Clinical Review

Diagnosis and management of intestinal ischaemic disorders

BMJ 2003; 326 doi: http://dx.doi.org/10.1136/bmj.326.7403.1372 (Published 19 June 2003) Cite this as: BMJ 2003;326:1372
  1. Jayaprakash Sreenarasimhaiah, assistant professor, gastroenterology (jayaprakashsree@hotmail.com)
  1. Department of Medicine, Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, MC 8887, Dallas, TX 75390, USA
  • Accepted 15 May 2003

Although intestinal ischaemia is an infrequent event, early recognition and appropriate treatment can reduce the potential for a devastating outcome

Introduction

Acute or chronic abdominal pain can be the result of many different pathophysiological processes. Many presentations are due to benign processes, whereas others may be life threatening if not recognised swiftly. Among the many possible causes, clinicians need to consider the possibility of intestinal ischaemic disorders. The variable vessels involved, location of bowel affected, and different levels of acuity of illness all result in multiple possible presentations. The detection of such a serious condition can be a diagnostic and therapeutic dilemma. This review aims to help clinicians to understand the features and management of acute and chronic mesenteric ischaemia, mesenteric venous thrombosis, and ischaemic colitis.

Sources and selection criteria

The information in this review is based on results of a Medline search for reviews and evidence based studies in major journals from the disciplines of gastroenterology, surgery, and radiology published between 1966 and 2003. The key words used included “intestinal ischemia,” “mesenteric ischemia,” “ischemic colitis,” “mesenteric venous thrombosis,” “mesenteric angiography,” “diagnosis,” “management,” and “treatment.”

Clinical features

Acute mesenteric ischaemia

The recognition of acute mesenteric ischaemia can be difficult, as most patients present with non-specific symptoms, particularly abdominal pain. Classically, pain is disproportionately exaggerated relative to the unremarkable physical findings and persists beyond two to three hours. However, signs of an acute abdomen with distension, guarding (rigidity), and hypotension may also occur, particularly when diagnosis has been delayed.1 Fever, diarrhoea, nausea, and anorexia are all commonly reported. Melena or haematochezia occurs in 15% of cases, and occult blood is detected in at least half of patients.2 The underlying process can involve emboli, arterial or venous thrombosis, vasoconstriction from low flow states, or vasculitis. Embolic occlusion of the superior mesenteric artery occurs in more than half of all cases. …

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