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  • Clinician

Intestinal ischemia

Summary

Intestinal ischemia occurs when blood flow to the bowels is reduced. The condition can be acute or chronic and may affect the large and/or the small intestine. Possible causes for decreased blood flow include thromboembolism, atherosclerosis, and severe hypotension. Mild forms of intestinal ischemia lead to abdominal discomfort (e.g., postprandial pain) and a change in bowel habits (e.g., bloody diarrhea). In severe cases, infarction of intestinal tissue leads to perforation of the bowel, sepsis, and death. Early diagnosis and therapy are, therefore, essential and sometimes emergency surgery is vital. Imaging techniques (e.g., CT angiography, ultrasound, colonoscopy) are used to detect stenoses, occlusions, and/or mucosal changes. Chronic and mild acute forms are associated with better prognosis and patients benefit from revascularization procedures (e.g., stents, bypass surgery) and symptomatic therapy. Complications such as peritonitis and sepsis result in poor prognosis.

Definition

Intestinal ischemia is classified into three main types:

Ischemic colitis

Epidemiology

  • Most common form of intestinal ischemia
  • Mainly occurs in adults > 60 years [2]
  • In ∼ 80–85% mild, nongangrenous form [3]

Etiology

Usually caused by transient hypoperfusion

Pathophysiology

The intestines can tolerate a state of ischemia for approx. 6 hours.

Clinical features

Typically presents with 3 clinical stages.

A classic case of ischemic colitis is a patient who presents with bloody diarrhea and severe abdominal pain after an abdominal aortic aneurysm repair.

Diagnostics

Differential diagnoses

Therapy

  • Mild to medium-severe forms
  • Severe forms (signs of peritonitis, sepsis): surgical intervention (laparotomy and bowel resection)

Complications

Prognosis

Acute mesenteric ischemia

Epidemiology

Etiology

Pathophysiology

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.g., tachycardia, hypotension)
  • Clinical courses
    • Acute arterial embolism: most abrupt and painful onset of all types
    • Acute arterial thrombosis: presentation less severe because patients have better collateral supply
    • Nonocclusive ischemia: symptoms develop over several days
    • Venous thrombosis: symptoms less dramatic, worsen gradually (e.g., abdominal discomfort evolves over a week)

A patient with acute arterial embolism typically presents with severe abdominal pain, fever, bloody diarrhea, leukocytosis, and atrial fibrillation.
A patient with acute arterial thrombosis typically has a known cardiovascular or peripheral vascular disease and/or symptoms of chronic mesenteric ischemia in addition to acute symptoms.

Diagnostics

If acute mesenteric ischemia is suspected, quickly initiating imaging studies (CT angiography, color Doppler sonography) is essential. In cases with peritonitis or risk of shock, however, emergency surgery without prior imaging is indicated.

Differential diagnoses

Treatment

Acute management checklist for acute mesenteric ischemia [8][9][10][11]

Complications

Prognosis

Chronic mesenteric ischemia

Epidemiology

Etiology

Pathophysiology

Clinical features

  • Some patients may be asymptomatic (see “Pathophysiology”)
  • Abdominal/intestinal angina
    • Recurrent, dull, postprandial epigastric pain usually within the first hour after eating
    • Can lead to a fear of eating weight loss and malabsorption
  • Bloating, nausea, occasional diarrhea
  • Abdominal bruit caused by stenosis of mesenteric vessels

A patient typically presents with postprandial abdominal pain (abdominal angina), food aversion, and weight loss.

Diagnostics

  • No specific laboratory findings in chronic mesenteric ischemia
  • Clinical suspicion → CT scan of the abdomen (identifies atherosclerotic vascular disease and rules out other abdominal disorders)
  • CT angiography or MR angiography: High-grade stenoses of at least two major vessels must be established for diagnosis.
  • Duplex sonography of the mesenteric vessels: best screening modality in an office setting

