Materiały źródłowe

• #1 Acute Mesenteric Ischemia – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK431068/

  Acute mesenteric ischemia is caused by a sudden decline in blood flow through the mesenteric vessels. Diagnosis can be difficult because symptoms are typically non-specific. […] The non-specific symptomatology in conjunction with rapid progression of acute mesenteric ischemia likely contribute to the high associated mortality rate of 60-80 percent. […] Diagnosis is difficult because symptoms are not specific, and the index of suspicion has to be high. […] Mortality rates for AMI range between 60% and 80%. […] Laboratory values and biomarkers for AMI are nonspecific and do not have diagnostic power. Elevated D(-)-lactate and lactate dehydrogenase are seen in late-stage AMI. CT angiography is the preferred method for imaging all types of AMI. […] The early identification of AMI is paramount to reduce the likelihood of debilitating morbidity and high mortality. […] The prognosis of AMI is poor, with patients experiencing high morbidity and mortality rates. […] The disorder is best managed by an interprofessional team that includes a radiologist, general surgeon, internist, emergency department physician, and a gastroenterologist.

• #2 Mesenteric ischemia: Recognizing an uncommon disorder and distinguishing among its causes | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/91/9/545

  Mesenteric ischemia occurs because of inadequate intestinal blood flow. Its severity depends on the vessels involved and whether collateral blood vessels are available to prevent malperfusion. Mesenteric ischemia is an uncommon cause of abdominal pain, but it is associated with high mortality and often poses a diagnostic challenge to clinicians because its symptoms are nonspecific. Early recognition and treatment are imperative to improve patient outcomes. […] Diagnosis requires a high index of suspicion with focused evaluation. […] Early recognition and intervention are key to preventing morbidity and mortality. […] The nonspecific nature of symptoms makes it difficult to differentiate acute mesenteric ischemia from other intra-abdominal pathologies such as acute cholecystitis, pancreatitis, and small-bowel obstruction. A high index of suspicion is critical to making the diagnosis and restoring blood flow, thereby improving patient outcomes.

• #3 Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery | World Journal of Emergency Surgery | Full Text

  https://wjes.biomedcentral.com/articles/10.1186/s13017-017-0150-5

  Severe abdominal pain out of proportion to physical examination findings should be assumed to be AMI until disproven. (Recommendation 1B) […] The key to early diagnosis is a high level of clinical suspicion. […] Computed tomography angiography (CTA) should be performed as soon as possible for any patient with suspicion for AMI. (Recommendation 1A) […] There are no laboratory studies that are sufficiently accurate to identify the presence or absence of ischemic or necrotic bowel, although elevated l-lactate and D-dimer may assist. (Recommendation 1B) […] Conventional plain X-ray films have limited diagnostic value in evaluating AMI, although signs of intestinal perforation may be seen. (Recommendation 1B) […] Non-occlusive mesenteric ischemia (NOMI) should be suspected in critically ill patients with abdominal pain or distension requiring vasopressor support and evidence of multi-organ dysfunction. (Recommendation 1B)

• #4 Improving the ED Diagnosis of Mesenteric Ischemia – emDocs

  https://www.emdocs.net/improving-the-ed-diagnosis-of-mesenteric-ischemia/

  Improving the ED Diagnosis of Mesenteric Ischemia […] Mesenteric ischemia remains a high mortality and easily missed diagnosis in emergency medicine. […] Prompt diagnosis significantly improves mortality with one study showing a mortality drop from 70% to 14% when time to diagnosis decreases from 24 to 12 hours. […] Mesenteric ischemia ultimately requires computed tomography angiography (CTA) abdomen and pelvis to rule out. […] Clinicians must actively maintain suspicion so as not to overlook this rare but fatal diagnosis. […] CTA of the abdomen and pelvis is the preferred diagnostic imaging modality for suspected mesenteric ischemia due to its speed, noninvasiveness, and high accuracy (93-100% sensitivity and specificity). […] Accurate and timely diagnosis significantly improves mortality in this deadly disease.

• #5 Chronic Mesenteric Ischemia: Diagnosis and Treatment

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3036470/

  Chronic mesenteric ischemia is a rare condition, generally characterized by postprandial abdominal pain. […] The diagnosis of chronic mesenteric ischemia requires a high clinical index of suspicion. An imaging study can confirm the presence of a stenosis or occlusion involving the mesenteric vessels in patients who are suspected of having chronic mesenteric ischemia. […] The history and physical exam as well as a high index of suspicion are important factors in diagnosing chronic mesenteric ischemia. Once the diagnosis of chronic mesenteric ischemia is suspected, imaging options for confirmation include ultrasound (US), computed tomography angiography (CTA), magnetic resonance angiography (MRA), and conventional angiography. […] Catheter angiography has been the gold standard for diagnosing mesenteric vascular disease for many years. If chronic mesenteric ischemia is suspected, an US, CT, or MRI/MRA may be performed to assist with treatment planning, including angioplasty or stent placement.

