Acute mesenteric ischemia in young adults

Computed-tomography angiography in arterial acute intestinal ischemia: prognostic interest of vascular semiology

PURPOSE

To investigate vascular features on abdominal Computed-Tomography Angiography (CTA) correlated with 48-h mortality in patients who underwent arterial acute intestinal ischemia (AAII) surgery. The secondary objective was to create a prognostic score on the 48-h mortality after surgery, based on the most relevant signs.

METHOD

We included 104 patients who underwent surgery for acute mesenteric ischemia. 2 radiologists retrospectively blind reviewed the preoperative CTA scans. They used a standardized analysis grid for the arterial and venous vascular signs described in angiography. When signs were present, the affected abdominal quadrant was specified in coronal reconstruction. Each sign was analyzed for 48-h mortality on CTA. A score based on signs correlated with early mortality was developed and evaluated by ROC curve analysis.

RESULTS

22 patients died within 48 h. The number of superior mesenteric artery (SMA) branches was significantly reduced in deceased patients (p = 0.006). Other prognostic factors associated with 48-h mortality were decreased venous return in area number 1 corresponding to right colic flexure, proximal half of the transverse colon, proximal ileum (p = 0.04) and decreased venous return in more than 2 zones (p = 0.01). The weighted AAII48 score included 1 protective clinical item and 5 radiological items. The area under the ROC curve was 0.784 with, for a 6-point threshold value, a sensitivity of 68% and a specificity of 77%. The intraclass correlation coefficient for interobserver reproducibility of the score was 0.81 [95% CI 0.73; 0.87].

CONCLUSION

Three vascular signs on CTA were found to be prognostic factors for early mortality: SMA branches number ≤ 5 (p = 0.006), decreased venous return in area 1 (p = 0.04), and > 2 areas of decreased venous return (p = 0.01). They were incorporated into the AAII48 score. This score could help to identify patients at risk and to adapt subsequent management.

Comprehensive review of acute small bowel ischemia: CT imaging findings, pearls, and pitfalls

Acute small bowel ischemia is a life-threatening condition with a high mortality rate due to its lack of specific symptoms and laboratory profile, which render difficulty in establishing early diagnosis. The etiology of acute small bowel ischemia includes occlusive forms (arterial embolism, arterial thrombosis, and venous thrombosis) and nonocclusive mesenteric ischemia, of which arterial causes are far more common than venous causes. CT, the mainstay of accurate diagnoses, allows the identification of the features of vascular abnormalities and intestinal ischemic injuries, and helps clinicians to restore intestinal blood flow. Without treatment, the prognosis for acute small bowel ischemia is poor. A high index of suspicion and familiarity with the CT spectral findings of bowel ischemia are required to ensure rapid recognition of this condition.

Outcomes of different acute mesenteric ischemia therapies in the last 20 years: A meta-analysis and systematic review

OBJECTIVE

Acute mesenteric ischemia is a disease with high morbidity and mortality, and it is traditionally treated with open surgery. Endovascular therapy and hybrid techniques are alternative treatments that are also currently available. We performed a meta-analysis to evaluate the outcomes of the different treatment approaches in the last 20 years.

METHODS

Studies on acute mesenteric ischemia that were indexed in PubMed, Embase, and MEDLINE databases (from January 1, 2000, to April 1, 2021) were reviewed. All related retrospective observational studies and case series were included. A random-effects model was used to calculate pooled estimates, and the results were reported as proportions and 95% confidence intervals (CIs).

RESULTS

In our study, a total of 2369 patients (in 39 studies) underwent endovascular, open surgery, or retrograde open mesenteric stenting. The pooled mortality estimates for open surgery, endovascular therapy, and retrograde open mesenteric stenting were 40% (95% CI, 0.33-0.47; I² = 84%), 26% (95% CI, 0.19-0.33; I² = 33%), and 32% (95% CI, 0.21-0.44; I² = 26%), respectively.

CONCLUSIONS

The mortality associated with open surgical treatment, endovascular therapy, and retrograde open mesenteric stenting tend to be similar in the last 20 years.

COVID-19-Induced Mesenteric Thrombosis

Gastrointestinal symptoms, such as diarrhea (most common among gastrointestinal symptoms), nausea/vomiting, anorexia, abdominal pain, abnormal liver enzymes, and pancreatitis, are being increasingly recognized in patients with coronavirus disease 2019 (COVID-19). Moreover, COVID-19 has also been implicated in coagulopathy, especially in patients with severe disease. Here, we report a case of acute intestinal ischemia secondary to superior mesenteric thrombosis in a young female patient with mild COVID-19.

Intestinal necrosis caused by acute mesenteric ischemia associated with pregnancy: A case report and literature review

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Acute mesenteric ischemia associated with pregnancy is a rare pathology that is difficult to treat.

