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    Mesenteric Ischemia


    Last Updated Jan 19, 2022
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    By Joseph Chong, Tracy Huynh


    • Mesenteric ischemia is uncommon cause of abdominal pain:
      • Less than 1 in 1000 hospital admissions.
    • However, mortality rate is high if diagnosis is delayed or missed.
    • Clinical starting point:
      • Have high index of suspicion and low threshold to CT, especially in patient presenting with acute abdominal pain and cardiovascular risk factors.
    • Clinical endpoint:
      • Disposition depends on etiology of ischemia, with better prognosis for venous rather than arterial etiology, and chronic rather than acute ischemia.
      • Patients with acute arterial ischemia are often very ill and prognosis guarded.
    • Chronic mesenteric ischemia is often caused by atherosclerosis and can be debilitating due to postprandial pain, food fear, and weight loss.
      • However, not acutely fatal and will not be considered further in this clinical summary.
    • Etiology:
      • Mesenteric arterial occlusion:
        • Embolic source: 40-50%
        • Thrombotic occlusion: 20-35%
        • Dissection: <5%
      • Mesenteric venous thrombosis: 5-15% of cases
        • Primary (idiopathic)
        • Secondary causes: thrombophilia, trauma, local inflammatory changes from pancreatitis, diverticulitis, inflammation, or infection, etc.
      • Nonocclusive mesenteric ischemia: 5-15% of cases
        • Cardiac insufficiency or low-flow states.
        • Increasingly identified in patients undergoing hemodialysis.

    Diagnostic Process

    • Risk factors:
      • Mesenteric arterial occlusion:
        • Arterial embolism: atrial fibrillation and other atrial tachyarrhythmias, recent MI or other embolic events (e.g.: stroke), less commonly cardiac valvular disease, endocarditis, proximal aneurysm, recent catheter-based angiography.
        • Arterial thrombosis: atherosclerosis.
      • Mesenteric venous thrombosis:
        • DVT
        • Hx of cancer, chronic liver disease.
        • Recent abdominal surgery.
        • Thrombophilia or family history of clotting disorders.
      • Nonocclusive mesenteric ischemia:
        • Low-flow states: severe heart failure, severe sepsis.
        • Recent cardiac surgery.
        • Hemodialysis.
    • History:
      • Look for evidence of atherosclerotic and vascular disease on history:
        • PAD, CVS, CAD
        • History of atrial fibrillation and recent MI hints to possible embolic source.
        • History of low-flow states such as severe cardiomyopathy points to non-occlusive source.
      • Wide spectrum of nonspecific patient presentations makes the diagnosis challenging:
        • Can vary from pain out of proportion to vague abdominal pain to absent abdominal symptoms altogether.
      • Classic triad: look for sudden, severe abdominal pain, gut emptying with vomiting/diarrhea, underlying cardiac disease.
      • Embolic source more likely if acute onset of ischemic symptoms in previously asymptomatic patient, with no prodrome and rapid progression.
      • Thrombotic source more likely if sudden worsening of symptoms in a patient with long history of intestinal angina.
    • Physical exam:
      • Nonspecific
      • Classically, pain out of proportion to exam should prompt the physician to consider mesenteric ischemia.
      • Absent bowel sounds, fecal occult blood are late findings.
      • Tachycardia, tachypnea, hyper or hypothermia.
      • Hypotension is late and ominous finding.
    • Investigations:
      • CT angiography is the gold standard,
      • CBC: elevated WBC may indicate full-thickness injury to bowel wall or ischemia with bacterial translocation,
      • Electrolytes
      • Metabolic acidosis
      • Lactate: often elevated late in disease; significant elevation associated with patient mortality,
      • ECG: look for arrhythmias such as atrial fibrillation.
      • Imaging: abdominal x-ray, duplex ultrasound, CT angiography.
        • X-ray may show bowel distention with air-fluid levels, progression to necrosis manifests as pneumatosis intestinalis (linear collections of air in bowel wall).
        • Duplex ultrasound has high sensitivity and specificity but can be difficult to obtain due to degree of pressure applied. It is best reserved for chronic mesenteric ischemia.
        • CT angiography has 95-100% accuracy and has become recommended method of imaging for diagnosis of visceral ischemic syndromes.
          • Decreased or absent bowel wall enhancement is most specific CT sign of intestinal ischemia.
          • Non-specific findings taken together are more specific for acute mesenteric ischemia: bowel wall thickening, mesenteric edema, luminal dilatation of intestine, portal venous gas.