• #6 Acute Mesenteric Ischemia: Practice Essentials, Anatomy, Pathophysiology

  https://emedicine.medscape.com/article/189146-overview

  Acute mesenteric ischemia (AMI) is a syndrome caused by inadequate blood flow through the mesenteric vessels, resulting in ischemia and eventual gangrene of the bowel wall. […] Symptoms are nonspecific initially, before evidence of peritonitis presents. Thus, diagnosis and treatment are often delayed until the disease is advanced. […] Fortunately, since 1930, many advances (eg, in magnetic resonance imaging [MRI] and Doppler flowmetry) have been made that allow earlier diagnosis and treatment. […] Because of the high mortality and the difficulty of diagnosis, mesenteric ischemia poses a substantial legal risk. This risk can be reduced by a high degree of clinical suspicion, early and aggressive diagnostic imaging, and early surgical consultation with clear documentation of timing. […] Guidelines for the management of AMI have been published by the World Society of Emergency Surgery (WSES).

• #7 Acute Mesenteric Ischemia Workup: Approach Considerations, Laboratory Studies, Plain Abdominal Radiography

  https://emedicine.medscape.com/article/189146-workup

  Various laboratory studies may be performed for suspected acute mesenteric ischemia (AMI), but in general, such studies will not establish the diagnosis. At most, they suggest the diagnosis; they do not exclude it. […] If serious suspicion of AMI exists, the clinician should order diagnostic imaging studies (eg, plain radiography, classic angiography, computed tomography [CT] angiography [CTA], magnetic resonance angiography [MRA], or ultrasonography [US]) without waiting for laboratory results. […] Laboratory findings in AMI are nonspecific and generally unreliable. No serum marker is sensitive or specific enough to establish or exclude the diagnosis of AMI. […] CT findings with a specificity greater than 95% for AMI include SMA or SMV thrombosis, intestinal pneumatosis, portal venous gas, lack of bowel-wall enhancement, and ischemia of other organs; less specific findings include distended bowel, absence of intestinal gas, thickened bowel wall, mesenteric or perienteric fat stranding, ascites, pneumoperitoneum, and air-fluid levels.

• #8 Mesenteric Ischemia

  https://mobile.fpnotebook.com/Surgery/GI/MsntrcIschm.htm

  No laboratory test has Test Sensitivity or Test Specificity to rule-in or rule-out Mesenteric Ischemia. […] Serum lactate is the most useful laboratory test when considering Mesenteric Ischemia as a diagnosis, as well as serial re-testing. […] Elevated Lactic Acid in Mesenteric Ischemia suggests severe segmental ischemia or infarction has already occurred. […] Normal Lactic Acid does not exclude Mesenteric Ischemia, and intervention is ideally before Lactic Acid rises. […] Test Sensitivity: 86%. […] Test Specificity: 44%. […] Cudnik (2013) Acad Emerg Med 20(11): 1087-1100 [PubMed]. […] Complete Blood Count (CBC) shows Leukocytosis 15k (and often over 20k) with Left Shift is common (may be absent in Immunocompromised patients). […] Other labs abnormal if prolonged bowel ischemia, infarction, necrosis or perforation occurs.

• #9 Ischaemic bowel clinical tool | Emergency Care Institute

  https://aci.health.nsw.gov.au/networks/eci/clinical/tools/ischaemic-bowel

  Mesenteric ischemia is a medical emergency and will often lead to bowel necrosis. Early diagnosis and intervention are key. Mortality for patients undergoing revascularisation ranges from 44% to 90%. […] Diagnosis of both conditions is challenging and requires a high index of clinical suspicion. […] An elevated or rising lactate is suggestive of ischaemic bowel. However it is non-specific and a normal lactate does not exclude the diagnosis (sensitivity 77-100%, specificity 42%). […] In a systematic review, the pooled sensitivity for D-dimer for acute mesenteric ischemia was 96 % with a pooled specificity of 40%. […] CT is preferred over MRI because of its lower costs, speed and wide availability. However, MR angiography may be more sensitive for the diagnosis of mesenteric venous thrombosis and may be necessary for those with an allergy to iodinated contrast. […] Patients with colonic infarction and necrosis require urgent surgical intervention, which can be lifesaving.

• #10 Mesenteric Ischemia

  https://mobile.fpnotebook.com/Surgery/GI/MsntrcIschm.htm

  Arterial Blood Gas (ABG) or Venous Blood Gas (VBG) with Metabolic Acidosis. […] Serum Amylase increased. […] Serum Phosphate Level increases within 4 hours (75%). […] Procalcitonin increased. […] D-Dimer increased, although non-specific, is elevated in most Mesenteric Ischemia cases. […] May be useful for its high Negative Predictive Value (unlikely to be Mesenteric Ischemia when negative). […] Block (2008) Scand J Clin Lab Invest 68(3): 242-8 [PubMed]. […] Intestinal Fatty Acid Binding Protein (I-FABP) is released from injured intestinal mucosal villi. […] Not available outside of experimental protocols as of 2022. […] Test Sensitivity: 80%. […] Test Specificity: 86%. […] Montagnana (2018) Ann Transl Med 6(17): 341 [PubMed]. […] Electrocardiogram (EKG) should be obtained in all patients with suspected Mesenteric Ischemia.

• #11 Mesenteric artery ischemia Information | Mount Sinai – New York

  https://www.mountsinai.org/health-library/diseases-conditions/mesenteric-artery-ischemia

  Mesenteric artery ischemia occurs when there is a narrowing or blockage of one or more of the three major arteries that supply the small and large intestines. […] When symptoms begin suddenly or become severe, blood tests may show increased white blood cell count and changes in the blood acid level. There may be blood in the stool. Typically pain starts first and is followed by rectal bleeding. […] A Doppler ultrasound or CT angiogram scan may show problems with the blood vessels and the intestine. […] A mesenteric angiogram is a test that involves injecting a special dye into your bloodstream to highlight the arteries of the intestine. Then x-rays are taken of the area. This can show the location of the blockage in the artery. […] People with acute mesenteric ischemia often do poorly because parts of the intestine may die before surgery can be done. This can be fatal. However, with prompt diagnosis and treatment, acute mesenteric ischemia can be treated successfully.

