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Acute mesenteric ischaemia

  • First described by Virchow in 1852
  • Occurs as result of either superior mesenteric arterial or venous occlusion
  • Affects bowel from 2nd part of duodenum to transverse colon
  • 50% embolic arterial occlusion
  • 25% atheromatous arterial occlusion
  • 10%  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
  • Often is out of proportion to the apparent clinical signs
  • Vomiting and rectal bleeding may also occur
  • Features of chronic mesenteric ischaemia may also be present
  • May also be evidence of an embolic source (e.g., recent MI, cardiac arrhythmia)
  • May also be other features of atherosclerotic disease
  • 75% have ischaemic heart disease
  • 25% have cerebrovascular disease
  • 10% 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
  • Mesenteric 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 SMA
    • Resect necrotic small intestine
Acute mesenteric ischaemia

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 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

Bibliography

Mansour M A.  Management of acute mesenteric ischaemia.  Arch Surg 1999;  134:  328-330.

McKinsey J F,  Gewertz B L.  Acute mesenteric ischaemia.  Surg Clin North Am 1997;  77:  307-318.

Shetty S,  Morris-Stiff G,  Lewis M H. Intestinal ischaemia.  Hosp Med 2002;  63:  354-360.

 

 
 

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