II. Epidemiology
- Age over 60 years
III. Pathophysiology
- Mesenteric Artery Embolism (50% of Acute Mesenteric Ischemia)
- Superior Mesenteric Artery is affected in most cases
- More than half lodge distal to the middle colic artery origin (6-8 cm from SMA origin)
- Superior Mesenteric Artery is affected in most cases
- Mesenteric Artery Thrombosis (15-25% of Acute Mesenteric Ischemia)
- Most often occurs at origin of major mesenteric vessel (Celiac Artery, SMA, IMA)
- Often at least two major vessels are occluded or stenosed
- Results in extensive bowel infarction
IV. Causes
- Mesenteric Artery Embolism, esp. superior Mesenteric Artery (50% of Acute Mesenteric Ischemia)
- Cardiac thrombus source is most common
- Mural thrombus (following Myocardial Infarction)
- Atrial thrombus
- Septic embolus
- Valvular endocarditis
- Mycotic aneurysm
- Vascular Sources
- Aortic atheromatous Plaque
- Vascular aortic prosthetic graft
- Asoociated with other emboli (20%)
- Malignancy
- Coagulation Disorder
- Cardiac thrombus source is most common
- Mesenteric Artery Thrombosis (15-25% of Acute Mesenteric Ischemia)
- Preexisting visceral atherosclerotic disease
- Typically associated with underlying Chronic Mesenteric Ischemia
- Other vascular conditions
- Aortic Dissection
- Mesenteric Artery rupture
- Fibromuscular Dysplasia
- Vasculitis (typically affects smaller vessels)
- Associated precipitating factors for acute thrombosis
- Abdominal Trauma
- Acute infection
- Preexisting visceral atherosclerotic disease
V. Symptoms
- See Mesenteric Ischemia
- Vomiting
- Severe, colicky or cramping, poorly localized Abdominal Pain
- Pain is severe and abrupt, sudden onset and out of proportion to exam in mesenteric embolism
- Pain is gradual and less severe in mesenteric thrombosis (due to incomplete Occlusion, collaterals)
- Other symptoms
- Nausea and Vomiting
- Forceful bowel evacuation (Diarrhea progressing to Constipation)
VI. Diagnosis: Classic Triad on presentation
- Cardiac disease
- Acute Abdominal Pain
- Acute gastrointestinal emptying (Vomiting and forceful bowel evacuation)
VII. Labs
-
Metabolic Acidosis
- Acute Abdominal Pain and Metabolic Acidosis is Acute Mesenteric Ischemia until definitively excluded
VIII. Imaging
- See Mesenteric Ischemia
- Angiography (gold standard)
-
CT Abdomen
Pelvis and CT Angiography
- First-line study in most cases
- Efficacy
- Test Sensitivity: 71-96%
- Test Specificity: 92-94%
- Progression of bowel changes in Mesenteric Ischemia
- Mesenteric Edema and streaking
- Bowel wall thickening (edema, Hemorrhage)
- Bowel wall gas (pneumotosis intestinalis) and Portal Vein gas in necrosis
- Findings in Mesenteric Occlusion
- Mesenteric Artery Thrombosis will demonstrate proximal stenosis or Occlusion of SMA, IMA or Celiac Artery
- Mesenteric Artery Embolism related Occlusion site is more difficult to identify on CT
- MRA Abdomen
- Similar findings to CT Angiogram
- Angiography (gold standard)
- Largely replaced by CT, but indicated in unclear cases (e.g. embolus)
- Also indicated for intervention
- Best defines Occlusion and stenosis sites
- Anteroposterior Views (collateral pathways)
- Lateral Views (visceral branches)
- Mesenteric Duplex Ultrasound
- Evaluates only proximal, main vessels (SMA, IMA and Celiac Artery)
- Test Sensitivity: 70-89%
- Test Specificity: 92-100%
- Abdominal XRay
- Listed for historical reasons only (all other advanced imaging is preferred)
- Normal initially
- Late findings
- Thumb printing
- Pneumatosis
- Portal venous gas
IX. Management
- See Mesenteric Ischemia
- Targeted Papaverine infusion via angiography
- Risk of Hypotension if catheter migrates into aorta
- Mesenteric Artery Embolism Reperfusion
- Catheter-Directed Local Thrombolysis within 8 hours of symptom onset
- Transverse Arteriotomy
- Palpable clot within vessel is extracted proximal to embolism with balloon-tipped Fogarty catheter
- Bypass Graft
- Mesenteric Artery Thrombosis
- Anticoagulation (Heparin transitioned to Warfarin, and continued for >=6 months)
- Revascularization (if bowel not gangrenous)
- Aortomesenteric bypass
- Trans-aortic endarterectomy
X. Prognosis
- Mortality: 70-90%
XI. Prevention
- Reduce Cardiovascular Risk Factors
- Refer Asymptomatic Superior Mesenteric Artery Stenosis to vascular surgery
XII. References
- Fraboni (2012) Board Review Express, San Jose
- Mastoraki (2021) World J Gastrointest Pathophysiol 7(1): 125-30 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
Concepts | Disease or Syndrome (T047) |
SnomedCT | 29000003, 57658009 |
Italian | Embolia dell'arteria mesenterica |
Japanese | 腸間膜動脈塞栓, チョウカンマクドウミャクソクセン |
