What is Mesentric Ischemia?
• A medical condition in which inflammation and injury of the small intestine occurs due to inadequate blood supply.
Acute Mesentric Ischemia
• Acute Mesentric Ischemia is a syndrome caused by inadequate blood flow through the mesenteric vessels, resulting in ischemia and eventual gangrene of the bowel wall
a) Non occlusive mesenteric ischemia (NOMI) due to spasm of artery
b) Occlusive mesenteric arterial ischemia (OMAI) Subdivision – Acute mesenteric arterial thrombosis (AMAT) , Acute mesenteric arterial embolism (AMAE)
• Venous - mesenteric venous thrombosis (MVT)
Chronic Mesentric Ischemia
• Occurs gradually as the main visceral arteries narrow
• It also can occur suddenly as a result of a blood clot severely restricting blood flow (acute on chronic mesenteric ischemia)
• Lack of oxygen-rich blood can permanently damage the intestines
• Diabetes mellitus
• Abdominal pain
• Bloody stools
• Weight loss
• Gangrene of intestine
• Multi organ failure
• CT / MR Angiography
• Mesenteric angiography
• After initial medical or surgical stabilization, patients with AMI typically have a prolonged inpatient recovery time.
• Inpatient medications:
- Heparin/low-molecular-weight heparin
- Broad-spectrum antibiotics and pain medications & Supportive medicines
• Note: Treat any predisposing cause(s) of AMI
• Acute mesenteric arterial embolism (AMAE) - Papaverine infusion, surgical embolectomy, and intra-arterial thrombolysis.
• Acute mesenteric arterial thrombosis (AMAT) - Papaverine infusion and arterial.
reconstruction, either through aortosuperior mesenteric arterial bypass grafting or through re implantation of the superior mesenteric artery (SMA) into the aorta.
• Non occlusive mesenteric ischemia (NOMI) - Papaverine infusion.
• Mesenteric venous thrombosis (MVT) - Anticoagulation with heparin or warfarin, either alone or in combination with surgery; immediate heparinization should be started even when surgical intervention is indicated.
• All cases of mesenteric ischemia with signs of peritonitis or possible bowel infarction, regardless of etiology, generally warrant immediate surgical intervention for the resection of ischemic or necrotic intestines.
• Hemodynamic instability can also be an indication for surgery
• Surgical treatment may be contraindicated if the risks from comorbid conditions preclude survival after general anesthesia
• If the ischemia is thought to be caused by vasospasm, surgery is not indicated. Medical management with anticoagulants and intra-arterial vasodilators is appropriate
• A second-look procedure is indicated whenever bowel of questionable viability is not resected
Percutaneous Endovascular Interventions (in selected cases)
• Especially in isolated spontaneous dissection of the SMA, stent placement may be the preferred option.
Long Term Monitoring
• Cardiac and renal status
• Carotid duplex studies - if diffuse atherosclerotic disease
• Outpatient medications –
- antiarrhythmics for patients with atrial fibrillation (AF)
- warfarin for MVT or AF ( for at least 6 months or for life if a hypercoagulable state was dis covered during treatment )
- Treatment of predisposing factors
- Periodic evaluation of coagulation status -the international normalized ratio (INR)