Mesenteric ischemia

Revision as of 18:36, 8 August 2019 by Rossdonaldson1 (talk | contribs) (Risk Factors)


  • Most commonly SMA, thus typically involves small bowel (especially jejunum) and right colon
  • Left colon uncommonly involved due to collateral flow


4 distinct entities:

  1. Mesenteric arterial embolism (ex. Afib)
  2. Mesenteric arterial thrombosis (ex. Vasculopath)
  3. Nonocclusive mesenteric ischemia (ex. Hypovolemia from diuretics)
  4. Mesenteric venous thrombosis (ex. hypercoagulable state)

Risk Factors

Risk Factors by Mesenteric Ischemia Type
Type Risk Factor
Arterial Embolism
  • Dysrhythmia (A. Fib)
  • Valve Disease
  • MI
Arterial Thrombosis
  • Atherosclerotic Disease
Venous Thrombosis
  • Prior thrombosis history
  • Hypercoagulable state (preg, cancer, clotting disorder)


  • Mean age: 70yo
  • 2/3 women

Clinical Features

  • Pain out of proportion to exam. Abdomen often soft, without guarding.
    • Pain often left sided around watershed areas of colon (splenic flexure and recto-sigmoid junction)
  • Severe, generalized, colicky
  • Bloody stools

Differential Diagnosis


Diffuse Abdominal pain


  • Labs
    • Lactate (higher later)
    • WBC (often >15K)
    • Chemistry (metabolic acidosis)
    • Hyperphosphatemia
  • Upright or left lateral decub XR with intraabdominal air
  • CTA
  • Mesenteric angiography considered gold standard


  • Aggressive IVF resuscitation, continued after revascularization due to capillary leak
  • Correct electrolyte imbalances prior to IV contrast or surgical exploration[1]
  • Opioid analgesia
  • IV antibiotics - broad spectrum antibiotics to prevent sepsis [2]
    • Second-generation cephalosporin plus metronidazole[3]


  • Anticoagulation with heparin is usually appropriate in all patients with mesenteric ischemia, with exception of those with typical contraindications
    • Some experts will recommend delaying heparin for 48 hours due to risk for intraluminal bleeding in bowels[5]

Acute arterial embolus

  • Papaverine infusion (30-60m g/h IV) OR
  • Surgical embolectomy OR
  • Mesenteric artery bypass surgery OR
  • Retrograde open mesenteric stenting OR
  • tPA intra-arterial thrombolysis with IR
  • PLUS/MINUS surgical resection of necrotic bowel after any of above interventions
  • PLUS/MINUS 24-48 hour second-look surgery

Nonocclusive mesenteric ischemia

  • Transcatheter vasodilation via:
    • PGE1, alprostadil
    • PGI2, epoprostenol
    • Papaverine, most commonly used, though use in caution with angina, recent stroke, MI, glaucoma

Mesenteric venous thrombosis

  • Heparin/warfarin either alone or in combination with surgery
  • Up to 5% of patients require intervention beyond anticoagulation alone[6]
  • Immediate heparinization should be started even when surgical intervention is indicated
    • Decreases progression of thrombosis and improves survival
  • PLUS/MINUS tPA intra-arterial thrombolysis with IR
  • PLUS/MINUS laparotomy for evidence of bowel necrosis, peritonitis, stricture, severe GI bleeding

Chronic mesenteric ischemia

  • Angioplasty with or without stent placement or surgical revascularization


  • Admit with consultation of one or more of the following
    • IR
    • Vascular
    • Surgery

See Also

External Links


  1. Wyers MC. Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010 Mar;23(1):9-20.
  2. Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341
  3. Klar E, Rahmanian PB, Bücker A, Hauenstein K, Jauch KW, Luther B. Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int. 2012 Apr;109(14):249-56 full-text, commentary can be found in Dtsch Arztebl Int 2012 Oct;109(42):709 full-text, Dtsch Arztebl Int 2012 Oct;109(42):710.
  4. Berland T, Oldenburg WA. Acute mesenteric ischemia. Curr Gastroenterol Rep. 2008 Jun;10(3):341-6.
  5. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology. 2000 May;118(5):954-68.
  6. Clair DG, Beach JM. Mesenteric Ischemia. N Engl J Med. 2016 Mar 10;374(10):959-68.