English | mesenteric artery infarction due to embolism (diagnosis), mesenteric artery infarction due to embolism, Mesenteric artery embolism, Embolism of mesenteric artery (disorder), Embolic mesenteric infarction, Embolism of mesenteric artery, Mesenteric arterial embolization, Embolic mesenteric infarction (disorder), Mesenteric arterial embolisation, Embolism of mesenteric artery -RETIRED- |
Czech | Embolie mezenterické arterie |
Spanish | embolia de la arteria mesentérica, embolia de la arteria mesentérica - RETIRADO -, embolismo de la arteria mesentérica, embolia de la arteria mesentérica - RETIRADO - (concepto no activo), infarto mesentérico embólico (trastorno), infarto mesentérico embólico, Embolia de la arteria mesentérica |
Hungarian | Arteria mesenterica embolisatio |
Portuguese | Embolia da artéria mesentérica |
Dutch | mesenterische arterie-embolie |
French | Embolie de l'artère mésentérique |
German | Embolie der Arteria mesenterica |
Ontology: Thrombosis of mesenteric artery (C0267410)
Concepts | Disease or Syndrome (T047) |
SnomedCT | 22398008, 243410003 |
Dutch | mesenterische arterietrombose, trombose mesenterische arterie |
French | Thrombose de l'artère mésentérique, THROMBOSE ARTERE MESENTERIQUE |
German | Thrombose einer Mesenterialarterie, Thrombose der Arteria mesenterica |
Italian | Trombosi dell'arteria mesenterica |
Portuguese | Trombose arterial mesentérica, TROMBOSE ARTERIAL MESENTERICA |
Spanish | Trombosis de la arteria mesentérica, oclusión trombótica de la arteria mesentérica, trombosis de la arteria mesentérica, trombosis de la arteria mesentérica (trastorno), trombosis de arteria mesentérica (trastorno), trombosis de arteria mesentérica, trombosis de la arteria mesentérica (concepto no activo) |
Japanese | 腸間膜動脈血栓症, チョウカンマクドウミャクケッセンショウ |
English | MESENTERIC ARTERY THROMBOSIS, mesenteric artery thrombosis, Thrombosis of mesenteric artery, Thrombosis of mesenteric artery (disorder), Thrombosis of mesenteric artery (disorder) [Ambiguous], Mesenteric artery thrombosis, Thrombosis mesenteric artery |
Czech | Trombóza mezenterické tepny, Trombóza mezenterické arterie |
Hungarian | Arteria mesenterica thrombosis, Arteria mesenterica thrombosisa |
Ontology: Occlusive mesenteric ischemia (C0341421)
Concepts | Disease or Syndrome (T047) |
SnomedCT | 235842000 |
Spanish | isquemia mesénterica oclusiva (trastorno), isquemia mesentérica oclusiva, isquemia mesentérica oclusiva (trastorno), isquemia mesénterica oclusiva |
English | Occlusive mesenteric ischaemia, Occlusive mesenteric ischemia, Occlusive mesenteric ischemia (disorder) |
Ontology: Superior mesenteric artery thrombosis (C0347888)
Concepts | Disease or Syndrome (T047) |
SnomedCT | 197000003 |
English | Sup mesenteric art thrombosis, Superior mesenteric artery thrombosis, Superior mesenteric artery thrombosis (disorder) |
Spanish | trombosis de la arteria mesentérica superior (trastorno), trombosis de la arteria mesentérica superior |
Ontology: Mesenteric artery stenosis (C0853208)
Concepts | Disease or Syndrome (T047) |
SnomedCT | 405545007 |
Italian | Stenosi dell'arteria mesenterica |
Japanese | 腸間膜動脈狭窄, チョウカンマクドウミャクキョウサク |
English | stenosis of mesenteric artery (diagnosis), stenosis of mesenteric artery, Mesenteric artery stenosis, Mesenteric artery stenosis (disorder) |
Czech | Stenóza mezenterické arterie |
Hungarian | Arteria mesenterica stenosis |
Portuguese | Estenose da artéria mesentérica |
Spanish | Estenosis de la arteria mesentérica, estenosis de arteria mesentérica (trastorno), estenosis de arteria mesentérica |
Dutch | mesenterische arteriestenose |
French | Sténose de l'artère mésentérique |
German | Stenose der Arteria mesenterica |
Ontology: Acute mesenteric arterial occlusion (C1313902)
Concepts | Disease or Syndrome (T047) |
SnomedCT | 243286001, 22398008 |
English | Acute mesenteric arterial occlusion, Acute mesenteric arterial occlusion (disorder) |
Spanish | oclusión arterial mesentérica aguda (trastorno), oclusión arterial mesentérica aguda |
Ontology: Coeliac artery stenosis (C1963847)
Concepts | Disease or Syndrome (T047) |
English | Celiac artery stenosis, Coeliac artery stenosis |
Spanish | Estenosis de la arteria celíaca |
French | Sténose du tronc coeliaque |
Dutch | stenose van arteria coeliaca |
Portuguese | Estenose da artéria celíaca |
German | Stenose der Arteria coeliaca |
Italian | Stenosi dell"arteria celiaca, Stenosi dell'arteria celiaca |
Japanese | 腹腔動脈狭窄, フククウドウミャクキョウサク, フックウドウミャクキョウサク |
Czech | Stenóza koeliakální tepny |
Hungarian | Coeliacia arteriai stenosis, Arteria coeliaca stenosisa |