Written by Laura Murphy
Spoon Feed
This is a concise review on the diagnosis and management of mesenteric ischemia.
Not everyone reads the textbook…
This is a high risk condition (mortality >50%) that is time-sensitive. Prevalence is 0.1%, and incidence is 5.3 to 8.4 per 100,000 per year. There are four categories of disease below:
Not surprisingly, abdominal pain is the most common symptom, but patients may have nausea, vomiting and diarrhea in up to 30% of cases. Findings such as hematochezia and peritonitis may not be present until later in the course. Pain is often acute and severe (but not always, particularly in thrombotic disease); classic “pain out of proportion to exam” does not occur in up to 25% of cases. Other historical red flags for patients with arterial or venous thrombosis include chronic or subacute food aversion and weight loss.
Elevated lactate is associated with a worse prognosis, but sensitivity is only 86% and is often normal early in the course. D-dimer is sensitive (>90%) but not specific, and urine intestinal fatty acid-binding protein (I-FABP) is promising but not widely available (never mind how hard it can be just to get a urine!). The bottom line is that lab values can’t rule this out, and if you suspect it, order triple-phase CT imaging (sensitivity and specificity >94%) so that both arterial and venous phases are visualized; it is one of the times that renal dysfunction should not preclude use of contrast. Look for filling defects, bowel wall edema, ascites, stranding, and signs of pneumatosis or perforation.
Treatment includes resuscitation and symptom control as well as empiric antimicrobial coverage due to risk of bacterial translocation. Early surgical consultation is advised, as hemodynamically unstable patients or those with peritonitis require surgical exploration. More stable patients may be candidates for treatment with anticoagulation alone for embolic or thrombotic causes (unfractionated heparin) but may require revascularization procedures. For patients with non-occlusive disease, treatment focuses on underlying cause.
How will this change my practice?
This is a highly morbid condition that should be considered in patients presenting with abdominal pain and associated risk factors. I will continue to emphasize importance of contrasted imaging in patients who are at risk for this and will pay more attention to subacute symptoms preceding a patient’s acute presentations.
Source
Just the facts: Evaluation and management of mesenteric ischemia. CJEM. 2024 May;26(5):316-318. doi: 10.1007/s43678-024-00696-2. Epub 2024 May 7. PMID: 38714638.