• #12 Serological biomarkers for acute mesenteric ischemia

  https://atm.amegroups.org/article/view/27540/html

  Acute mesenteric ischemia (AMI) defines a complex of conditions characterized by an interruption of the splanchnic circulation, leading to insufficient oxygen delivery or utilization to fill the metabolic needs of the visceral organs. Early diagnosis and immediate therapy are the cornerstones of early ischemia to reach a successful outcome and are necessary to reduce the high mortality. […] Although there is still lack of specific biomarkers to assist the diagnosis of AMI in clinical practice, there are several biomarkers with high specificity, may become a potential tools in early diagnosis of AMI, including intestinal fatty acid binding protein (I-FABP), a-glutathione S-transferase (a-GST), D-dimer, L- and D-lactate, citrulline, ischemia modified albumin, procalcitonin (PCT). […] Though there are still no specific diagnostic biomarkers for AMI, occlusive mesenteric ischemia is quite easier to diagnosis with high specific computed tomography angiography (CTA). However, it is being tough to obtain the definitive diagnosis of NOMI, which compromises 2030% of all cases of AMI, in clinical practice there has neither specific makers nor radiology test, especially in early stage.

• #13 Serological biomarkers for acute mesenteric ischemia

  https://atm.amegroups.org/article/view/27540/html

  Early diagnosis and timely intervention are therefore key factors to improving the clinical outcomes of patients with AMI. […] However, many laboratory indexes were tested for their values to early diagnosis of mesenteric ischemia, unfortunately, most of the studied biomarkers appeared when the AMI developed to the late stage, such as Lactic acidosis. […] As a whole, its emphasizing the importance of early and reliable diagnosis. So, there is a great need for a plasma biomarker, which would be best if its tissue specific, metabolic stable from intestine to peripheral blood with high specificity and sensitivity to AMI. […] In the past decades, there are several most promising biomarkers, including Intestinal fatty acid binding protein (I-FABP), a-glutathione S-transferase (a-GST), D-dimer, L- and D-lactate, citrulline, ischemia modified albumin, procalcitonin (PCT), being studied for diagnosis of intestinal ischemia. […] However, it is still tough to obtain a definitive early diagnosis, because current available clinical, radiological, and laboratory tests are not good enough to diagnose early, reversible stage mesenteric ischemia.

• #14 Mesenteric Ischemia

  https://errolozdalga.com/medicine/pages/mesentericischemia.cr.5.16.11.html

  Mesenteric Ischemia can be divided into Acute vs Chronic, and Small Bowel vs Colonic Ischemia. […] Acute Mesenteric Ischemia can be further divided into Occlusive vs Non-occlusive etiologies. […] Clinical presentation is classically that of acute onset of severe periumbilical pain that is out of proportion to physical exam findings, +/- nausea/vomiting. […] It is important to note that in nonocclusive disease, ~25% of patients may have no abdominal pain. […] Diagnosis of Mesenteric Ischemia: No lab is diagnostic, but should be suspicious in the appropriate setting with elevated WBC and metabolic acidosis, especially lactic acidosis. […] Acute abdominal pain + metabolic acidosis = Mesenteric Ischemia until proven otherwise !! […] Imaging: X-rays are generally insensitive. CTA and MRA are better, and gold standard remains angiography. […] Early angiography is indicated both for diagnosis and therapy intraarterial vasodilators or thrombolysis/angioplasty is possible.

• #15 Mesenteric ischemia: what the radiologist needs to know – Olson – Cardiovascular Diagnosis and Therapy

  https://cdt.amegroups.org/article/view/21705/html

  Acute mesenteric ischemia (AMI) is a life-threatening condition that often presents with abdominal pain. Early diagnosis with contrast-enhanced computed tomography and revascularization can reduce the overall mortality in AMI. […] Diagnosis is challenging secondary to the rarity of the disease, its nonspecific clinical presentation, and often subtle or non-specific imaging findings. […] Consequently, a high index of suspicion on the part of the clinician and the radiologist, as well as familiarity with the spectrum of imaging findings associated with mesenteric ischemia, is required to ensure prompt recognition of the disease. […] Per the American College of Radiology (ACR) Appropriateness Criteria, computed tomographic angiography (CTA) is the first-line diagnostic modality for mesenteric ischemia.

• #16 An Overview of Acute Mesenteric Ischemia | Applied Radiology

  https://appliedradiology.com/articles/an-overview-of-acute-mesenteric-ischemia

  Acute mesenteric ischemia (AMI), a surgical emergency, is an uncommon but serious condition that accounts for 1 in 1000 hospital admissions in the United States and Europe and has extremely high mortality rates, ranging between 50 and 69%. Mortality remains high despite advances in diagnostic and treatment options, including the advent and widespread use of multidetector computed tomography (MDCT). […] Biphasic MDCT has become the standard of care for investigating and diagnosing AMI, particularly given its easy availability in the emergency setting. With its capacity to identify mesenteric ischemia, its severity, and potential causes, MDCT can have very high sensitivity and specificity. […] Today, MDCT is capable of diagnosing AMI, as well as potential other causes of acute abdomen, with excellent sensitivity and specificity. In a recent meta-analysis of six studies (3 prospective and 3 retrospective) with 142 positive AMI cases out of 619, MDCT was shown to have a pooled sensitivity and specificity of 93.3% and 95.9%, respectively, for AMI when analyzed by experienced radiologists.

