Chronic Mesenteric Ischaemia

Original Author: James Wolff
Last Updated: August 27, 2016
Revisions: 15

Chronic mesenteric ischaemia (CMI) is a lack of blood supply to the bowel which gradually deteriorates over time as a result of atherosclerosis in the coeliac trunk (CT), superior mesenteric artery (SMA), and/or inferior mesenteric artery (IMA).

Retrospective autopsy data has shown that the cause of death in the general population of mesenteric ischaemia is less than 0.01%

In this article, we shall look at the causes, clinical features and management of the patient with chronic mesenteric ischaemia.


Aetiology and Pathophysiology

The gradual buildup of atherosclerotic plaque causes narrowing of the blood vessel lumen, reducing blood flow and resulting in ischaemia to the bowel. The degree of communication within the visceral blood supply means that in the majority of circumstances at least two of the CT, SMA, and IMA must be affected.

When there is an increased demand on the blood supply (such as when eating) or reduction in supply (i.e. hypovolemic states) in patients with chronic mesenteric ischaemia, a transient ischemia of the bowel results.

Chronic mesenteric ischaemia occurs mostly in patients >60yrs and more commonly in females. Patients with atherosclerotic disease in the mesenteric vessels are often asymptomatic, and as such the condition is typically under-reported. However the prevalence of atherosclerotic involvement in the mesenteric vessels has been reported between 30% – 50%.

Fig 1- The arerial supply from the superior mesenteric artery to the midgut

Fig 1 – The arterial supply from the superior mesenteric artery to the midgut. In normal circumstances, at least two of the coeliac trunk, superior mesenteric artery and inferior mesenteric artery must be affected by atherosclerosis for the patient to have symptoms of CMI.


Risk Factors

The main risk factors for chronic mesenteric ischaemia are smoking, hypertension, diabetes mellitus, and hypercholesterolemia.


Clinical Features

The classical set of symptoms associated with chronic mesenteric ischaemia are:

  • Postprandial pain – classically occurring around 10mins-4hrs after eating.
    • This may be associated with a fear of eating (Sitophobia), as eating becomes linked to pain.
  • Weight loss – a combination of decreased calorie intake and malabsorption.
  • Concurrent vascular co-morbidities – previous MI, stroke, PVD.

Other less specific symptoms may include change in bowel habit (typically loose), nausea, and vomiting.

Examination findings are often non specific. Evidence of malnutrition/cachexia, generalised abdominal tenderness, and abdominal bruits may be present.


Differential Diagnosis

Often a patient has undergone several other investigations for other pathologies before the diagnosis of chronic mesenteric ischaemia is reached.

Possible differentials for the chronic non-specific abdominal pain may include chronic pancreatitis, gallstone pathology, peptic ulcer disease, or upper GI malignancy


Investigations

Laboratory Tests

Blood tests will routinely be normal, yet typically a full work-up of bloods (including FBC, U&Es, and LFTs) will have been performed prior to the diagnosis of chronic mesenteric ischaemia being reached.

Anaemia may confound symptoms and cardiovascular risk profile factors (lipids, glucose) may be raised.

Imaging

CT angiography is the diagnostic test of choice, providing good anatomical views of all vessels and can help gauge any intervention required. Catheter angiography remains the gold standard but is now used less due to the improvement of CT angiography.


Management

Management plans for chronic mesenteric ischaemia are typically made jointly between the radiologists and vascular surgeons.

Patients should be placed on best medical therapy, mainly an antiplatelet and a statin, alongside advice of promoting weight loss, increasing exercise, and smoking cessation. Evidence suggests that stabilising the atherosclerotic plaque with such agents will prevent subsequent worsening of the disease.

Fig 3 - Angioplasty and stenting. This is one of the surgical options available for the treatment of chronic limb ischaemia.

Fig 3 – A diagramatic representation of angioplasty with stenting

Surgical Treatment

Surgical intervention is warranted in severe disease, progressive disease, or presence of debilitating symptoms (including signs of weight loss or malabsorption).

The ultimate decision about which approach to take will depend on the location and severity of the disease, alongside patient factors and co-morbidities:

  • Endovascular procedures (more common) – consists of mesenteric angioplasty with stenting.
    • This is typically performed percutaneously, through either the femoral artery or brachial/axillary artery to allow a catheter to be passed to the appropriate vessel, under radiological guidance.
    • A small balloon is expanded to dilate the vessel (angioplasty), with any stent also deployed.
    • Such procedures provide a shorter hospital stay with faster mobilisation. The main complications from endovascular intervention are haematoma at the arterial puncture site, embolisation, or vessel perforation.
  • Open procedures (less common) – consists of an endartectomy or a bypass procedure.

Complications

The main complications of chronic mesenteric ischaemia are bowel infarction with necrosis or malabsorption. Many patients will also have concurrent cardiovascular disease which also needs addressing.

Prognosis after intervention is good, with comparable results in terms of relief of symptoms between open surgery and endovascular methods.

Further Reading

Mesenteric Ischemia
Clair DG et al., NEJM

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