Mesenteric ischemia: the importance of differential diagnosis for the surgeon

Abstract

BackgroundIntestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods (US, CT) will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies.MethodsBasing on our institutions experience, 163 cases of mesenteric ischemia/infarction from various cases, investigated with CT and undergone surgical treatment were retrospectively evaluated, in particular trought the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction (liver, kidney, spleen).ResultsTo make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive (arterial, venous) and non occlusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text.ConclusionThe radiological findings of mesenteric ischemia have different course in case of different etiology. In venous etiology the progression of damage results faster than arterial even if the symptomatology is less acute; bowel wall thickening is an early finding and easy to detect, simplifying the diagnosis. In arterial etiology the damage progression is slower than in venous ischemia, bowel wall thinning is typical but difficult to recognize so diagnosis may be hard. In the NOMI before/without reperfusion the ischemic damage is similar to AAMI with additional involvement of large bowel parenchymatous organs. In reperfusion after NOMI and after AAMI the CT and surgical findings are similar to those of AVMI, and the injured bowel results quite easy to identify. The prompt recognition of each condition is essential to ensure a successful treatment.

Role of Serum Lactic Acid Level in Diagnosing Mesenteric Bowel Ischemia With the Aid of the Ct Angiogram.

“…(Table 10) Pearson correlation showed non-significant positive correlation between lactic acid and age. Discussion: -AMI consists of two varied pathophysiological existence diagnostic & treatment , while the treatment consist of instrumental arterial reperfusion and resection of necrotic bowel segments, still the diagnosis had several challenges & difficulties due to the fact that patients could be admitted to the ER without specific symptoms of abdominal pain , (2,10) In two thirds of the cases the cause of intestinal ischemia were "arterial embolism or thrombosis with blood flow impairment in the superior mesenteric artery (SMA) distribution affecting all or portions of the small bowel and right colon" which increase CT-scandisparity ,…”

“…A study conducted in 2009 by Evennett et al, the authors recommended the use of serological markerssuch as D-lactate, GST, andI-FABPand study their accuracy in diagnosis (2,11) Where the pathophysiology of acute mesenteric ischemia is the decreasing in mesenteric blood flow which induce cells dying, these necrotic cells in the gut wall release chemical substances to the blood , by detecting these substances which serum lactate is one of them , doctors could diagnose acute mesenteric ischemia early, however this hypothesis didn't take to the account the other causes of increasing serum lactate level such as damaged liver or kidney function in sepsis and shock, agents that can uncouple oxidative phosphorylation ( toxins, drugs) or underlying disorders change lactate metabolism (congenital mitochondrial disorders, diabetes, malignancies). (7) 879 several studies (case series, experimental and prospective) since 1970s conduct to investigate the effectiveness of using serum lactate levels changes as a reliable biomarker of AMI.…”

Clinical significance and MDCT angiographic presentation of the mesenteric collateral circulation of the colon

“…The first symptom is usually abdominal pain (33). Occlusion of mesenteric arteries is characterized by slow progression and non-specific clinical features, unlike venous occlusion (34). MDCTA represents the gold standard in the diagnosis of this condition (35).…”

Deficient Protein C and Protein S Induced Acute Venous Mesenteric Ischemia: A Case Report

“…[1] Though rare, the main predicament with mesenteric ischemia is that intestinal gangrene almost always sets in by the time it is recognized, thus posing a challenge to the surgeon. [2] About 5-10% of mesenteric ischemia is accredited to Acute Venous Mesenteric Ischemia (AVMI), impaired intestinal venous drainage due to Superior Mesenteric Vein (SMV) occlusion; causing vascular engorgement, swelling and hemorrhage in the bowel wall.…”

“…[2] About 5-10% of mesenteric ischemia is accredited to Acute Venous Mesenteric Ischemia (AVMI), impaired intestinal venous drainage due to Superior Mesenteric Vein (SMV) occlusion; causing vascular engorgement, swelling and hemorrhage in the bowel wall. [1] SMV occlusion can be either primary (Idiopathic) or secondary to diverse conditions, one of them being secondary to Protein C and Protein S deficiency. [3] Protein C and S deficiency are infrequent having an autosomal dominant pattern of inheritance, with a prevalence rate of 0.2-0.3 % and 0.2-0.5% respectively.…”