• #17 Mesenteric ischemia: what the radiologist needs to know – Olson – Cardiovascular Diagnosis and Therapy

  https://cdt.amegroups.org/article/view/21705/html

  Rapid, widely available, and relatively inexpensive, CTA has a sensitivity of 96% and a specificity of 94% in the diagnosis of both the acute and chronic forms of mesenteric ischemia. […] Given the potentially catastrophic consequences of a missed diagnosis, elevated creatinine or impaired renal function should not preclude administration of intravenous contrast material and performance of CTA. […] Once considered the gold standard for diagnosis of mesenteric ischemia, catheter-based angiography has been relegated to a second-line modality given its invasive nature and lack of availability at some centers. […] Due to its longer image-acquisition times and limited spatial resolution, magnetic resonance angiography (MRA) is best suited for assessment of chronic mesenteric ischemia, for which it has been shown to have high sensitivity and specificity.

• #18 Radiological diagnosis of acute mesenteric ischemia in adult patients: a systematic review and meta-analysis | Scientific Reports

  https://www.nature.com/articles/s41598-025-94846-w

  Computed tomography (CT) is widely used in diagnosing acute mesenteric ischemia (AMI), but robust identification of distinctive subtypes and stages of progression is lacking. […] Diagnostic accuracy of CT angiography (CTA) was high – sensitivity of 92.0% and specificity of 98.8% (I2 45% and 79%, respectively), but lower for other CT protocols (sensitivity 75.8 and specificity 90.5; I2 83%). […] CTA is the method of choice for diagnosing AMI with high diagnostic accuracy. […] None of the non-vascular features alone is sufficiently reliable to diagnose AMI or its progression to transmural necrosis, whereas a combination of different radiological features conveys a potential. […] The accuracy of the diagnosis of AMI with CT considering any applicable features (hereafter referred as composite diagnosis) is presented in Fig. 2.

• #19 10 Mesenteric Ischemia | Radiology Key

  https://radiologykey.com/10-mesenteric-ischemia/

  Mesenteric ischemia is an unusual clinical entity with several causes. […] Because patient presentation, prognosis, and treatment options differ for the various subtypes of mesenteric ischemia, it is important to differentiate among these distinct causes. […] The difficulty in establishing a diagnosis of AMI may contribute to its poor prognosis, as delays in diagnosis and treatment are associated with increased mortality. […] The use of invasive catheter arteriography to establish the diagnosis of occlusive mesenteric ischemia has largely been replaced by CT evaluation, which is noninvasive and more widely available. […] Ideally, CT evaluation in mesenteric ischemia is biphasic, with both arterial and venous phases. […] CT findings suggestive of mesenteric ischemia are shown in Table 10.1.

• #20 Mesenteric ischemia | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/mesenteric-ischaemia?lang=us

  Mesenteric ischemia, also commonly referred to as bowel or intestinal ischemia, refers to vascular compromise of the bowel and its mesentery that in the acute setting has a very high mortality if not treated expediently. […] Although historically catheter angiography was the gold standard for imaging of suspected intestinal ischemia, CT has replaced it, with its ability to volumetrically assess the whole abdomen in multiple vascular phases, e.g. arterial, portal venous, delayed. […] As such CT is now the investigation of choice for patients with suspected intestinal ischemia. […] In stable patients, CT of the abdomen and pelvis should be performed with intravenous contrast and a neutral luminal contrast (e.g. water) so that bowel wall enhancement and thickness can be adequately assessed. […] It is important to note that bowel wall thickness is not increased in all cases, and can in fact be thinned in complete arterial occlusion or bowel obstruction. […] Although treatment will vary according to the severity and cause of the ischemia, in general the treatment is surgical.

• #21 Acute mesenteric ischemia: A review of the main imaging techniques and signs | Radiología (English Edition)

  https://www.elsevier.es/en-revista-radiologia-english-edition–419-articulo-acute-mesenteric-ischemia-a-review-S2173510720300501?newsletter=true

  Acute mesenteric ischaemia is an abdominal emergency because reduced blood flow to bowel loops rapidly leads to irreversible necrosis and death. […] Since the clinical and laboratory findings are nonspecific, imaging tests play an important role in the diagnosis of mesenteric ischaemia. Multidetector computed tomography is the first-choice technique for the initial workup in cases of suspected acute mesenteric ischaemia because it can rule out other causes of acute abdominal pain. It is important to know the characteristic radiological signs of this entity, because early diagnosis is essential to prevent progression to life-threatening intestinal necrosis. […] At present, multidetector computed tomography (MDCT) is the initial imaging technique of choice for the diagnosis of suspected AMI and, in addition, enables other causes of acute abdominal pain to be ruled out.

