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Mesenteric ischaemia is a blockage or interruption in the blood flow of the intestine. It can be caused simply by low flow or by an embolism or thrombosis of the artery. It causes necrosis or tissue death of the intestines, which secondarily leads to inflammation and infection of the intestines and the body itself. The pain is often severe and out of proportion to what the doctor finds on examination. It is difficult to diagnose it early; however, angiography and early exploratory laparoscopy or laparotomy are sensitive enough to pick up the disease early. The treatment is to remove the embolus or reopen the artery involved. Dead tissue is removed and viable tissue is saved and reconnected to other viable tissue. Mortality rate in this disease is very high.

The intestinal mucosa needs a great deal of blood flow. It is estimated that 20-25 percent of cardiac output goes to the GI tract at any given period of time. Ischaemia to the intestinal lining results in a release of toxins, bacteria and vasoactive mediators so that there is a systemic response to the iscahaemia. This results in septic shock and multisystem organ failure. Eventually, there is death of the individual due to multisystem organ failure and/or hypotension. This can happen within twelve hours after the onset of symptoms.

The cause of the intestinal ischaemia involves damage to the celiac trunk (a major artery), the superior mesenteric artery or the inferior mesenteric artery. The celiac trunk, if damaged, affects the stomach, oesophagus, proximal duodenum, gallbladder, liver, spleen and pancreas. The superior mesenteric artery affects the distal duodenum, ileum, jejunum and colon (up to the splenic flexure). The inferior mesenteric colon affects the descending colon, rectum and sigmoid colon. The splenic flexure is partially supplied by both the SMA and the IMA and is vulnerable to ischemia.

Risk factors for mesenteric ischaemia include coronary arterial disease, valvular heart disease, heart failure or a history of emboli, generalized atherosclerosis or a hypercoagulable state. Certain traumatic or inflammatory conditions can lead to mesenteric ischemia. Venous thrombosis is also possible and is caused by renal failure, portal hypertension, and decompression sickness (the bends).

Signs and symptoms of mesenteric ischaemia include severe abdominal pain with a lack of obvious physical findings. There is no hardening of the abdomen and there is minimal tenderness. Later, when peritonitis occurs, there is guarding, rigidity and absent bowel sounds. The stool may be positive for blood and signs of shock are noticeable. The sudden onset of pain is suggestive but not diagnostic for an embolism and gradual onset of pain is typical of venous thrombosis. There is postprandial abdominal discomfort that is consistent with arterial thrombosis.

The diagnosis of the disease of mesenteric ischaemia can be difficult. Doctors need to rely on clinical suspicion for the disease. You can have a mesenteric angiogram performed that will nail the diagnosis of blockage of one of the three main arteries or of veins. Mortality increases significantly after necrosis occurs so it is important to diagnose it as early as possible. Doctors need to consider this as a possibility in any patient over fifty who has known risk factors for the disease. Referral to the operating room should be undertaken whenever there is a suspicion for mesenteric ischaemia. Regular x-rays of the abdomen can rule out other causes of abdominal pain. An ultrasound can show arterial occlusion in some cases but it isn't a very sensitive test.

Mortality is low if infarction hasn't taken place yet but if there is infarction and necrosis of the intestines or abdominal organs, the mortality approaches 70-90 percent.

Treatment of mesenteric ischemia include having a surgical embolectomy, resection of dead tissue and revascularization of the mesenteric arteries. Vasodilators can be used to increase blood flow as can thrombolysis with medications. In the long term, medications for anticoagulation or anti-platelet medications are recommended.

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