Nonocclusive mesenteric ischemia
- 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
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Sciences Center - Dallas Campus
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- 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 intestinal hypoperfusion, which can be due to a nonocclusive reduction of arterial blood flow. Nonocclusive arterial hypoperfusion is most commonly due to primary splanchnic vasoconstriction. Nonocclusive mesenteric ischemia was first described by Ende in patients with heart failure . The majority of cases involve spasm of branches of the superior mesenteric artery (SMA) supplying the small intestine and proximal colon. Early diagnosis is based upon a high index of clinical suspicion in patients with risk factors, but often requires arteriography to firmly establish the diagnosis. Nonocclusive mesenteric ischemia is less common than in the past, and when it occurs, it is managed by reversal of inciting factors, including cessation of vasoconstrictive medicines, correction of the underlying cause of hypoperfusion (if possible), and anticoagulation to limit arterial thrombosis. Selective infusion of the SMA with papaverine or other vasodilator is an option, but is uncommonly performed today.
Nonocclusive mesenteric ischemia will be reviewed here. Acute and chronic mesenteric arterial occlusion affecting the small intestine, and colonic ischemia are discussed separately. (See "Overview of intestinal ischemia in adults" and "Mesenteric venous thrombosis in adults" and "Chronic mesenteric ischemia" and "Colonic ischemia".)
BLOOD SUPPLY TO THE SMALL INTESTINE
The circulation to the small intestines is derived primarily from the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) (figure 1 and figure 2). The venous drainage parallels the arterial circulation and drains into the portal venous system (figure 3 and figure 4). An extensive collateral circulation (figure 5) protects the intestines from transient periods of inadequate perfusion [2,3].
NONOCCLUSIVE ISCHEMIC INJURY
Ischemic injury to the intestine develops when delivery of oxygen and nutrients are insufficient for cellular metabolism. The likelihood of developing intestinal ischemia depends upon the adequacy of systemic perfusion and collateral circulation, the number and caliber of mesenteric vessels that are affected, and the duration of the ischemic insult. The intestine is able to compensate for approximately a 75 percent acute reduction in mesenteric blood flow for up to 12 hours without substantial injury, in part because of increased oxygen extraction .
The pathogenesis of nonocclusive mesenteric ischemia is related to a homeostatic mechanism that maintains cardiac and cerebral blood flow at the expense of the splanchnic and peripheral circulation [5-7]. Vasopressin and angiotensin are likely the neurohormonal mediators of this phenomenon. Spasm may also be triggered by vasoactive and cardiotonic drugs [5,8]. The normal physiology of the intestine and response to ischemia are discussed in more detail elsewhere.
- ENDE N. Infarction of the bowel in cardiac failure. N Engl J Med 1958; 258:879.
- McKinsey JF, Gewertz BL. Acute mesenteric ischemia. Surg Clin North Am 1997; 77:307.
- Reinus JF, Brandt LJ, Boley SJ. Ischemic diseases of the bowel. Gastroenterol Clin North Am 1990; 19:319.
- Boley SJ, Frieber W, Winslow PR, et al. Circulatory responses to acute reduction of superior mesenteric arterial flow. Physiologist 1969; 12:180.
- Krämer SC, Görich J, Oertel F, et al. [Non-occlusive mesenteric ischemia]. Rofo 2003; 175:1177.
- Bobadilla JL. Mesenteric ischemia. Surg Clin North Am 2013; 93:925.
- Wilcox MG, Howard TJ, Plaskon LA, et al. Current theories of pathogenesis and treatment of nonocclusive mesenteric ischemia. Dig Dis Sci 1995; 40:709.
- Stöckmann H, Roblick UJ, Kluge N, et al. [Diagnosis and therapy of non-occlusive mesenteric ischemia (NOMI)]. Zentralbl Chir 2000; 125:144.
- Boley SJ, Brandt LJ, Sammartano RJ. History of mesenteric ischemia. The evolution of a diagnosis and management. Surg Clin North Am 1997; 77:275.
