Acute mesenteric arterial occlusion
- David A Tendler, MD
David A Tendler, MD
- Assistant Consulting Professor of Medicine
- Duke University
- J Thomas Lamont, MD
J Thomas Lamont, MD
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — Anorectal Disorders and Misc. Lower GI Disease
- Section Editor — Nutrition, Malabsorption, and Misc. Upper GI Disease
- Professor of Medicine
- Harvard Medical School
- Gregory Pearl, MD
Gregory Pearl, MD
- Professor of Surgery
- Texas A&M Health Sciences Center
- Chief, Division of Vascular Surgery
- Baylor University Medical Center
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Acute mesenteric ischemia refers to the sudden onset of small intestinal hypoperfusion, which can be due to acute embolic occlusion of the intestinal blood supply, most commonly the superior mesenteric artery (SMA). Acute ischemia can also be related to acute thrombotic occlusion, typically of an already diseased mesenteric vessel (eg, atherosclerosis, dissection).
Acute mesenteric ischemia due to acute arterial obstruction involving the small intestine will be reviewed here. Colonic ischemia, chronic mesenteric ischemia, and other forms of mesenteric ischemia, including mesenteric venous occlusion and nonocclusive mesenteric ischemia, are reviewed elsewhere. (See "Mesenteric venous thrombosis in adults" and "Chronic mesenteric ischemia" and "Colonic ischemia" and "Nonocclusive mesenteric ischemia".)
MESENTERIC ANATOMY AND PHYSIOLOGY
The arterial anatomy of the intestinal circulation is given in the figures (figure 1 and figure 2). Ischemic injury to the intestine develops when there is insufficient delivery of oxygen and nutrients required for cellular metabolism. An overview of intestinal anatomy, normal intestinal vascular physiology, and the response to acute ischemia are discussed in detail elsewhere. (See "Overview of intestinal ischemia in adults", section on 'Intestinal vascular anatomy' and "Overview of intestinal ischemia in adults", section on 'Physiology and mechanisms of ischemia'.)
Acute superior mesenteric arterial occlusion, in the absence of preexisting stenosis, causes a greater reduction in blood flow compared with other causes of intestinal ischemia. Inciting factors such as dehydration, low cardiac output states, or transient thrombophilia can lead to acute thrombosis of a modest stenosis causing typical symptoms of mesenteric ischemia.
The intestine may be able to compensate to some extent because of increased oxygen extraction as well as the presence of collateral flow pathways (figure 3) . The status of the collateral circulation is particularly important in determining the severity of symptoms . For some patients, progression from stenosis to occlusion can be asymptomatic due largely to a sufficient time course to develop these collaterals.
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- MESENTERIC ANATOMY AND PHYSIOLOGY
- ETIOLOGY OF MESENTERIC ARTERIAL OCCLUSION
- EPIDEMIOLOGY AND RISK FACTORS
- Risk factors
- CLINICAL FEATURES
- DIFFERENTIAL DIAGNOSIS
- Approach to treatment
- Surgical versus endovascular intervention
- ENDOVASCULAR INTERVENTION
- Pharmacomechanical thrombolysis
- Mesenteric angioplasty/stenting
- - Retrograde open mesenteric stenting
- Abdominal exploration/damage control
- - Embolectomy
- - Mesenteric bypass
- Bowel and abdominal closure
- POSTPROCEDURE CARE AND FOLLOW-UP
- Second-look laparotomy and abdominal wall closure
- Long-term medical management
- Stent surveillance
- MORBIDITY AND MORTALITY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS