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Chronic mesenteric ischemia

David A Tendler, MD
J Thomas Lamont, MD
Section Editors
John F Eidt, MD
Joseph L Mills, Sr, MD
Lillian S Kao, MD, MS
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Mesenteric ischemia is caused by a reduction in intestinal blood flow and is classified as acute (sudden onset of intestinal hypoperfusion) or chronic depending on the time course of symptoms. Chronic mesenteric ischemia, also called intestinal angina, refers to episodic or constant hypoperfusion of the small intestine that can occur, typically in patients with multivessel mesenteric stenosis or occlusion.

The clinical features, diagnosis, and management of chronic mesenteric ischemia will be reviewed here. The diagnosis and management of acute mesenteric ischemia, including acute-on-chronic ischemia (usually related to sudden thrombotic occlusion of an already stenotic mesenteric vessel), and colonic ischemia are reviewed separately. (See "Overview of intestinal ischemia in adults" and "Acute mesenteric arterial occlusion" and "Colonic ischemia".)


The majority of cases of chronic mesenteric ischemia are caused by atherosclerotic narrowing of the origins of the celiac or superior mesenteric arteries [1,2]. Atherosclerosis of the mesenteric vessels is fairly common; however, clinical manifestations as a consequence of mesenteric arterial disease are rare [3,4]. Up to 18 percent of individuals over 65 in the general population have significant stenosis of the celiac or superior mesenteric artery without any known prior symptoms [3,5,6]. In one autopsy series, 29 of 120 individuals showed atherosclerotic disease within 2 cm of the origins of the celiac or mesenteric arteries, and 18 of 120 had at least two stenotic vessels; only one patient had evidence of bowel necrosis [7]. The occurrence of disease was strongly associated with aging and correlated with atherosclerotic disease of cerebral arteries at the skull base. In a study of 184 asymptomatic patients, the prevalence of celiac or superior mesenteric artery stenosis or occlusion was 18 percent for those over 65 using duplex ultrasound [6]. Single-vessel disease was more common in the celiac artery compared with the superior mesenteric artery (81 versus 19 percent). A population-based study found a similar prevalence of 17.5 percent among 870 patients over 65 [3]. Multivariate analysis identified renal artery stenosis and high-density lipoprotein >40 mg/dL as significantly associated with celiac or mesenteric artery stenosis or occlusion.

Rare causes of chronic mesenteric ischemia include median arcuate ligament syndrome (compression of the celiac artery from the median arcuate ligament of the diaphragm), fibromuscular dysplasia, aortic or mesenteric artery dissection, vasculitis (polyarteritis nodosum, Takayasu's disease [8]), and retroperitoneal fibrosis [9]. Advanced endografts (eg, fenestrated) can cause partial obstruction of the visceral vessels during endovascular aortic repair. Acute mesenteric ischemia has also been reported as a rare complication of cardiac surgery, particularly in patients with renal failure, shock, and intra-aortic balloon pump prior to cardiac surgery [10,11]. (See "Celiac artery compression syndrome" and "Clinical manifestations and diagnosis of fibromuscular dysplasia" and "Overview of gastrointestinal manifestations of vasculitis" and "Clinical features and diagnosis of acute aortic dissection" and "Spontaneous mesenteric arterial dissection" and "Complications of endovascular abdominal aortic repair" and "Clinical manifestations and diagnosis of retroperitoneal fibrosis".)


History — Most patients with atherosclerotic mesenteric vascular disease do not exhibit symptoms, because a large collateral network can form to compensate for reduced flow (figure 1). In one review of 270 patients with occlusive disease of one or more splanchnic vessels, 61 (60 percent) had no symptoms [12]. In a study of 82 patients identified on arteriography to have a 50 percent stenosis in at least one mesenteric artery, 4 of15 patients with significant three-vessel disease developed mesenteric ischemia during follow-up [4]. One of these had no abdominal complaints prior to an acute presentation resulting in necrosis of the entire gut. The others developed typical symptoms of chronic mesenteric ischemia at 7, 24, and 24 months.

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