Chronic mesenteric ischaemia

Chronic mesenteric ischaemia is an uncommon type of intestinal ischaemia usually affecting elderly patients as a result of significant stenosis of two or more mesenteric arteries.

Normally seen in patients older than 60 years of age and is three times more common in women.

Reported features include:

  • postprandial abdominal pain (classically starts 15-30 minutes post meal and typically lasts for 30 minutes)
  • significant weight loss
  • food fear
  • nausea
  • vomiting
  • diarrhoea

Chronic mesenteric ischaemia is often multifactorial in aetiology. The most common cause is atherosclerosis involving the proximal portions of the coeliac artery, superior mesenteric artery (SMA), or inferior mesenteric artery (IMA). Less common aetiologies include:

  • dissection
  • vasculitis
  • fibromuscular dysplasia
  • radiation
  • cocaine abuse.

Chronicity of the symptoms is caused by the gradual decrease in blood flow to the intestines. The normal vascular supply to the bowel is from the coeliac artery, superior mesenteric and inferior mesenteric arteries. Extensive collateralization can occur between the vascular territories of these vessels. Because of this collateral circulation, patients may experience symptoms, not until two or three major mesenteric vessels are involved. 

Ultrasound

Useful for diagnosing a haemodynamically significant stenosis involving the coeliac artery or SMA.

Fasting duplex criteria for significant mesenteric stenosis suggest that a superior mesenteric artery peak systolic velocity of 275 cm/s or greater and a coeliac artery peak systolic velocity of 200 cm/s or greater are reliable indicators of a 70% or greater stenosis.

CT

Typical findings include:

  • stenosis of mesenteric vessels
  • bowel wall thickening
  • pneumatosis
  • peritoneal free fluid
  • 3D imaging may help in visualisation of collateral pathways
MRI

Helps in visualising mesenteric vessel stenosis. The inferior mesenteric artery may be poorly visualised, depending on the sequence.

Angiography/CTA/MRA

Catheter angiography is the gold standard for diagnosing mesenteric vascular disease. Not only does it directly visualises the mesenteric vasculature, selective catheterisation and pressure measurements across a stenosis can determine the haemodynamic significance of the questionable lesions.

If a diagnosis of chronic mesenteric ischaemia is made, patients should undergo definitive treatment due to the risk of continued weight loss, acute infarction, perforation, sepsis, or death.

Medical treatment is usually reserved for patients who are not healthy enough to be treated, either surgically or endovascularly. The treatment consists of long-term anticoagulation, such as Warfarin. 

An open surgical repair includes a transaortic endarterectomy, direct reimplantation on the aorta, or antegrade or retrograde bypass grafting. 

Endovascular repair includes angioplasty and/or stent placement of lesions within the mesenteric vasculature.

Possible considerations include:

 It was first described as “abdominal angina” by G H Goodman


Ultrasound - general index
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Article Information

rID: 25647
Section: Pathology
Tags: refs, cases
Synonyms or Alternate Spellings:
  • Chronic mesenteric ischemia
  • Chronic intestinal ischaemia
  • Chronic mesenteric ischaemia

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