- Acosta S, Ogren M, Sternby NH, et al. Fatal nonocclusive mesenteric ischaemia: population-based incidence and risk factors. J Intern Med 2006; 259:305.
- Björck M, Wanhainen A. Nonocclusive mesenteric hypoperfusion syndromes: recognition and treatment. Semin Vasc Surg 2010; 23:54.
- Sitges-Serra A, Mas X, Roqueta F, et al. Mesenteric infarction: an analysis of 83 patients with prognostic studies in 44 cases undergoing a massive small-bowel resection. Br J Surg 1988; 75:544.
- Bassiouny HS. Nonocclusive mesenteric ischemia. Surg Clin North Am 1997; 77:319.
- Rossi UG, Petrocelli F, Seitun S, Ferro C. Nonocclusive mesenteric ischemia in a dialysis patient with extensive vascular calcification. Am J Kidney Dis 2012; 60:843.
- Quiroga B, Verde E, Abad S, et al. Detection of patients at high risk for non-occlusive mesenteric ischemia in hemodialysis. J Surg Res 2013; 180:51.
- Groesdonk HV, Klingele M, Schlempp S, et al. Risk factors for nonocclusive mesenteric ischemia after elective cardiac surgery. J Thorac Cardiovasc Surg 2013; 145:1603.
- Sudhakar CB, Al-Hakeem M, MacArthur JD, Sumpio BE. Mesenteric ischemia secondary to cocaine abuse: case reports and literature review. Am J Gastroenterol 1997; 92:1053.
- Liu JJ, Ardolf JC. Sumatriptan-associated mesenteric ischemia. Ann Intern Med 2000;132:597.
- Weil J, Sen Gupta R, Herfarth H. Nonocclusive mesenteric ischemia induced by digitalis. Int J Colorectal Dis 2004; 19:277.
- Guglielminotti J, Tremey B, Maury E, et al. Fatal non-occlusive mesenteric infarction following digoxin intoxication. Intensive Care Med 2000; 26:829.
- Diamond SM, Emmett M, Henrich WL. Bowel infarction as a cause of death in dialysis patients. JAMA 1986; 256:2545.
- Gennaro M, Ascer E, Matano R, et al. Acute mesenteric ischemia after cardiopulmonary bypass. Am J Surg 1993; 166:231.
- Garofalo M, Borioni R, Nardi P, et al. Early diagnosis of acute mesenteric ischemia after cardiopulmonary bypass. J Cardiovasc Surg (Torino) 2002; 43:455.
- Endress C, Gray DG, Wollschlaeger G. Bowel ischemia and perforation after cocaine use. AJR Am J Roentgenol 1992; 159:73.
- Mitsuyoshi A, Obama K, Shinkura N, et al. Survival in nonocclusive mesenteric ischemia: early diagnosis by multidetector row computed tomography and early treatment with continuous intravenous high-dose prostaglandin E(1). Ann Surg 2007; 246:229.
- Finucane PM, Arunachalam T, O'Dowd J, Pathy MS. Acute mesenteric infarction in elderly patients. J Am Geriatr Soc 1989; 37:355.
- Hagspiel KD, Leung DA, Angle JF, et al. MR angiography of the mesenteric vasculature. Radiol Clin North Am 2002; 40:867.
- Bradbury MS, Kavanagh PV, Chen MY, et al. Noninvasive assessment of portomesenteric venous thrombosis: current concepts and imaging strategies. J Comput Assist Tomogr 2002; 26:392.
- Ofer A, Abadi S, Nitecki S, et al. Multidetector CT angiography in the evaluation of acute mesenteric ischemia. Eur Radiol 2009; 19:24.
- Aschoff AJ, Stuber G, Becker BW, et al. Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography. Abdom Imaging 2009; 34:345.
- American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia. Gastroenterology 2000; 118:951.
- http://www.gastro.org/practice/medical-position-statements/archive (Accessed on June 25, 2013).