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Acute mesenteric ischemia can be caused by a venous thrombosis associated with gestation.

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Acute mesenteric ischemia should be considered in pregnant woman.

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Patient with intense intestinal necrosis, need a intestinal resection which would cause a short bowel syndrome.

Introduction

Mesenteric ischaemia associated with pregnancy is a rare disease with a high mortality rate and its prognosis depends on the time passing between diagnosis and final management.

Presentation of case

A 38-year-old Peruvian woman developed intestinal necrosis during week 35 of her pregnancy because of mesenteric ischaemia associated with her pregnancy.

Discussion

Given the findings of extensive intestinal necrosis, surgical resection was performed, causing short bowel syndrome. Histopathological analysis confirmed that the immediate cause of the patient’s ischaemia was venous thrombosis associated with her gestation.

Conclusion

Acute mesenteric ischaemia should be considered as a possible diagnosis in pregnant woman with risk factors for thrombophilia presenting with abdominal pain.

Acute mesenteric ischaemia: imaging and intervention

Acute mesenteric ischaemia (AMI) is an abdominal emergency in which an acute reduction in mesenteric arterial supply threatens bowel viability and may result in bowel infarction, perforation, and death. Despite improvements in diagnosis and treatment over recent decades, mortality rates in AMI remain very high. This article discusses the aetiological classification, pathophysiology, and clinical aspects of AMI. The specific imaging characteristics of each aetiological type of AMI are detailed and the role of different imaging methods in the diagnosis of AMI is discussed. Surgery is the established treatment of choice for AMI, but there is increasing use of endovascular techniques in treating AMI in cases where there are no clinical features of peritonism or radiological evidence of irreversible ischaemia. This article reviews the evidence for different diagnostic and management strategies for patients with AMI and discusses the advantages and disadvantages of surgical and endovascular treatments. Endovascular techniques have been reported to have high technical success rates and favourable outcomes when compared to open surgery; however, patient selection bias and a paucity of data limit the conclusions that can be drawn.

Acute mesenteric ischaemia: a pictorial review

Abstract

Acute mesenteric ischaemia (AMI) is an uncommon cause of acute hospital admission with high mortality rates (50–90%) that requires early diagnosis and treatment. With the increase in average life expectancy, AMI represents one of the most threatening abdominal conditions in elderly patients. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can reverse this process leading to a full recovery, but the diagnosis of AMI is difficult. The failure to recognise AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Unfortunately, common CT findings in bowel ischaemia are not specific. Therefore, it is often a combination of nonspecific clinical, laboratory and radiological findings that helps most in the correct interpretation of CT findings. The purpose of this article is to provide an overview of the anatomy, physiology of mesenteric perfusion and discussions of causes, pathogenesis and CT findings in various types of acute bowel ischaemia. Familiarity with various imaging features of mesenteric injury is essential to make a timely diagnosis that will lead to improved patient outcomes.

Teaching Points

• AMI is a potentially life-threatening disorder whose prognosis depends on early recognition, accurate diagnosis and timely intervention.

• Arterial inflow occlusion due to thrombosis or embolisation is the most common cause of AMI.

• Four aetiological types of AMI have been associated with different characteristics and risk factors (EAMI, TAMI, VAMI and NOMI).

• 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.

• Although a number of scoring systems for prognosis have been proposed, these have not been validated in large-scale studies.

ESTES guidelines: acute mesenteric ischaemia

PURPOSE

Acute mesenteric ischaemia (AMI) accounts for about 1:1000 acute hospital admissions. Untreated, AMI will cause mesenteric infarction, intestinal necrosis, an overwhelming inflammatory response and death. Early intervention can halt and reverse this process leading to a full recovery, but the diagnosis of AMI is difficult and failure to recognize AMI before intestinal necrosis has developed is responsible for the high mortality of the disease. Early diagnosis and prompt treatment are the goals of modern therapy, but there are no randomized controlled trials to guide treatment and the published literature contains a high ratio of reviews to original data. Much of that data comes from case reports and often small, retrospective series with no clearly defined treatment criteria.

METHODS

A study group of the European Society for Trauma and Emergency Surgery (ESTES) was formed in 2013 with the aim of developing guidelines for the management of AMI. A comprehensive literature search was performed using the Medical Subject Heading (MeSH) thesaurus keywords "mesenteric ischaemia", "bowel ischaemia" and "bowel infarction". The bibliographies of relevant articles were screened for additional publications. After an initial systematic review of the literature by the whole group, a steering group formulated questions using a modified Delphi process. The evidence was then reviewed to answer these questions, and recommendations formulated and agreed by the whole group.

RESULTS

The resultant recommendations are presented in this paper.

CONCLUSIONS

The aim of these guidelines is to provide recommendations for practice that will lead to improved outcomes for patients.

