- First described by Virchow in 1852
- Occurs as result of either superior mesenteric arterial or venous
occlusion
- Affects the bowel from the 2nd part of duodenum to transverse
colon
- 50% cases are due to embolic arterial occlusion
- 25% cases are due to atheromatous arterial occlusion
- 10% cases result from venous occlusion
- Whatever the underlining aetiology, reduced capillary flow causes
intestinal necrosis
- Overall mortality is approximately 90%
Clinical features
- No single clinical feature provided conclusive evidence of the
diagnosis
- As a result, the diagnosis is difficult and often delayed
- Early diagnosis requires a high index of suspicion
- Severe central abdominal pain is a common presentation
- The pain is often out of proportion to the apparent clinical signs
- Vomiting and rectal bleeding may also occur
- Features of chronic mesenteric ischaemia may also be present
- There may also be evidence of an embolic source (e.g., recent MI, cardiac
arrhythmia)
- There may be other features of atherosclerotic disease
- 75% of patients have ischaemic heart disease
- 25% of patients have cerebrovascular disease
- 10% patients have peripheral vascular disease
Investigations
- No single investigation provides pathognomic evidence
- Serum white cell count is often raised
- Arterial blood gases may show a metabolic acidosis
- Serum amylase is raised in 50% of patients
- Abdominal x-ray may be normal early in the disease process
- Late features include dilated small bowel and 'thumb printing' due
to mucosal oedema
- CT angiography may confirm the diagnosis
Management
- Papaverine infusion into the SMA may be beneficial
- If fails to rapidly improve symptoms then laparotomy may be
indicated
- Laparotomy allows:
- Confirmation of diagnosis and assessment of extent of ischaemia
- Opportunity to revascularise the SMA
- Resection of necrotic small intestine
Picture provided by Asam Ishtiaq, Waterford Regional
Hospital, Ireland
- Revascularisation may be achieved by embolectomy, bypass or
endarterectomy
- Resection and primary anastomosis my be possible
- If there is doubt over bowel viability then a 'second-look' laparotomy may be
considered
- If extensive necrosis in elderly patient then palliative care may be
preferred option
Picture provided by John Cooper, Rotherham District
Hospital, Rotherham, United Kingdom
- There have been resent development in endovascular management
- These may allow surgery to be avoided.
Bibliography
Shetty S, Morris-Stiff G, Lewis M H. Intestinal ischaemia.
Hosp Med 2002; 63: 354-360. Upponi S, Harvey J J,
Uberoi R et al. The role of radiology in the diagnosis and
treatment or mesenteric ischaemia. Postgrad Med J 2013;
89: 165-172. |