Clinical features Periumbilical pain that is disproportionate to physical findings Nausea and vomiting Diarrhea : bloody in later stages currant jelly stools Gangrenous bowel: rectal bleeding and signs of sepsis e. Aggressive IV fluid resuscitation Avoid vasopressors , if feasible Electrolyte repletion Nasogastric tube insertion Administer supplemental oxygen. IV anticoagulation : unfractionated heparin infusion [9] Parenteral analgesics see acute pain management [12] Broad-spectrum IV antibiotics : See empiric antibiotic therapy for intra-abdominal infection.
Duplex sonography of the mesenteric vessels : best screening modality in an office setting Differential diagnoses Malignancy Chronic cholecystitis Chronic pancreatitis Peptic ulcer disease Therapy Nutritional support frequent, small meals and low-fat diet [15] Long-term anticoagulation therapy [16] Revascularization procedures to prevent bowel infarction in patients with abdominal pain and weight loss Angioplasty and stenting Mesenteric artery bypass surgery Prognosis In chronic mesenteric ischemia , surgical revascularization and reduction of risk factors can lead to significant pain reduction.
Ischemic colitis: Clinical practice in diagnosis and treatment. World Journal of Gastroenterology. Investigation and management of ischemic colitis.. Cleve Clin J Med. Systematic review of the management of ischaemic colitis. Colorectal Disease. Risk factors effecting mortality in acute mesenteric ischemia and mortality rates: a single center experience..
Int Surg. Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities.. World journal of gastrointestinal pathophysiology. Mesenteric venous thrombosis.. CT of the Acute Abdomen pp Cite as. Diagnosis of intestinal disease related to vascular disorders could represent a critical diagnostic challenge for the emergency radiologist. Both terms indicate as different degrees or stages of disease an injury caused by interruption of the blood supply to the intestinal tissue.
It is possible to distinguish three main different conditions underlying an intestinal ischemic event: arterial blood supply deficiency mainly related to embolism or thrombosis; impaired venous drainage; decreased mesenteric blood flow or low-flow state. Acute mesenteric ischemia can be considered a real, true emergency because of the associated significant mortality rate, which can be extremely high. A prompt diagnosis of any intestinal ischemic disorder of the intestine is imperative.
However, because most patients affected by bowel ischemia can present with nonspecific signs and symptoms, it could be difficult to diagnose intestinal ischemia or infarction. Diagnostic imaging and especially multidetector computed tomography MDCT could be of great help in the management of patients with acute abdomen related to suspected acute mesenteric ischemia. Knowledge of the pathophysiology of the intestine is essential in order to recognize findings related to pathologic changes of the intestine affected by vascular disorders in different stages of disease from different causes.
In this chapter, MDCT findings of disorders from impaired venous drainage and from arterial blood flow insufficiency involving the small and the large intestine will be considered, considering also criteria for differential diagnosis. Skip to main content. This service is more advanced with JavaScript available. Advertisement Hide.
This process is experimental and the keywords may be updated as the learning algorithm improves. This is a preview of subscription content, log in to check access. Patient may also report weight loss in addition to other complaints such as nausea and diarrhea. Ischemic colitis is a form of mesenteric ischemia limited to the colon. It is caused by a low flow state, usually affects the elderly and is likely due to the shunting of blood away from the mucosa.
It often develops insidiously and many a times, no specific cause can be found. It manifests with lower abdominal pain, rectal bleeding and in later cases patients may develop symptoms of peritonitis. The subacute variety is the commonest variant and manifests with a lesser degree of pain and bleeding. Mesenteric ischemia is an uncommon occurrence, accounting for less than 1 in hospital admissions. The most recent American Gastroenterological Association position statement on this topic in , noted that the mortality rate had not changed over last 70 years.