• #22 Diagnostic Role of Multi-Detector Computed Tomography in Acute Mesenteric Ischemia

  https://www.mdpi.com/2075-4418/14/12/1214

  The optimal CT protocol includes a multiphasic examination: non-enhanced acquisition followed by biphasic contrast-enhanced phases. […] The identification of bowel ischemia can be better identified in the conventional 120 kVp-like images. […] The role of Dual-Energy CT (DECT) is still controversial. […] The sensitivity and specificity of the so-called “smaller SMV sign” for the detection of acute SMA occlusion have been reported at 70% and 99.2%, respectively. […] The clinical onset of venous thrombosis is subacute because ischemia develops gradually and more slowly than arterial ischemia. […] Mortality in veno-occlusive mesenteric ischemia reaches 44% but is lower than in patients with arterial ischemia. […] Acute mesenteric ischemia is a life-threatening condition that requires prompt diagnosis and treatment. MDCTA is mandatory in patients suspected of having mesenteric ischemia because it can confirm the diagnosis and allow a differential diagnosis between different types of intestinal ischemia.

• #23 Small Bowel Ischemia – American College of Gastroenterology

  https://gi.org/topics/small-bowel-ischemia/

  Small bowel ischemia (also called mesenteric ischemia) is a potentially life-threatening group of conditions that reduce blood flow to the small intestine (e.g., duodenum, jejunum or ileum). Symptoms can range from mild to severe depending on the cause. […] Early diagnosis and treatment are essential for the best possible outcomes to restore digestive function. […] Small bowel ischemia requires prompt medical care to avoid damage to intestinal tissue that can lead to death. […] Small bowel ischemia can be a medical emergency, especially if it is acute. Seek immediate medical attention if you experience sudden, severe abdominal pain with or without bloody diarrhea, or any other possible symptoms. […] Early diagnosis and prompt treatment are essential to improve your chances for a good-outcome. The longer you go without treatment, the higher the chance of irreversible damage to the small bowel and, in an acute case, death.

• #24 Mesenteric ischemia: the importance of differential diagnosis for the surgeon | BMC Surgery | Full Text

  https://bmcsurg.biomedcentral.com/articles/10.1186/1471-2482-13-S2-S51

  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. […] Computed tomography angiography has surpassed angiography as the diagnostic test of choice and represents the gold standard due to its ability to define the arterial anatomy and to evaluate secondary signs of mesenteric ischemia, with sensitivity ranging from 82% to 96% and specificity of 94%.

• #25 Acute Mesenteric Ischemia: Diagnosis & Treatment – EM Board Bombs Podcast

  https://www.emboardbombs.com/study-guide/2020-3-9-the-abominable-pain-acute-mesenteric-ischemia-7sjmx/

  Blood in stool (often hematochezia), is concerning and should really raise suspicion. However, it is unreliable- present in less than 50% of patients. […] Everyone talks about lactate elevation, and its sensitivity is 86% for acute mesenteric ischemia (specificity 44%). However, lactates will not be elevated until late disease, so a normal lactate cannot reliably exclude the diagnosis. […] CT angiogram (CTA) of the abdomen and pelvis with IV contrast: this is the best test in the ED. […] Findings specific for mesenteric ischemia: focal or segmental bowel thickening, intestinal pneumatosis, bowel dilation, mesenteric stranding, organ infarction. […] If the CTA is negative but suspicion remains high, a mesenteric arteriogram should be performed. […] First step is to call a surgeon as those with peritoneal signs get an ex-lap with open surgical embolectomy.

• #25 Acute Mesenteric Ischemia: Diagnosis & Treatment – EM Board Bombs Podcast

  https://www.emboardbombs.com/study-guide/2020-3-9-the-abominable-pain-acute-mesenteric-ischemia-7sjmx/

  Acute Mesenteric Ischemia: sudden small intestinal hypoperfusion due to mesenteric arterial embolism (50 percent), mesenteric arterial thrombosis (15 to 25 percent), mesenteric venous thrombosis (5 percent), and non-occlusive mesenteric ischemia due to intestinal hypoperfusion (20 to 30 percent). […] The history is the most important piece of the puzzle. The physical exam sucks, the labs suck, and a CT angiogram of the abdomen/pelvis without oral contrast is great but not that great. So you need to start with a high index of suspicion. Very high. The most common presenting complaint is sudden abdominal pain. […] Classically, abdominal pain out of proportion to physical exam. Easier said than done. This is only seen in ~40% of patients. Patients vary in their pain thresholds, and despite this old adage usually being true, inexperienced providers will often miss this condition. Not to mention the majority of these patients are 65 years old. This is perhaps why mesenteric ischemia is so difficult to diagnose.

• #26 Mesenteric ischemia – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/mesenteric-ischemia/diagnosis-treatment/drc-20450391

  If you have pain after eating that causes you to limit food and lose weight, your health care provider might suspect that you have chronic mesenteric ischemia. A narrowing of the major arteries to the small intestine can help confirm the diagnosis. […] Tests might include: […] Angiography. Your health care provider might recommend a CT scan, MRI or X-ray of your abdomen to find out if the arteries to your small intestine have narrowed. Adding a contrast dye can help pinpoint areas where the arteries have narrowed. […] Doppler ultrasound. This noninvasive test uses sound waves to check blood flow, which can determine narrowing of the arteries.