- Lee SS, Park SH. Computed tomography evaluation of gastrointestinal bleeding and acute mesenteric ischemia. Radiol Clin North Am 2013; 51:29.
- Kougias P, Lau D, El Sayed HF, et al. Determinants of mortality and treatment outcome following surgical interventions for acute mesenteric ischemia. J Vasc Surg 2007; 46:467.
- Upponi S, Harvey JJ, Uberoi R, Ganeshan A. The role of radiology in the diagnosis and treatment of mesenteric ischaemia. Postgrad Med J 2013; 89:165.
- Siegelman SS, Sprayregen S, Boley SJ. Angiographic diagnosis of mesenteric arterial vasoconstriction. Radiology 1974; 112:533.
- Mazzei MA, Mazzei FG, Marrelli D, et al. Computed tomographic evaluation of mesentery: diagnostic value in acute mesenteric ischemia. J Comput Assist Tomogr 2012; 36:1.
- Boley SJ, Sprayregan S, Siegelman SS, Veith FJ. Initial results from an agressive roentgenological and surgical approach to acute mesenteric ischemia. Surgery 1977; 82:848.
- Lock G. Acute mesenteric ischemia: classification, evaluation and therapy. Acta Gastroenterol Belg 2002; 65:220.
- Oliva IB, Davarpanah AH, Rybicki FJ, et al. ACR Appropriateness Criteria ® imaging of mesenteric ischemia. Abdom Imaging 2013; 38:714.
- Li KC. Magnetic resonance angiography of the visceral arteries: techniques and current applications. Endoscopy 1997; 29:496.
- Laissy JP, Trillaud H, Douek P. MR angiography: noninvasive vascular imaging of the abdomen. Abdom Imaging 2002; 27:488.
- Fleischmann D. Multiple detector-row CT angiography of the renal and mesenteric vessels. Eur J Radiol 2003; 45 Suppl 1:S79.
- Laghi A, Iannaccone R, Catalano C, Passariello R. Multislice spiral computed tomography angiography of mesenteric arteries. Lancet 2001; 358:638.
- Horton KM, Fishman EK. The current status of multidetector row CT and three-dimensional imaging of the small bowel. Radiol Clin North Am 2003; 41:199.
- Kim AY, Ha HK. Evaluation of suspected mesenteric ischemia: efficacy of radiologic studies. Radiol Clin North Am 2003; 41:327.
- Nakamura Y, Urashima M, Toyota N, et al. Non-occlusive mesenteric ischemia (NOMI): utility of measuring the diameters of the superior mesenteric artery and superior mesenteric vein at multidetector CT. Jpn J Radiol 2013.
- Habboushe F, Wallace HW, Nusbaum M, et al. Nonocclusive mesenteric vascular insufficiency. Ann Surg 1974; 180:819.
- http://www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm314742.htm (Accessed on November 18, 2013).
- Boley, SJ, Treiber, W, Winslow, PR, et al. Circulatory responses to acute reduction of superior mesenteric arterial flow. Physiologist 1969; 12:180.
- Park WM, Gloviczki P, Cherry KJ Jr, et al. Contemporary management of acute mesenteric ischemia: Factors associated with survival. J Vasc Surg 2002; 35:445.
- Ward D, Vernava AM, Kaminski DL, et al. Improved outcome by identification of high-risk nonocclusive mesenteric ischemia, aggressive reexploration, and delayed anastomosis. Am J Surg 1995; 170:577.
- BLOOD SUPPLY TO THE SMALL INTESTINE
- NONOCCLUSIVE ISCHEMIC INJURY
- EPIDEMIOLOGY AND RISK FACTORS
- Risk factors
- CLINICAL FEATURES
- History and physical
- Laboratory studies
- Plain abdominal films
- Cross-sectional abdominal imaging
- DIFFERENTIAL DIAGNOSIS
- Hemodynamic support and monitoring
- Vasodilator infusion
- Abdominal exploration
- MORBIDITY AND MORTALITY
- SUMMARY AND RECOMMENDATIONS