Patients usually are elderly, smokers with diffuse atherosclerotic vascular disease. Females to male predominance is Ischemic colitis is predominantly a disease of the elderly with the majority of cases not progressing to gangrene. Due to its non specific presentation findings, mesenteric ischemic will be in the differential of almost all causes of abdominal pain. It is often a diagnosis of exclusion and any elderly patient with unexplained abdominal pain should be evaluated for mesenteric ischemia.
Notably, ischemic colitis can mimic most forms of colitis includes infectious, radiation colitis , diverticulitis and even colon cancer. Acute mesenteric ischemia is characterized by pain which is out of proportion to exam. This means that patient may not have involuntary guarding or rigidity these may however be seen later in the course of the disease as bowel gangrene sets in.
Some patients will have hypoactive bowel sounds and abdominal distension. Guiaic positive stool are also seen but may also manifest as frank hematochezia. In patients with chronic mesenteric ischemia more often than not there are no physical exam findings. Sometimes there may be vague complaints of abdominal tenderness and blood in the stool. In some rare cases, an abdominal bruit may be heard over an area of turbulent flow due to vascular narrowing.
Early diagnosis is the key in managing mesenteric ischemia with the goal to prevent infarction. Notably, most diagnostic modalities do not show specific findings until it is too late.
Multi detector abdominal Computed Tomography MDCT : This is the diagnostic test of choice since it allows for rapid and early detection of ischemia. Mural thickening is the commonest finding however other findings include pneumatosis intestinalis and portal vein gas. This technique remains the gold standard for diagnosis of mesenteric ischemia however with development of the MDCT, it is now mostly used to confirm the diagnosis.
It does require an interventional radiology specialist who may not always be available in all centers. Angiography offers the advantage of allowing option for immediate therapy with selective infusion of vasodilatory drugs. Air fluid levels and distension may also be seen. This has been utilized to evaluate for mesenteric ischemia, however it can not appropriately evaluate much of the small bowel hence lacking sensitivity. Colonoscopy may be used to look for colonic ischemia however it is done without any bowel preparation and with minimization of air insufflation to minimize risk of perforation.
Endoscopic techniques allow biopsies to be taken which can then be tested for ischemic damage. Newer modality which can provide accurate images of the arterial and venous vasculature.
However, technique is less reliable for detecting distal lesions and is less preferred than CT which is quicker to do. Also limited by its cost, claustrophobia and surgical clips in the abdomen which will interfere with image interpretation.
There are no laboratory tests which are diagnostic of mesenteric ischemia. However some commonly observed laboratory abnormalities include:. In CMI, mild leukocytosis may be the only abnormality found on blood work. Metabolic acidosis with anion gap is commonly seen in mesenteric ischemia especially in advanced cases. PositiveD Dimeris a non specific finding on blood work. Kougias et al. Elevations inserum phosphate and potassiumare usually late occurrences and indicate bowel necrosis.
Barium enema has no role in the management of patients with acute mesenteric ischemia and introduction of barium may in fact potentially increase the risk for perforation. Barium will also interfere with interpretation of other more useful tests such CT. Onceacute mesenteric ischemiais suspected, the cornerstone of treatment is fluid resuscitation and surgical consult while concurrently trying to identify the underlying cause.
The goal of surgical management is to preserve as much of the bowel as possible. Follow up second look laparotomy after 24 hours is often done to ensure bowel viability. Acute mesenteric venous thrombosis can be managed safely without surgery if there is no evidence of infarction. In these cases, immediate anticoagulation early in the course of the disease improves survival. Most cases ofchronic mesenteric ischemiaare managed conservatively.
In patients with chronic venous mesenteric vein thrombosis, long term anticoagulation may be recommended if found to have an underlying prothrombotic state. Both acute and chronic mesenteric ischemia are caused by a decrease in blood flow to the small intestine.
Acute mesenteric ischemia is most commonly caused by a blood clot in the main mesenteric artery. The blood clot often originates in the heart. The chronic form is most commonly caused by a buildup of plaque that narrows the arteries.
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