1
|
Sinha D, Kale S, Kundaragi NG, Sharma S. Mesenteric ischemia: a radiologic perspective. Abdom Radiol (NY) 2022; 47:1514-1528. [PMID: 33230592 DOI: 10.1007/s00261-020-02867-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 02/08/2023]
Abstract
Mesenteric ischemia is a broad term encompassing several clinical conditions leading to impaired vascularity of bowel loops. Absence of specific clinical presentation and a definitive laboratory marker often lead to delayed diagnosis with high morbidity and mortality in the acute setting. Imaging plays a crucial role in the diagnosis and management. Multi-detector CT (MDCT) is the first line imaging modality for the evaluation of patients with suspected mesenteric ischemia and plays an important role for assessing its severity and complications. This review article highlights the causes, pathophysiology, imaging features and possible endovascular treatment options of mesenteric ischemia.
Collapse
|
2
|
[Management of mesenteric ischemia in the era of intestinal stroke centers: The gut and lifesaving strategy]. Rev Med Interne 2017; 38:592-602. [PMID: 28259479 DOI: 10.1016/j.revmed.2017.01.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/21/2017] [Indexed: 02/06/2023]
Abstract
Mesenteric ischemia is a gut and life-threatening, medical and surgical, digestive and vascular emergency. Mesenteric ischemia is the result of an arterial or venous occlusion, a vasospasm secondary to low-flow states in intensive care patients, aortic clamping during vascular surgery or intestinal transplantation. Progression towards mesenteric infarction and its complications is unpredictable and correlates with high rates of mortality or a high risk of short bowel syndrome in case of survival. Thus, mesenteric ischemia should be diagnosed and treated at an early stage, when gut injury is still reversible. Diagnostic workup lacks sensitive and specific clinical and biological marker. Consequently, diagnosis and effective therapy can be achieved by a high clinical suspicion and a specific multimodal management: the gut and lifesaving strategy. Based on the model of ischemic stroke centers, the need for a multidisciplinary and expert 24/24 emergency care has led, in 2016, to the inauguration of the first Intestinal Stroke Center (Structure d'urgences vasculaires intestinales [SURVI]) in France. This review highlights the pathophysiological features of chronic and acute mesenteric ischemia, as well as the diagnosis workup and the therapeutic management developed in this Intestinal Stroke Center.
Collapse
|
3
|
Gastric presentation (vasculitis) mimics a gastric cancer as initial symptom in granulomatosis with polyangiitis: a case report and review of the literature. Rheumatol Int 2015; 35:1925-9. [DOI: 10.1007/s00296-015-3334-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 07/22/2015] [Indexed: 10/23/2022]
|
4
|
Spontaneous duodenal perforation as a complication of kawasaki disease. Case Rep Pediatr 2015; 2015:689864. [PMID: 25883825 PMCID: PMC4391158 DOI: 10.1155/2015/689864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 03/13/2015] [Accepted: 03/14/2015] [Indexed: 11/17/2022] Open
Abstract
Kawasaki disease is generally known as a systemic vasculitis that often concerns doctors due to its serious cardiac complications; however, other visceral organs may get involved as well. Surgical manifestations of the intestinal tract in Kawasaki disease are rare. In this report, we describe the case of a 2.5-year-old boy with typical Kawasaki disease who presented with GI bleeding and surgical abdomen. The diagnosis of duodenal perforation was confirmed.
Collapse
|
5
|
Corcos O, Nuzzo A. Gastro-intestinal vascular emergencies. Best Pract Res Clin Gastroenterol 2013; 27:709-25. [PMID: 24160929 DOI: 10.1016/j.bpg.2013.08.006] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 08/13/2013] [Accepted: 08/21/2013] [Indexed: 01/31/2023]
Abstract
Gastro-Intestinal Vascular Emergencies include all digestive ischaemic injuries related to acute or chronic vascular and/or haemodynamic diseases. Gastro-intestinal ischaemic injuries can be occlusive or non-occlusive, arterial or venous, localized or generalized, superficial or transmural and share the risks of infarction, organ failure and death. The diagnosis must be suspected, at the initial presentation of any sudden, continuous and unusual abdominal pain, contrasting with normal physical examination. Risk factors are often unknown at presentation and no biomarker is currently available. The diagnosis is confirmed by abdominal computed tomography angiography identifying intestinal ischaemic injury, either with vascular occlusion or in a context of low flow. Recent knowledge in the pathophysiology of acute mesenteric ischaemia, clinical experience and existing recommendations have generated a multimodal and multidisciplinary management strategy. Based on the gastro-intestinal viability around a simple algorithm, and coordinated by gastroenterologists, the dual aim is to avoid large intestinal resections and death.
Collapse
Affiliation(s)
- Olivier Corcos
- Department of Gastroenterology, IBD, Nutritional Support and Intestinal Transplantation, Beaujon Hospital Clichy, Paris VII University, 100 Boulevard du General Leclerc, 92110 Clichy, France.
| | | |
Collapse
|
6
|
Battula N, Tsapralis D, Takhar A, Coldham C, Mayer D, Isaac J, Muiesan P, Sutcliffe RP, Marudanayagam R, Mirza DF, Bramhall SR. Aetio-pathogenesis and the management of spontaneous liver bleeding in the West: a 16-year single-centre experience. HPB (Oxford) 2012; 14:382-9. [PMID: 22568414 PMCID: PMC3384862 DOI: 10.1111/j.1477-2574.2012.00460.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Spontaneous liver bleeding (SLB) is a rare but potentially fatal complication. In contrast to the East, various benign pathologies are the source of SLB in the West. An accurate diagnosis and a timely implementation of appropriate treatment are crucial in the management of these patients. The present study presents a large Western experience of SLB from a specialist liver centre. METHODS A retrospective analysis of patients presented with SLB between January 1995 and January 2011. RESULTS Sixty-seven patients had SLB, 44 (66%) were female and the median age at presentation was 47 years. Abrupt onset upper abdominal pain was the presenting symptom in 65 (97%) patients. The aetiology for SLB was hepatic adenoma in 27 (40%), hepatocellular carcinoma (HCC) in 17 (25%) and various other liver pathologies in the rest. Emergency treatment included a conservative approach in 42 (64%), DSA and embolization in 6 (9%), a laparotomy and packing in 6 (9%) and a liver resection in 11 (16%) patients. Eleven (16%) patients had further planned treatments. Seven (10%) died during the same admission but the mortality was highest in patients with HELLP syndrome. At a median follow-up of 54 months all patients with benign disease are alive. The 1-, 3- and 5-year survival of patients with HCC was 59%, 35% and 17%, respectively. CONCLUSION SLB is a life-threatening complication of various underlying conditions and may represent their first manifestation. The management should include initial haemostasis followed by appropriate staging investigations to provide a definitive treatment for each individual patient.
Collapse
|
7
|
Battula N, Tsapralis D, Morgan M, Mirza D. Spontaneous liver haemorrhage and haemobilia as initial presentation of undiagnosed polyarteritis nodosa. Ann R Coll Surg Engl 2012; 94:e163-5. [PMID: 22613289 PMCID: PMC5827234 DOI: 10.1308/003588412x13171221590737] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2011] [Indexed: 02/06/2023] Open
Abstract
Polyarteritis nodosa (PAN) is a systemic necrotising vasculitis that could result in multifocal aneurysms of visceral arteries. Isolated multiple aneurysms of the hepatic arteries in the setting of PAN is extremely rare. Patients are typically asymptomatic and, very rarely, spontaneous rupture with life threatening haemorrhage could be the initial presentation of an undiagnosed PAN. Accurate diagnosis, effective haemostasis and prompt initiation of immunosuppressive treatment with the help of a multidisciplinary team will improve the clinical outcomes.
Collapse
Affiliation(s)
- N Battula
- Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK.
| | | | | | | |
Collapse
|
8
|
Jang SY, Kim JH, Ha SH, Hwang JA, Park SJ, Paik SY. [A case of idiopathic recurrent duodenojejunitis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2012; 59:245-9. [PMID: 22460574 DOI: 10.4166/kjg.2012.59.3.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
There are various etiologies of duodenojejunitis such as Henoch-Schönlei purpura (H-S purpura), vasculitis, Crohn's disease, celiac sprue, ischemia, lymphoma, Zollinger-Ellison syndrome, bacteria or parasite infection, radiation, drug induced jejunitis, eosinophilic jejunitis, and toxins. A 31-year-old man presented with left upper quadrant pain. He did not have febrile sense, hematochezia, melena, diarrhea, arthralgia and hematuria. He had neither drug history nor traveling history. Esophagogastroduodenoscopy showed diffuse mucosal erythema and segmental hemorrhagic erosions on the distal area to the descending portion of the duodenum and proximal jejunum, which were commonly observed in the gastrointestinal involvement of H-S purpura. However, he showed no skin lesions, joint and urologic problems until the discharge. Autoimmune markers such as antinuclear antibody and antineutrophil cytoplasmic antibody were negative. Celiac and mesenteric angiogram showed no vascular abnormality. After the administration of oral prednisolone 40 mg daily for therapeutic trial, abdominal pain and endoscopic lesions were improved. He experienced relapses of same episode without skin lesions 16 times during follow-up of 8 years, which were also treated with prednisolone. The abdominal computed tomography during the follow-up also showed no significant finding. We report a case of primary recurrent duodenojejunitis similar to the gastrointestinal involvement of H-S purpura without purpura.
