Learning Radiology xray montage
 
 
 
 
 

Mesenteric Ischemia
Submitted by Jonathon Dorff, MD


  • Acute interruption of blood flow to small or large intestine

  • Causes:

    • Arterial embolism
      • Superior mesenteric artery most commonly involved
    • Arterial thrombosis
    • Nonocclusive mesenteric ischemia
      • Low cardiac output state with diffuse mesenteric vasoconstriction
    • Mesenteric venous thrombosis  
  • Risk Factors

    • Atrial fibrillation/flutter
    • Recent acute MI
      • Ventricular aneurysm
      • Cardiomyopathies
      • Valvular disease
    • Hypovolemia or hypotension (sepsis)
    • Coagulation disorders or malignancy
    • Pancreatitis
    • Portal hypertension/cirrhosis
    • Medications
      • Vasopressor medications
      • Beta-blockers
      • Digoxin
      • Diuretics  
  • Clinical signs and symptoms

    • Severe abdominal pain out of proportion to physical exam
    • Pain initially of a visceral nature and poorly localized
    • Nausea
    • Vomiting
    • Diarrhea
    • GI bleeding may be present  
  • Imaging

    • Plain abdominal radiographs (abnormal in 20-60% of cases)
      • Thumbprinting
        • Non-specific finding indicating intestinal wall edema with hemorrhage in the setting of acute mesenteric ischemia
      • Pneumatosis
      • Portal venous gas
      • Pneumoperitoneum
        • All are indicative of infarcted bowel
    • CT
      • Bowel wall  thickening from edema or hemorrhage
      • Lack of enhancement indicates infarction
      • Pneumatosis, portal venous gas, pneumoperitoneum
      • Intraluminal thrombus in involved vessel

Mesenteric Vascular Ischemia

Mesenteric Vascular Ischemia. Top CT image shows gas in portal venous system (blue circle); center image shows absence of contrast in superior mesenteric artery due to thrombosis of this vessel (blue arrow) [The patient also has a markedly dilated common duct, not related to mesenteric ischemia]; lower image shows extensive pneumatosis intestinalis (red arrows)

  • Mesenteric angiogram
    • Can distinguish between arterial embolic and thrombotic causes of acute mesenteric ischemia
  • Treatment

    • Mesenteric angiogram
      • Vasodilator therapy
      • Thrombectomy/Embolectomy
    • Surgery
      • Thrombectomy/Embolectomy
      • Arterial bypass
      • Resection of necrotic bowel

  • Complications

    • Sepsis/septic shock
    • Multiple system organ failure
    • Death

  • Mortality

    • 70-90% overall
    • From arterial embolism: 60-80%
    • From arterial thrombosis: 70-100%
    • From nonocclusive mesenteric ischemia: 40%
    • From mesenteric venous thrombosis: 25-30%