Differential diagnoses

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

Prognosis

  • 1. Theodoropoulou A, ΚoutroubakisWorld L. Ischemic colitis: Clinical practice in diagnosis and treatment. World Journal of Gastroenterology. 2008; 14(48): pp. 7302–7308. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2778113/.
  • 2. Park CJ, Jang MK, Shin WG, et al. Can We Predict the Development of Ischemic Colitis Among Patients with Lower Abdominal Pain?. Diseases of the Colon & Rectum. 2007; 50(2): pp. 232–238. doi: 10.1007/s10350-006-0753-5.
  • 3. Baixauli J, Kiran RP, Delaney CP. Investigation and management of ischemic colitis. Cleve Clin J Med. 2003; 70(11): pp. 920–921. doi: 10.3949/ccjm.70.11.920.
  • 4. O’Neill S, Yalamarthi S. Systematic review of the management of ischaemic colitis. Colorectal Disease. 2012; 14(11): pp. e751–e763. doi: 10.1111/j.1463-1318.2012.03171.x.
  • 5. Aliosmanoglu I, Gul M, Kapan M, et al. Risk factors effecting mortality in acute mesenteric ischemia and mortality rates: a single center experience. Int Surg. ; 98(1): pp. 76–81. doi: 10.9738/CC112.1.
  • 6. Mastoraki A, Mastoraki S, Tziava E, et al. Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities. World journal of gastrointestinal pathophysiology. 2016; 7(1): pp. 125–30. doi: 10.4291/wjgp.v7.i1.125.
  • 7. Hmoud B, Singal AK, Kamath PS. Mesenteric venous thrombosis. Journal of clinical and experimental hepatology. 2014; 4(3): pp. 257–63. doi: 10.1016/j.jceh.2014.03.052.
  • 8. Fidelman N, AbuRahma AF, Cash BD, et al. ACR Appropriateness Criteria ® Radiologic Management of Mesenteric Ischemia. Journal of the American College of Radiology. 2017; 14(5): pp. S266–S271. doi: 10.1016/j.jacr.2017.02.014.
  • 9. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. Gastroenterology. 2000; 118(5): pp. 954–968. doi: 10.1016/s0016-5085(00)70183-1.
  • 10. Bala M, Kashuk J, Moore EE, et al. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World Journal of Emergency Surgery. 2017; 12(1). doi: 10.1186/s13017-017-0150-5.
  • 11. Tilsed JVT, Casamassima A, Kurihara H, et al. ESTES guidelines: acute mesenteric ischaemia. European Journal of Trauma and Emergency Surgery. 2016; 42(2): pp. 253–270. doi: 10.1007/s00068-016-0634-0.
  • 12. Rushfeldt CF, Sveinbjørnsson B, Søreide K, Vonen B. Risk of anastomotic leakage with use of NSAIDs after gastrointestinal surgery. Int J Colorectal Dis. 2011; 26(12): pp. 1501–1509. doi: 10.1007/s00384-011-1285-6.
  • 13. Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD. Acute Mesenteric Ischemia. Arch Intern Med. 2004; 164(10): p. 1054. doi: 10.1001/archinte.164.10.1054.
  • 14. Kougias P, El Sayed HF, Zhou W, Lin PH. Management of chronic mesenteric ischemia. The role of endovascular therapy. J Endovasc Ther. 2007; 14(3): pp. 395–405. doi: 10.1583/07-2102.1.
  • 15. Good L, Burnett BP. Management of Loose, Frequent Stools and Fecal Incontinence in a Chronic Mesenteric Ischemia Patient with Oral Serum-derived Bovine Immunoglobulin. Clin Med Insights Gastroenterol. 2015; 8: p. CGast.S21307. doi: 10.4137/cgast.s21307.
  • 16. Hohenwalter EJ. Chronic Mesenteric Ischemia: Diagnosis and Treatment. . ; 26(4): pp. 345–351. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036470/.
  • Herold G. Internal Medicine. Cologne, Germany: Herold G; 2014.
  • Ginsburg M, et al. ACR Appropriateness Criteria® Imaging of Mesenteric Ischemia. Journal of the American College of Radiology. 2018; 15(11): pp. S332–S340. doi: 10.1016/j.jacr.2018.09.018.
  • Tabriziani H, et al. A Nonsurgical Approach to Mesenteric Vascular Disease. Cardiol Rev. 2018; 26(2): pp. 99–106. doi: 10.1097/crd.0000000000000180.
last updated 11/11/2020
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