Chronic Mesenteric Ischemia

Aka: Chronic Mesenteric Ischemia, Abdominal Angina, Intestinal Angina

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II. Epidemiology

  1. Age: 60 years is mean age of diagnosis
  2. Gender predominance: Female (by ratio to 3:1)

III. Causes

  1. Diffuse atherosclerotic disease in 95% of cases
    1. All major mesenteric vessels (SMA, IMA, Celiac Artery) with stenosis or Occlusion
  2. Other causes
    1. Radiation Therapy
    2. Malignancy
    3. Fibromuscular dysplasia
    4. Vasculitis (often involves smaller vessels)
      1. Takayasu Arteritis
      2. Giant Cell Arteritis
      3. Polyarteritis Nodosa
      4. Systemic Lupus Erythematosus
      5. Thromboangiitis Obliterans

IV. Risk Factors

  1. Cardiovascular Risk Factors
  2. Tobacco Abuse (75-80%)

V. Symptoms

  1. Symptoms are typically present for 4 -6 months at presentation
    1. Diagnosis is often delayed as much as 18 months
  2. Postprandial, diffuse Abdominal Pain
    1. Crampy, Abdominal Pain
    2. Pain is typically diffuse and poorly localized, or periumbilical
  3. Associated findings
    1. Weight loss of 15-25 pounds
    2. Nausea

VI. Signs

  1. Abdominal bruit (60-90%)
  2. Fecal Occult Blood Testing (10%)

VII. Labs

  1. See Mesenteric Ischemia
  2. Malnutrition Labs in Chronic Mesenteric Ischemia
    1. Anemia
    2. Leukopenia or Lymphopenia
    3. Hypoalbuminemia

VIII. Imaging: Diagnosis

  1. See Mesenteric Ischemia
  2. CT Abdomen and CT Angiography
    1. First-line study in most cases
    2. Occlusion of 2 major visceral arteries with significant stenosis of the third
  3. Angiography (gold standard)
  4. Contrast-Enhanced MRA Abdomen
    1. Contrast-Enhanced MRA is the best modality to fully evaluate for abdominal vascular disease
  5. Mesenteric Duplex Ultrasound

IX. Management

  1. Medical Short-Term Measures while pending surgical management
    1. Bowel Rest
    2. Tobacco Cessation
    3. Perioperative Intra-arterial directed papaverine (vasodilator) to prevent arterial spasm
    4. Nitroglycerin as needed
    5. Anticoagulants (Heparin, Warfarin)
  2. Surgical (Vascular Surgery, Endovascular procedures)
    1. Indications
      1. All patients with Chronic Mesenteric Ischemia unless surgical risk outweighs benefit
      2. Endovascular techniques are preferred for high-risk surgical candidates (esp. short Life Expectancy)
        1. Lower morbidity and mortality than open procedures
      3. Open revascularization is preferred for patients who can withstand more invasive surgery
        1. Lower restenosis rates than with endovascular procedures
        2. Long-term symptomatic relief
    2. Procedures
      1. Resection of necrotic bowel
      2. Transaortic Endarderectomy (Celiac Artery or SMA)
      3. Anterograde bypass (from supraceliac aorta)
      4. Retrograde bypass (from infrarenal aorta or common iliac artery)

X. References

  1. Fraboni (2012) Board Review Express, San Jose
  2. Mastoraki (2021) World J Gastrointest Pathophysiol 7(1): 125-30 [PubMed]

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Related Studies

Ontology: Chronic mesenteric ischemia (C0311262)

Concepts Disease or Syndrome (T047)
ICD9 557.1
SnomedCT 111354009, 197008005, 241154007, 197005008, 266448009
English Chro intest vasc insuff, Chronic GIT vasc.insuffic.NOS, Chronic intestinal vascular insufficiency NOS, CMI - Chron mesenteric ischaem, Chr vasc insuff intest, chronic mesenteric ischemia, chronic intestinal ischemia, CMI - Chronic mesenteric ischemia, Chronic intestinal vascular insufficiency NOS (disorder), Chronic mesenteric ischaemia (disorder), CMI - Chronic mesenteric ischaemia, Chronic vascular insufficiency of intestine, Chronic intestinal ischaemia, Chronic intestinal ischemia, Chronic intestinal vascular insufficiency, Chronic mesenteric ischaemia, Chronic intestinal ischaemic syndrome, Chronic intestinal ischemic syndrome, Chronic vascular insufficiency of intestine (disorder), Chronic mesenteric ischemia, ischemia; bowel, chronic, Chronic intestinal ischemic syndrome, NOS, Chronic vascular insufficiency of intestine, NOS, Chronic intestinal ischaemic syndrome, NOS, Chronic mesenteric ischaemia [Ambiguous]
Dutch chronische vasculaire insufficiëntie van de ingewanden, ischemie; darm, chronisch
French Insuffisance intestinale chronique vasculaire
German chronische vaskulaere Insuffizienz des Darms
Portuguese Insuficiência vascular crónica do intestino
Spanish Insuficiencia vascular crónica del intestino, isquemia mesentérica crónica, insuficiencia vascular intestinal crónica, SAI (trastorno), insuficiencia vascular intestinal crónica, SAI, insuficiencia vascular crónica del intestino (trastorno), insuficiencia vascular crónica del intestino, síndrome de isquemia intestinal crónica
Japanese 慢性腸血行不全, ﾏﾝｾｲﾁｮｳｹｯｺｳﾌｾﾞﾝ
Italian Insufficienza vascolare cronica dell'intestino
Czech Chronická cévní nedostatečnost střeva
Hungarian Bél chronikus vascularis elégtelensége
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Abdominal angina (C1280008)

Concepts Sign or Symptom (T184)
SnomedCT 197005008, 240342007, 24988007, 241154007
English Abdominal Angina, intestinal angina, abdominal angina, angina abdominal, angina intestinal, Angina - abdominal, Intestinal angina (disorder), Abdominal angina, Intestinal angina, Abdominal angina (disorder)
Italian Angina intestinale
Japanese 腸管アンギナ, ﾁｮｳｶﾝｱﾝｷﾞﾅ
Czech Abdominální angina
Hungarian Intestinalis angina
Spanish angina intestinal, angina intestinal (trastorno), angina abdominal (trastorno), angina abdominal, Angina intestinal
Portuguese Angina intestinal
Dutch intestinale angina
French Angor intestinal
German Angina intestinalis
Derived from the NIH UMLS (Unified Medical Language System)

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