    Figure taken from article by Blaser et al. A clinical approach to acute mesenteric ischemia. Current Op in Crit Care. 2021; 27: 183-92

    Mesenteric Arterial Ischemia:

    • Initial management:
      • Aggressive IV fluids and electrolyte monitoring, AVOID vasopressors.
      • IV broad-spectrum antibiotics.
      • IV unfractionated heparin: decision should be made with surgical consult.
      • NPO in acute mesenteric ischemia.
      • Enteral nutrition or parenteral nutrition in chronic mesenteric ischemia.
    • Stable: endovascular intervention with pharmacomechanical thrombolysis (embolic disease) or stenting (thrombotic disease).
    • Unstable: laparotomy with thromboembolectomy, mesenteric bypass and/or retrograde mesenteric stent, and bowel resection, if necessary.

    Mesenteric Venous Thrombosis:

    • Stepwise approach:
      • If symptoms are mild and no CT evidence of compromised bowel perfusion, LMWH and transition to oral anticoagulation.
      • If symptoms are severe and CT shows edematous bowel, continuous IV UFH.
      • If medical treatment fails, options include percutaneous mechanical thrombectomy and/or catheter-directed thrombolysis via transhepatic access.
    • Any evidence of peritonitis, stricture, GI bleed should prompt exploratory laparotomy.

    Nonocclusive Mesenteric Ischemia:

    • Ensure hemodynamic stability: fluid resuscitation and electrolytes, blood transfusion.
    • Manage underlying cause (HF or sepsis).
    • IV infusion of vasodilatory and antispasmodic agents can be used:
      • Papaverine 60 mg bolus followed by infusion (30-60 mg/hr) with repeated angiograms obtained every 24 hours.
    • Laparotomy when bowel necrosis is suspected.

    Long-term management:

    • Aspirin lifelong in all patients who undergo endovascular or open repair.
    • Clopidogrel for 1-3 months after endovascular repair.
    • DOAC indicated in patients with atrial fibrillation, MVT.
    • Lifestyle management: smoking cessation, exercise, manage dyslipidemia and hypertension.

    Quality Of Evidence?


    Society guidelines and critical reviews.


    Related Information


    Reference List

    1. Bala M, Kashuk J, et al. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. Wor J of Emerg Surg. 2017; 12: 38-49.

    2. Blaser AR, Acosta S, Arabi YM. A clinical approach to acute mesenteric ischemia. Current Op in Crit Care. 2021; 27: 183-92.

    3. Clair DG, Beach JM. Mesenteric Ischemia. New Eng J Med. 2016; 374: 959-68.

    4. Hawkins BM et al. Endovascular Treatment of Mesenteric Ischemia. Cathet and Cardio Interv. 2011; 78: 948-52.

    5. Karkkainen JM, Acosta S. Acute mesenteric ischemia (part I): Incidence, etiologies, and how to improve early diagnosis. Best Prac & Res Clin Gastro. 2017; 31: 15-25.

    6. Karkkainen JM, Acosta S. Acute mesenteric ischemia (part II): Vascular and endovascular approaches. Best Prac & Res Clin Gastro. 2017; 31: 27-38.

    7. Martinez JP, Hogan GJ. Mesenteric ischemia. Emerg Med Clin of North Am. 2004; 22: 909-28.

    8. Zhao Y, Yin H, et al. Management of Acute Mesenteric Ischemia: A Critical Review and Treatment Algorithm. Vasc and Endovasc Surg. 2016; 50(3): 183-92.


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