• #27 Diagnosing Mesenteric Ischemia | NYU Langone Health

  https://nyulangone.org/conditions/mesenteric-ischemia/diagnosis

  NYU Langone doctors are experts in diagnosing mesenteric ischemia, a narrowing or blockage in the mesenteric arteries, which supply blood to the small and large intestines. […] To diagnose mesenteric ischemia, cardiovascular specialists at NYU Langone conduct a physical exam and perform imaging tests. […] A Doppler ultrasound is an imaging test that uses sound waves to produce detailed images of blood vessels and other structures inside the body. This test is used to measure blood flow and identify blockages in blood vessels. […] A CT scan uses X-ray technology to produce cross-sectional images of the body. It can help identify problems with the arteries, such as aortic dissection, which is a tear in the aorta, the body’s largest artery. […] A magnetic resonance angiogram is a type of MRI scan that uses a contrast agent to provide clear images of blood flow in the arteries that lead to the intestines. […] An angiogram is an X-ray that enables doctors to view your blood vessels. When the arteries are studied, it’s called an arteriogram.

• #28 Mesenteric Ischemia – Charlotte, NC: South Charlotte General and Vascular Surgery

  https://www.scgvs.com/contents/conditions/mesenteric-ischemia

  Mesenteric ischemia results from a lack of blood flow to the intestines, spleen and liver which may develop in certain patients who are at risk of atherosclerosis. […] This condition requires prompt diagnosis and emergency treatment. […] Many symptoms of chronic mesenteric ischemia are frequently present in other conditions, therefore detailed tests must be performed to obtain a definitive diagnosis of mesenteric ischemia. […] With mesenteric ischemia, especially the acute type, the white blood cells may be elevated. Tests may also show if the acid level in the blood is high, a condition called acidosis. This may indicate serious bowel injury. […] Doppler ultrasound uses high-frequency sound waves which bounce off blood vessels. This test is designed to measure blood flow and may reveal which arteries are blocked.

• #29 Acute Mesenteric Ischemia Workup: Approach Considerations, Laboratory Studies, Plain Abdominal Radiography

  https://emedicine.medscape.com/article/189146-workup

  CTA has a sensitivity of 71-96% and a specificity of 92-94% for AMI. In current clinical practice, CTA is ordered much more frequently than classic angiography. […] Magnetic resonance imaging (MRI) and MRA yield findings similar to those of CT in AMI. MRA has a sensitivity of 100% and a specificity of 91%. […] Duplex US is highly specific (92-100%), but its sensitivity (70-89%) does not match that of angiography. […] ECG may show myocardial infarction or atrial fibrillation.

• #30 Mesenteric ischemia: what the radiologist needs to know – Olson – Cardiovascular Diagnosis and Therapy

  https://cdt.amegroups.org/article/view/21705/html

  Doppler ultrasound can be used to evaluate for chronic mesenteric ischemia, with peak systolic velocities above 275 cm/s in the SMA and 200 cm/s in the CA correlating with 70% stenosis in these vessels. […] However, the accuracy of US is heavily operator dependent, and the presence of gas within the bowel lumen or large patient size can impede visualization of the mesenteric vessels and their distal course. […] For these reasons, US is not routinely used to diagnose AMI. […] Recent analyses suggest that use of dual-energy CT (DECT) may reduce radiation exposure and increase the accuracy of mesenteric ischemia diagnosis. […] The creation of iodine-selective, virtual noncontrast, and low keV monoenergetic images using dual-energy post-processing techniques enhances the conspicuity of differential bowel wall enhancement and identifies bowel wall hemorrhage, aiding in the recognition of ischemic segments.

• #31 Delayed Diagnosis of Mesenteric Ischemia | PSNet

  https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia

  Physical exam and laboratory studies can be relatively unrevealing early in the disease process, until frank bowel ischemia progresses to intestinal infarction and acute abdominal pain develops. […] There are no laboratory studies that are sufficient or accurate enough to diagnose bowel ischemia or infarction, although elevated lactate or d-dimer levels might be helpful. […] A definitive diagnosis for acute ischemia requires either exploration in the operating room or, more commonly, computed tomographic (CT) angiography of the abdomen to evaluate the mesenteric vessels and bowel viability. […] In the setting of chronic mesenteric ischemia, abdominal duplex ultrasound of the mesenteric vasculature can be used for monitoring and surveillance. […] Early diagnosis is critical in mesenteric ischemia and requires a mesenteric angiogram, usually by CT.

• #31 Delayed Diagnosis of Mesenteric Ischemia | PSNet

  https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia

  Mesenteric ischemia occurs when there is reduced blood flow to the small or large intestines from multiple potential etiologies involving interruptions of either the arterial or venous systems. […] This disease can result from several different pathophysiological processes, be challenging to diagnose, and have high morbidity and mortality if unrecognized, particularly in the acute setting. […] Given the potential for devastating outcomes when not diagnosed in a timely fashion, as in the presented case, mesenteric ischemia is an important diagnosis to consider in all patients with severe abdominal pain. […] The most common universal presenting symptom is abdominal pain; for acute ischemia this is classically described as pain out of proportion to exam with an abdominal bruit on auscultation, although this is not present in all patients.

• #32 Intestinal Ischemia | AMBOSS Rotation Prep

  https://resident360.amboss.com/adult-medicine/gastroenterology/intestinal-ischemia/intestinal-ischemia.html

  Mesenteric ischemia can be difficult to diagnose because of the rare incidence and nonspecific symptoms. Therefore, diagnosis requires a high index of suspicion. […] The hallmark of early presentation is abdominal pain out of proportion to physical exam. In addition, patients with chronic mesenteric ischemia can present with other nonspecific GI symptoms, such as postprandial pain, nausea, vomiting, weight loss related to food avoidance, or change in bowel habits. […] Although laboratory studies are nonspecific, lactic acidosis, leukocytosis, and an elevated D-dimer level may be seen in patients with suspected mesenteric ischemia. […] Definitive diagnostic tests should be initiated immediately in patients with suspected mesenteric ischemia and risk factors (e.g., atherosclerosis, atrial fibrillation). Imaging options include: […] Computed tomography angiography (CTA) is the diagnostic study of choice. […] Mesenteric angiography is the gold standard but has been replaced largely by CTA. Although invasive, it can be therapeutic if a lesion is found that is amenable to intervention.