Collapse
Affiliation(s)
- Sung Yeol Jang
- Department of Internal Medicine, Bundang Jesaeng General Hospital, Seongnam, Korea
| | | | | | | | | | | |
Collapse
|
9
|
Hokama A, Kishimoto K, Ihama Y, Kobashigawa C, Nakamoto M, Hirata T, Kinjo N, Higa F, Tateyama M, Kinjo F, Iseki K, Kato S, Fujita J. Endoscopic and radiographic features of gastrointestinal involvement in vasculitis. World J Gastrointest Endosc 2012; 4:50-6. [PMID: 22442741 PMCID: PMC3309893 DOI: 10.4253/wjge.v4.i3.50] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 11/04/2011] [Accepted: 03/01/2012] [Indexed: 02/05/2023] Open
Abstract
Vasculitis is an inflammation of vessel walls, followed by alteration of the blood flow and damage to the dependent organ. Vasculitis can cause local or diffuse pathologic changes in the gastrointestinal (GI) tract. The variety of GI lesions includes ulcer, submucosal edema, hemorrhage, paralytic ileus, mesenteric ischemia, bowel obstruction, and life-threatening perforation.The endoscopic and radiographic features of GI involvement in vasculitisare reviewed with the emphasis on small-vessel vasculitis by presenting our typical cases, including Churg-Strauss syndrome, Henoch-Schönlein purpura, systemic lupus erythematosus, and Behçet’s disease. Important endoscopic features are ischemic enterocolitis and ulcer. Characteristic computed tomographic findings include bowel wall thickening with the target sign and engorgement of mesenteric vessels with comb sign. Knowledge of endoscopic and radiographic GI manifestations can help make an early diagnosis and establish treatment strategy.
Collapse
Affiliation(s)
- Akira Hokama
- Akira Hokama, Kazuto Kishimoto, Yasushi Ihama, Tetsuo Hirata, Futoshi Higa, Masao Tateyama, Jiro Fujita, Department of Infectious, Respiratory and Digestive Medicine, Faculty of Medicine, University of the Ryukyus, Okinawa 903-0125, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Kim M, Lee HJ, Yeo MK, Lee YS, Moon HS, Lee SI, Cho JS, Song KS. Lymphocytic Phlebitis of the Stomach - A Case Report with Literature Review -. KOREAN JOURNAL OF PATHOLOGY 2011. [DOI: 10.4132/koreanjpathol.2011.45.6.654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Meeran Kim
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyun-Jung Lee
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Korea
| | - Min-Kyung Yeo
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Korea
| | - Young-Suk Lee
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sang-Il Lee
- Department of Surgery, Chungnam National University School of Medicine, Daejeon, Korea
| | - June-Sik Cho
- Department of Radiology, Chungnam National University School of Medicine, Daejeon, Korea
| | - Kyu-Sang Song
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Korea
| |
Collapse
|
11
|
Rits Y, Oderich GS, Bower TC, Miller DV, Cooper L, Ricotta JJ, Kalra M, Gloviczki P. Interventions for mesenteric vasculitis. J Vasc Surg 2010; 51:392-400.e2. [PMID: 20141962 DOI: 10.1016/j.jvs.2009.08.082] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Revised: 08/26/2009] [Accepted: 08/26/2009] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study reviewed the outcomes of open and endovascular revascularization for mesenteric vasculitis (MV). METHODS We reviewed the clinical data of all patients who underwent revascularization for occlusive MV from 1984 to 2008. Patients treated for aneurysms or mucosal bleeding without ischemic symptoms were excluded. End points were early mortality and morbidity, survival, freedom from mesenteric symptoms, and patency. Outcomes of open reconstructions were compared with the results of 163 patients who underwent open operations for atherosclerotic disease. RESULTS There were 15 patients (13 females, 2 males) with a mean age of 38 years (range, 15-66 years). Etiologies were Takayasu's arteritis in 7, polyarteritis nodosa in 4, indeterminate in 3, and giant cell arteritis in 1. The celiac axis was affected in 13, superior mesenteric artery (SMA) in 13, renal arteries in 8, and the aorta in 4. Seven patients had active disease, and eight were in remission. Nine (60%) presented with symptomatic chronic (n = 8) and acute (n = 1) mesenteric ischemia. Six patients with asymptomatic disease underwent mesenteric revascularization during other aortic-based operations. Fourteen patients (93%) had 10 mesenteric bypasses (8 aortic based; 2 iliac), three had aortoplasties, of which two had mesenteric patch angioplasties, and one underwent arcuate ligament release with patch angioplasty. One patient (7%) underwent percutaneous transluminal angioplasty of SMA stenosis. There were no early deaths. Early complications occurred in three patients (20%) after open reconstruction, including gastrointestinal hemorrhage, ileus with re-exploration, and superior mesenteric vein thrombosis. Median follow-up was 22 months. One graft thrombosis in a patient with active disease was treated with redo bypass 74 months after aorta-celiac-SMA bypass. All patients were alive at 10 years, with similar expected survival compared with the general population (P = .69). Compared with patients with atherosclerotic disease, open reconstructions for MV had similar freedom from mesenteric symptoms (83% vs 75%, P = .80) and similar primary graft patency (83% vs 84%, P = .9). CONCLUSION Mesenteric vasculitis is a rare manifestation of Takayasu arteritis, polyarteritis nodosa, indeterminate, or giant cell arteritis. Open revascularization is durable and effective when needed.
Collapse
Affiliation(s)
- Yevgeniy Rits
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Pryshchep O, Ma-Krupa W, Younge BR, Goronzy JJ, Weyand CM. Vessel-specific Toll-like receptor profiles in human medium and large arteries. Circulation 2008; 118:1276-84. [PMID: 18765390 DOI: 10.1161/circulationaha.108.789172] [Citation(s) in RCA: 240] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Inflammatory vasculopathies, ranging from the vasculitides (Takayasu arteritis, giant cell arteritis, and polyarteritis nodosa) to atherosclerosis, display remarkable target tissue tropisms for selected vascular beds. Molecular mechanisms directing wall inflammation to restricted anatomic sites within the vascular tree are not understood. We have examined the ability of 6 different human macrovessels (aorta and subclavian, carotid, mesenteric, iliac, and temporal arteries) to initiate innate and adaptive immune responses by comparing pathogen-sensing and T-cell-stimulatory capacities. METHODS AND RESULTS Gene expression analysis for pathogen-sensing Toll-like receptors (TLRs) 1 to 9 showed vessel-specific profiles, with TLR2 and TLR4 ubiquitously present, TLR7 and TLR9 infrequent, and TLR1, TLR3, TLR5, TLR6, and TLR8 expressed in selective patterns. Experiments with vessel walls stripped of the intimal or adventitial layer identified dendritic cells at the media-adventitia junction as the dominant pathogen sensors. In human artery-severe combined immunodeficiency (SCID) mouse chimeras, adoptively transferred human T cells initiated vessel wall inflammation if wall-embedded dendritic cells were conditioned with TLR ligands. Wall-infiltrating T cells displayed vessel-specific activation profiles with differential production of CD40L, lymphotoxin-alpha, and interferon-gamma. Vascular bed-specific TLR fingerprints were functionally relevant, as exemplified by differential responsiveness of iliac and subclavian vessels to TLR5 but not TLR4 ligands. CONCLUSIONS Populated by indigenous dendritic cells, medium and large human arteries have immune-sensing and T-cell-stimulatory functions. Each vessel in the macrovascular tree exhibits a distinct TLR profile and supports selective T-cell responses, imposing vessel-specific risk for inflammatory vasculopathies.
Collapse
Affiliation(s)
- Olga Pryshchep
- Lowance Center for Human Immunology and Rheumatology, Emory University, School of Medicine, Atlanta, GA 30322, USA
| | | | | | | | | |
Collapse
|
13
|
Kuwahara Y, Shima Y, Tanaka T, Kimura H, Hoshida Y, Aozasa K, Kawase I. Successful treatment with intravenous cyclophosphamide pulse therapy of severe intestinal involvement in Wegener's granulomatosis. Scand J Rheumatol 2006; 35:243-5. [PMID: 16766375 DOI: 10.1080/03009740500381179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|