Intestinal ischemia

Last updated: July 12, 2022

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Intestinal ischemia occurs if bowel perfusion cannot meet the metabolic demands of the intestine. This relative hypoperfusion may be the result of atherosclerosis, thromboembolic disease, or severe systemic hypotension. Intestinal ischemia is often classified based on its onset and location: acute mesenteric ischemia (AMI), chronic mesenteric ischemia (CMI), or colon ischemia (ischemic colitis). Each type has a different manifestation and treatment. AMI is a vascular emergency and manifests with sudden, severe abdominal pain; CMI manifests with chronic recurrent postprandial abdominal pain. Colon ischemia manifests with cramping abdominal pain and bloody diarrhea and is often self-limited, though, rarely, it may progress to fulminant bowel necrosis. Diagnosis is primarily made with cross-sectional imaging and CT angiography (CTA). Laboratory studies are used to determine disease severity and monitor the effects of resuscitation. Early diagnosis, surgical consultation, and definitive treatment with urgent surgical or endovascular revascularization are essential in AMI, which has a mortality rate of > 50%. Patients with CMI have a more favorable prognosis but still benefit from timely revascularization. Colon ischemia is primarily managed with supportive care and monitoring for symptom progression. Bowel perforation, intestinal infarct, and/or sepsis are associated with a poor prognosis, regardless of the type of intestinal ischemia.

Overview of intestinal ischemia

Types

Colon ischemia

Acute mesenteric ischemia Chronic mesenteric ischemia
Etiology
Sites of ischemia
Clinical features
Diagnostic tests
Management

Definition [1][2][3]

Epidemiology [2][4]

  • Most common type of intestinal ischemia
  • Most commonly affects individuals > 60 years of age
  • ∼ 80% of cases are nongangrenous, resolving without surgery
  • Isolated right-sided colon ischemia (IRCI): 10–25% of cases [5]

Etiology [3][6]

Older patients with risk factors for atherosclerosis are at especially high risk for developing colon ischemia. [8]

Severe abdominal pain and bloody diarrhea after an abdominal aortic aneurysm repair is a classic manifestation of colon ischemia.

Pathophysiology [4][6]

Injury to the intestinal mucosa can occur after just 20 minutes of ischemia; transmural infarction and gangrene occur after 8–16 hours of ischemia. [6]

Clinical features [2][3]

Consider colon ischemia in any patient with abdominal pain and/or bloody diarrhea without a clear infectious etiology, as many do not have the classic presentation of colon ischemia. [3]

In colon ischemia, pain is typically milder and more laterally located than in small intestinal ischemia. [3]

Red flags in colon ischemia

The following are poor prognostic markers:

Classification

The severity of colon ischemia determines the appropriate approach to diagnostics and treatment. . [2]

Diagnostics [2][3][11]

Approach

CT abdomen is the preferred initial test for all patients with suspected colon ischemia.

Laboratory studies [3]

Hallmark findings of severe colon ischemia include leukocytosis, metabolic acidosis, lactate, LDH, and CPK.

Imaging [8]

Colonoscopy

Colonoscopy confirms the diagnosis, defines the distribution of the ischemia, and excludes other pathology.

Colonoscopy should be performed within 48 hours in patients with suspected colon ischemia. [2]

Differential diagnoses [3]

Treatment [2][3][12]

  • Colon ischemia usually resolves spontaneously and requires no specific therapy.
  • Surgical intervention is required in severe cases (e.g., patients with gangrenous bowel).

Initial management

Conservative management

Surgery

Complications

Prognosis [2]

  • Overall mortality: 4–12%
  • Recurrence rate: up to 10% within 5 years

Definition

Epidemiology

  • Most commonly occurs in individuals > 60 years of age [14]
  • Prevalence in patients with acute abdomen: ∼ 1% [15]
  • Mortality: 50–70% [13][16][17]

Etiology [13][15][16]

AMI has various etiologies, which manifest with similar clinical features despite having different underlying risk factors and pathology.

Pathophysiology [15][16]

Clinical features [13][15][16]

Patients with acute mesenteric artery embolism typically present with the classic triad of severe abdominal pain, bloody diarrhea, and atrial fibrillation.

Patients with acute mesenteric artery thrombosis typically have known cardiovascular or peripheral vascular disease and/or symptoms of CMI in addition to acute symptoms.

Evaluate patients with atrial fibrillation and acute abdominal pain for acute mesenteric ischemia. [15]

Approach to management

Patients presenting with peritonitis and/or hemodynamic instability may need to proceed to surgery before imaging can be obtained.

Diagnostics [13][15][21][22]

CTA abdomen and pelvis [22]

CTA is the test of choice for AMI. [16][17]

Do not delay CTA while waiting for other diagnostic test results. [16][17]

Other imaging

Laboratory studies [13][15][16]

These can help establish AMI severity and guide resuscitation efforts but are not diagnostic for AMI. [13]

Patients with AMI may have normal lactate levels and pH on initial presentation.

Treatment [13][16]

Initial treatment [17][23][24]

Definitive treatment [15]

Definitive treatment is determined by the etiology of the AMI, the integrity of the bowel wall, and institutional resources .

Emergency laparotomy is indicated if there are signs of peritonitis, intestinal infarct, or hemodynamic instability. [13][15]

Immediate anticoagulation and endovascular revascularization may be considered in hemodynamically stable patients with AMI and no signs of advanced bowel ischemia.

Patients who do not improve after endovascular intervention should undergo surgical intervention. [24]

Long-term management [13][23][24]

Complications

Definition [27]

Epidemiology [27][28][29]

  • MAOD is common, while CMI is rare.
  • CMI most commonly occurs in adults > 60 years of age; >

Etiology [27][28]

Pathophysiology

CMI manifests as postprandial pain because oxygen demand increases significantly during digestion but the supply is limited by the fixed obstruction. [27][28]

Clinical features [28]

The recurrent dull postprandial pain associated with CMI is sometimes referred to as intestinal or abdominal angina.

Diagnostics [15][18][27][28]

Evidence of mesenteric artery stenosis is diagnostic for CMI in patients with suggestive clinical features and no other etiologies of postprandial abdominal pain. [27]

Differential diagnoses [28]

Treatment [15][18][27][28]

Approach

Revascularization

Revascularization is recommended in all patients with CMI.

Nutritional therapy

  • Frequent, small meals and a low-fat diet may provide some symptom relief.
  • Total parenteral nutrition should only be considered as a temporary supportive measure.

Long-term management

Prognosis

  • 5-year mortality for untreated CMI is close to 100%. [27][30]
  • Symptoms are relieved in 95% of patients following revascularization. [23]
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