• #33 Chronic mesenteric ischemia | Radiology Reference Article | Radiopaedia.org

  https://radiopaedia.org/articles/chronic-mesenteric-ischaemia?lang=us

  Chronic mesenteric ischemia, also known as intestinal angina, is an uncommon type of intestinal ischemia usually affecting elderly patients as a result of significant stenosis of two or more mesenteric arteries. […] Ultrasound can be useful for diagnosing a haemodynamically significant stenosis involving the celiac artery or SMA. […] Catheter angiography is the gold standard for diagnosing mesenteric vascular disease. Not only does it directly visualizes the mesenteric vasculature, selective catheterization and pressure measurements across a stenosis can determine the hemodynamic significance of the questionable lesions. […] If a diagnosis of chronic mesenteric ischemia is made, patients should undergo definitive treatment due to the risk of continued weight loss, acute infarction, perforation, sepsis, or death.

• #34 Acute Mesenteric Ischemia – Gastrointestinal Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-surgical-gastroenterology/acute-mesenteric-ischemia

  The development of peritoneal signs at any time during the evaluation suggests the need for immediate surgery. […] If diagnosis is made by angiography, infusion of the vasodilator papaverine through the angiography catheter may improve survival in nonocclusive ischemia. […] For arterial occlusion, thrombolysis or surgical embolectomy may be done. […] If diagnosis and treatment take place before infarction occurs, mortality is low; after intestinal infarction, mortality is high and varies depending on the etiology. […] For this reason, clinical diagnosis of mesenteric ischemia should supersede diagnostic tests, which may delay treatment. […] Surgical exploration is often the best diagnostic measure for patients with clear peritoneal findings. […] For other patients, mesenteric angiography or CT angiography is done.

• #34 Acute Mesenteric Ischemia – Gastrointestinal Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-surgical-gastroenterology/acute-mesenteric-ischemia

  Early diagnosis of mesenteric ischemia is particularly important because mortality increases significantly once intestinal infarction has occurred. […] Clinical diagnosis more important than diagnostic tests. […] Mesenteric angiography or CT angiography if diagnosis unclear. […] Patients with clear peritoneal signs should proceed directly to the operating room for both diagnosis and treatment. […] For others, selective mesenteric angiography or CT angiography is the diagnostic procedure of choice. […] Other imaging studies and serum markers can show abnormalities but lack sensitivity and specificity early in the course of the disease when diagnosis is most critical. […] If diagnosis is made during exploratory laparotomy, options are surgical embolectomy, revascularization, and resection.

• #35 Improving the ED Diagnosis of Mesenteric Ischemia – emDocs

  https://www.emdocs.net/improving-the-ed-diagnosis-of-mesenteric-ischemia/

  Strategies to avoid missing the diagnosis include recognizing the presentations of the four main etiologies (arterial embolism, arterial thrombosis, nonocclusive, venous thrombosis), maintaining a high index of suspicion and communicating this to the radiologist, raising your clinical suspicion in the elderly, and relying only on CTA to rule out the diagnosis.

• #36 Acute mesenteric ischaemia: a pictorial review | Insights into Imaging | Full Text

  https://insightsimaging.springeropen.com/articles/10.1007/s13244-018-0641-2

  Acute mesenteric ischaemia (AMI) is an uncommon cause of acute hospital admission with high mortality rates (50-90%) that requires early diagnosis and treatment. […] The failure to recognise AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. […] Therefore, it is often a combination of nonspecific clinical, laboratory and radiological findings that helps most in the correct interpretation of CT findings. […] Physical examination and laboratory findings are not sensitive or specific for diagnosing AMI; therefore, MDCT is still the first-line imaging method in suspected AMI. […] The diagnosis of NOMI is the most challenging, first because it is often silent as it occurs in patients that are critically ill and often ventilated and second because CT findings overlap with those of other forms of bowel disease such as infectious and inflammatory enteritis and colitis.

• #37 Diagnosis of non-occlusive acute mesenteric ischemia in the intensive care unit | Annals of Intensive Care | Full Text

  https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-016-0213-x

  Non-occlusive mesenteric ischemia (NOMI) is a common complication and accounts for a major cause of death in critically ill patients. The diagnosis of NOMI with respect to the eventual indications for surgical treatment is challenging. […] The diagnosis of AMI is often challenging in critically ill patients, most especially for NOMI. It can be suspected in the presence of clinical deterioration associated with digestive symptoms and biological manifestations suggestive of profound tissue ischemia or acute cell lysis. Contrast-enhanced abdominal CT-scan is the cornerstone of the diagnostic strategy and may provide direct or indirect arguments for impaired vascularization of the bowel. However, its accuracy for the diagnosis of NOMI in critically ill patients is questionable. A confirmatory diagnosis as well as the assessment of the extent of necrosis still commonly involves a direct visualization of the digestive tract by endoscopy and/or surgical exploration. […] The performance of abdominal CT-scan for the diagnosis of NOMI is limited. Radiological signs of advanced-stage ischemia are good predictors of definite mesenteric ischemia, while their absence should not be considered sufficient to rule out the diagnosis.

