–779.
52. Furrer J, Gruntzig A, Kugelmeier J, Goebel N. Treatment of abdominal angina with percutaneous dilatation of an arteria mesenterica superior stenosis. Preliminary communication. Cardiovasc Intervent Radiol1980;3:43–44.
53. Sharafuddin MJ, Olson CH, Sun S, et al. Endovascular treatment of celiac and mesenteric arteries stenoses: Applications and results. J Vasc Surg 2003;38:692–698.
54. Matsumoto AH TC, Angle JF. Endovascular interventions for chronic mesenteric ischemia. In: BaumS PM, ed. New York: Little, Brown & Co, 1997:326–338.
55. Matsumoto AH, Angle JF, Spinosa DJ, et al. Percutaneous transluminal angioplasty and stenting in the treatment of chronic mesenteric ischemia: Results and long-term followup. J Am Coll Surg 2002;194:S22–31.
56. Feldman RL, Wargovich TJ, Bittl JA. No-touch technique for reducing aortic wall trauma during renal artery stenting. Catheter Cardiovasc Interv 1999;46:245–248.
What about medical management for a patient who is not able to tolerate any procedures? Are there any recommended medications for chronic patients? Anti hypertensives? Long acting nitrates? Would a long acting nitrate be good just before eating or if the B/P is stable a nitro SL before or after eating?
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