Management of Acute Mesenteric Ischemia

Background:

Acute mesenteric ischemia (AMI) due to a sudden loss or decrease in blood perfusion to the mesentery represents a highly lethal condition. However, the optimal surgical management remains debatable and merits a more clear recommendation based on a higher level of evidence.

Methods:

A systematic review of articles published between 2000 and 2013 was performed. Patients were divided into endovascular treatment (ET), open surgery (OS), and hybrid technique (HT) groups. Data of patients’ demographics, procedural information, clinical outcomes including mortality, morbidity, primary patency rate, technique success, primary intestinal resection rate, and second-look laparotomy rate, and follow-up were all retrieved. Comparison between the ET and the OS groups was made using 2-sided Student t test and 2-sided χ2 test or Fisher exact test where appropriate.

Results:

Twenty-eight articles with a total of 1110 patients were included for the review. The ET group had lower in-hospital mortality and morbidity but similar survival rate during follow-up compared to the OS group. The primary patency rate was higher in the ET group. The overall bowel resection rate was lower in the ET group, and nearly every patient in the cohort who required second-look laparotomy required bowel resection. The HT group seemed to have the lowest mortality and acceptable second-look laparotomy rate and morbidity. Comparison between the HT group and other groups was not possible due to the limited number of cases available for review.

Conclusion:

Endovascular treatment may serve as a first-line therapy for select patients when there is a low suspicion for intestinal necrosis. Open surgery should be reserved for emergency conditions requiring exploratory laparotomy. Hybrid technique may be an especially effective approach for treating AMI, with low morbidity and mortality, although further studies are required comparing it to OS and ET.

Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies

AIM

The primary aim of this study was to determine whether the in-hospital mortality for acute mesenteric infarction has reduced in the last decade. The secondary aim was to determine if there was a statistical difference in mortality between patients having acute primary mesenteric infarction due to different causes.

METHOD

A literature search was performed of PubMed, Ovid (Embase) and Google Scholar databases. Studies on acute mesenteric infarction of primary vascular pathology were included for pooled analyses while studies that had reported comparative mortality between arterial, venous and non-occlusive mesenteric infarction (NOMI) were included in meta-analyses. Their quality was assessed using the National Institute for Health and Care Excellence assessment scale. Odds ratios (ORs) of mortality were calculated using a Mantel-Haenszel random effect model.

RESULTS

The total number of patients was 4527 and the male/female ratio was 1912/2247. The pooled in-hospital mortality was 63%. There was no significant reduction of in-hospital mortality rate in the last decade (P = 0.78). There was a significant difference in in-hospital mortality between acute arterial mesenteric infarction (73.9%) compared with acute venous mesenteric infarction (41.7%) [OR 3.47, confidence interval (CI) 2.43-4.96, P < 0.001] and NOMI (68.5%) compared with acute venous mesenteric infarction (44.2%) (OR 3.2, CI 1.83-5.6, P < 0.001). There was no difference in mortality between acute arterial mesenteric infarction and NOMI (OR 1.08, CI 0.57-2.03, P = 0.82).

CONCLUSION

In-hospital mortality rate has not changed in the last decade. Patients with arterial mesenteric infarction or with NOMI are over three times more likely to die during the first hospital admission compared with those with venous mesenteric infarction.

The length of necrosis and renal insufficiency predict the outcome of acute mesenteric ischemia

BACKGROUND

Acute mesenteric ischemia (AMI) is a potentially life-threatening condition because of its diagnostic difficulty, operative challenges, and comorbidities a patient may have. The aim of this study was to identify factors associated with adverse outcomes in patients with AMI.

METHODS

The hospital records and clinical data of all patients with AMI were reviewed for a recent 4-year period. Clinical outcomes and factors influencing mortality were analyzed.

RESULTS

Included in the study were 104 patients (46 females and 58 males) with an overall mean age of 66 ± 13.4 years. The cause of AMI was arterial pathology in 74 (71%) patients, venous thrombosis in 15 (14%) patients, and nonocclusive ischemia in 12 (12%) patients. Abdominal pain was the most common presenting symptom (97% of patients). The 30-day mortality rate was 66%. Univariate analysis showed that mortality was associated with renal insufficiency (p = 0.004), an age greater than 70 years (p = 0.02), the presence of comorbidities (p = 0.001), a leukocyte count greater than 18,000/mL (p = 0.04), and small bowel necrosis of more than 100 cm (p < 0.0001). Logistic regression analysis showed that independent predictors of mortality were small bowel necrosis of more than 100 cm (p = 0.002) and a serum creatinine level greater than 2 mg/dL (p = 0.04).

CONCLUSION

The length of the necrosis and renal insufficiency are the primary factors that result in a poor outcome in AMI patients. Prompt diagnostic evaluation and early therapeutic interventions may help to prevent the development of these fatal predictors.