• #38 Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery | World Journal of Emergency Surgery | Full Text

  https://wjes.biomedcentral.com/articles/10.1186/s13017-017-0150-5

  When the diagnosis of AMI is made, fluid resuscitation should commence immediately to enhance visceral perfusion. Electrolyte abnormalities should be corrected, and nasogastric decompression initiated. (Recommendation 1B) […] Broad-spectrum antibiotics should be administered immediately. Unless contraindicated, patients should be anticoagulated with intravenous unfractionated heparin. (Recommendation 1B) […] Prompt laparotomy should be done for patients with overt peritonitis. (Recommendation 1A) […] Damage control surgery is an important adjunct for patients who require intestinal resection due to the necessity to reassess bowel viability and in patients with refractory sepsis. Planned re-laparotomy is an essential part of AMI management. (Recommendation 1B) […] Mesenteric venous thrombosis can often be successfully treated with a continuous infusion of unfractionated heparin. (Recommendation 1B)

• #39

  https://link.springer.com/article/10.1007/s00068-023-02349-y

  The study concluded that bed-side diagnostic laparoscopy is a useful and safe diagnostic tool for early diagnosis and can help to avoid potentially a risky transport to the radiology suite or an unnecessary laparotomy. […] In summary, despite the advances made in the care of abdominal emergencies, acute mesenteric ischemia remains a major diagnostic and therapeutic challenge. No single diagnostic approach is sensitive enough for early diagnosis of this condition. The combination of high index of clinical suspicion, CT angio, biomarkers, and laparoscopic evaluation is critical for early diagnosis and optimal outcomes.

• #40 Small Bowel Ischemia – American College of Gastroenterology

  https://gi.org/topics/small-bowel-ischemia/

  The goals of treatment are to restore blood supply to the intestines and maintain proper function in the digestive tract. Treatment options for intestinal ischemia vary depending on the cause of the condition and the severity of damage in the intestines. […] If you have small bowel ischemia but no damage to intestinal tissue, medications may be enough to manage the condition. […] Depending on your specific case, surgery might be the best treatment option. Typical surgical procedures include: Laparoscopy: The surgeon makes a few tiny incisions and uses small instruments to restore blood flow to the small bowel.

• #41 Acute Mesenteric Ischemia: Diagnosis & Treatment – EM Board Bombs Podcast

  https://www.emboardbombs.com/study-guide/2020-3-9-the-abominable-pain-acute-mesenteric-ischemia-7sjmx/

  Importantly, avoid any vasoconstrictive agents. […] Anticoagulation: The mainstay is unfractionated heparin to limit thrombus propagation. […] Survival for acute ischemia is worse for arterial etiology rather than venous. These patients are very ill after surgery and often they stay in the hospital for a month with poor prognosis. Mortality rates exceed 60%!

• #42

  https://link.springer.com/article/10.1007/s00068-023-02349-y

  Delayed diagnosis of acute mesenteric ischemia is the most common diagnostic error in acute care surgery, in both the emergency department and the intensive care unit. […] The absence of significant abdominal signs is the most common reason for the delayed diagnosis. […] The diagnosis becomes even more challenging in unevaluable patients, such as in sedated and mechanically ventilated patients or patients with severe associated comorbidities. […] The study concluded that the history of patient, physical exam, and biological data are not sufficient for early diagnosis and emphasized the need of increased awareness and new biomarkers, to improve early diagnosis. […] The diagnostic challenges of clinical examination and CT scan evaluation in the early diagnosis of ischemia, were highlighted recently by Bergamini et al.

• #43

  https://journals.lww.com/jtrauma/fulltext/9900/diagnosis_and_management_of_acute_mesenteric.933.aspx

  Acute mesenteric ischemia (AMI) is associated with high mortality rates. There are multiple challenges to establishing an accurate early diagnosis and providing state-of-the-art care for AMI patients. A high index of suspicion is key for early diagnosis. Once suspicion is raised, a triphasic computed tomography angiography is the essential diagnostic tool. […] The acute care surgeon has a central role in performing laparotomies and bowel resections when needed and coordinating the management flow in close collaboration with vascular surgeons and interventional radiologists for prompt and effective revascularization. […] There are no reliable tools for predicting transmural bowel necrosis, and individual assessment and clinical experience are very important in decision-making when choosing between laparotomy and close observation. […] Using hospital-specific management pathways is very useful for the standardization of care in arterial occlusive AMI.

• #44 Mesenteric ischemia: Recognizing an uncommon disorder and distinguishing among its causes | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/91/9/545

  The diagnosis is further supported by radiographic findings of high-grade stenosis or occlusion of at least 2 mesenteric vessels. Computed tomography angiography is recommended as the initial study of choice for mesenteric ischemia by the Society for Vascular Surgery, American College of Radiology, and European Society of Vascular Surgery, with close to 100% sensitivity. However, duplex ultrasonography is an effective, low-cost alternative that is more than 90% sensitive and specific in detecting high-grade stenosis. […] Mesenteric ischemia remains a diagnostic challenge to many clinicians because it is uncommon and its symptoms are nonspecific. Early recognition and focused evaluation are crucial for timely diagnosis and prevention of catastrophic complications.

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