II. Epidemiology

  1. Age over 60 years

III. Pathophysiology

  1. Mesenteric Artery Embolism (50% of Acute Mesenteric Ischemia)
    1. Superior Mesenteric Artery is affected in most cases
      1. More than half lodge distal to the middle colic artery origin (6-8 cm from SMA origin)
  2. Mesenteric Artery Thrombosis (15-25% of Acute Mesenteric Ischemia)
    1. Most often occurs at origin of major mesenteric vessel (Celiac Artery, SMA, IMA)
    2. Often at least two major vessels are occluded or stenosed
    3. Results in extensive bowel infarction

IV. Causes

  1. Mesenteric Artery Embolism, esp. superior Mesenteric Artery (50% of Acute Mesenteric Ischemia)
    1. Cardiac thrombus source is most common
      1. Mural thrombus (following Myocardial Infarction)
      2. Atrial thrombus
        1. Atrial Fibrillation
        2. Mitral Stenosis
      3. Septic embolus
        1. Valvular endocarditis
        2. Mycotic aneurysm
    2. Vascular Sources
      1. Aortic atheromatous Plaque
      2. Vascular aortic prosthetic graft
    3. Asoociated with other emboli (20%)
      1. Malignancy
      2. Coagulation Disorder
  2. Mesenteric Artery Thrombosis (15-25% of Acute Mesenteric Ischemia)
    1. Preexisting visceral atherosclerotic disease
      1. Typically associated with underlying Chronic Mesenteric Ischemia
    2. Other vascular conditions
      1. Aortic Dissection
      2. Mesenteric Artery rupture
      3. Fibromuscular Dysplasia
      4. Vasculitis (typically affects smaller vessels)
    3. Associated precipitating factors for acute thrombosis
      1. Abdominal Trauma
      2. Acute infection

V. Symptoms

  1. See Mesenteric Ischemia
  2. Vomiting
  3. Severe, colicky or cramping, poorly localized Abdominal Pain
    1. Pain is severe and abrupt, sudden onset and out of proportion to exam in mesenteric embolism
    2. Pain is gradual and less severe in mesenteric thrombosis (due to incomplete Occlusion, collaterals)
  4. Other symptoms
    1. Nausea and Vomiting
    2. Forceful bowel evacuation (Diarrhea progressing to Constipation)

VI. Diagnosis: Classic Triad on presentation

  1. Cardiac disease
  2. Acute Abdominal Pain
  3. Acute gastrointestinal emptying (Vomiting and forceful bowel evacuation)

VIII. Imaging

  1. See Mesenteric Ischemia
  2. Angiography (gold standard)
  3. CT Abdomen Pelvis and CT Angiography
    1. First-line study in most cases
    2. Efficacy
      1. Test Sensitivity: 71-96%
      2. Test Specificity: 92-94%
    3. Progression of bowel changes in Mesenteric Ischemia
      1. Mesenteric Edema and streaking
      2. Bowel wall thickening (edema, Hemorrhage)
      3. Bowel wall gas (pneumotosis intestinalis) and Portal Vein gas in necrosis
    4. Findings in Mesenteric Occlusion
      1. Mesenteric Artery Thrombosis will demonstrate proximal stenosis or Occlusion of SMA, IMA or Celiac Artery
      2. Mesenteric Artery Embolism related Occlusion site is more difficult to identify on CT
  4. MRA Abdomen
    1. Similar findings to CT Angiogram
  5. Angiography (gold standard)
    1. Largely replaced by CT, but indicated in unclear cases (e.g. embolus)
    2. Also indicated for intervention
    3. Best defines Occlusion and stenosis sites
      1. Anteroposterior Views (collateral pathways)
      2. Lateral Views (visceral branches)
  6. Mesenteric Duplex Ultrasound
    1. Evaluates only proximal, main vessels (SMA, IMA and Celiac Artery)
    2. Test Sensitivity: 70-89%
    3. Test Specificity: 92-100%
  7. Abdominal XRay
    1. Listed for historical reasons only (all other advanced imaging is preferred)
    2. Normal initially
    3. Late findings
      1. Thumb printing
      2. Pneumatosis
      3. Portal venous gas

IX. Management

  1. Targeted Papaverine infusion via angiography
    1. Risk of Hypotension if catheter migrates into aorta
  2. Mesenteric Artery Embolism Reperfusion
    1. Catheter-Directed Local Thrombolysis within 8 hours of symptom onset
      1. Tenecteplase Infusion
      2. Reteplase Infusion
      3. Schoots (2005) J Vasc Interventional Rad 16:317-29 [PubMed]
      4. Yanar (2013) World J Energ Surg 8:8 +PMID: 23394456 [PubMed]
      5. Wang (2011) Abdom Imaging 36:390-8 [PubMed]
    2. Transverse Arteriotomy
      1. Palpable clot within vessel is extracted proximal to embolism with balloon-tipped Fogarty catheter
    3. Bypass Graft
  3. Mesenteric Artery Thrombosis
    1. Anticoagulation (Heparin transitioned to Warfarin, and continued for >=6 months)
    2. Revascularization (if bowel not gangrenous)
      1. Aortomesenteric bypass
      2. Trans-aortic endarterectomy

X. Prognosis

  1. Mortality: 70-90%

XI. Prevention

  1. Reduce Cardiovascular Risk Factors
  2. Refer Asymptomatic Superior Mesenteric Artery Stenosis to vascular surgery

XII. References

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

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Embolic mesenteric infarction (C0267407)

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