What is chronic mesenteric ischaemia?
A lack of blood supply to the bowel which gradually deteriorates over time as a result of atherosclerosis in the coeliac trunk, superior mesenteric artery, and/or inferior mesenteric artery
What is the pathophysiology of the development of chronic mesenteric ischaemia?
The gradual buildup of atherosclerotic plaque causes the narrowing of the blood vessel lumen, reducing blood flow and resulting in ischaemia of the bowel
What is the result of the degree of communication within the visceral blood supply in chronic mesenteric ischaemia?
In the majority of circumstances, at least 2 of the CT, SMA, and IMA must be affected
What causes symptom onset in chronic mesenteric ischaemia?
When there is increased demand on the blood supply or reduction in blood supply in patients with chronic mesenteric ischaemia a transient ischaemia of the bowel occurs, resulting in symptom onset
What can cause an increased demand on the blood supply to the gut?
What can cause a reduction in blood supply to the gut?
Who does chronic mesenteric ischaemia mostly occur in?
Patients >60 yrs
Which gender does chronic mesenteric ischaemia more commonly occur in?
Why is chronic mesenteric ischaemia typically under-reported?
Because patients with atherosclerotic disease in the mesenteric vessels are often asymptomatic
What is the prevalence of atherosclerotic involvement in the mesenteric vessels?
What are the main risk factors for chronic mesenteric ischaemia?
- Diabetes mellitus
What are the classical symptoms of chronic mesenteric ischaemia?
- Post-prandial pain
- Weight loss
When does postprandial pain occur in chronic mesenteric ischaemia?
Typically around 10mins - 4 hours after eating
What may postprandial pain be associated with?
Fear of eating (sitophobia), as eating becomes linked to pain
Why can chronic mesenteric ischaemia lead to weight loss?
A combination of decreased calorie intake and malabsorption
What concurrent vascular co-morbidites may be present with chronic mesenteric ischaemia?
- Previous MI
- Previous stroke
What are the less specific symptoms of chronic mesenteric ischaemia?
- Change in bowel habit (typically loose)
What are the examination findings in chronic mesenteric ischaemia?
Often non-specific, including;
- Evidence of malnutrition/cachexia
- Generalised abdominal tenderness
- Abdominal bruits
What are the differentials for chronic, non-specfiic abdominal pain?
- Chronic pancreatitis
- Gallstone pathology
- Peptic ulcer disease
- Upper GI malignancy
What investigations are done in suspected chronic mesenteric ischaemia?
- Routine bloods, including FBC, U&Es, and LFTs
- CT angiography
What may be found on routine bloods in chronic mesenteric ischaemia?
They will usually be normal
Cardiovascular risk profile (lipids, glucose) may be abnormal
Why is CT angiography useful in the investigation of chronic mesenteric ischaemia?
- Provides good anatomical view of all vessels
- Can help gauge any intervention required
What used to be the gold standard of imaging in chronic mesenteric ischaemia?
Catheter angiography, but now used less due to the improvement of CT angiography
Who decides on the management plans for chronic mesenteric ischaemia?
Typically made jointly between interventional radiologists and vascular surgeons
What is involved in the best medical therapy of chronic mesenteric ischaemia?
- Antiplatelet agent
- Advice promoting weight loss, increasing exercise, and smoking cessation
What effect will stabilising the atherosclerotic plaque have in chronic mesenteric ischaemia?
It will prevent subsequent worsening of the disease
When is surgical intervention warranted in chronic mesenteric ischaemia?
- Severe disease
- Progressive disease
- Presence of debilitating symptoms, including weight loss or malabsorption
What will the ultimate decision about which surgical approach to take in chronic mesenteric ischaemia depend on?
- Location and severity of disease
- Patient factors
What are the options for surgical management of chronic mesenteric ischaemia?
- Endovascular procedures
- Open procedures
What is the more common surgical management technique in chronic mesenteric ischaemia?
What do endovascular procedures consist of in chronic mesenteric ischaemia?
Mesenteric angioplasty and stenting
What do open procedures in chronic mesenteric ischaemia involve?
Endartectomy or bypass procedure
How is mesenteric angioplasty performed?
Typically percutaneously, through either the femoral artery or brachial/axillary artery, allowing a catheter to be passed to the appropriate vessel under radiological guidance. A small balloon is expanded to dilate the vessel, with any stent deployed if required
What is the advantage of mesenteric angioplasty compared to other techniques?
It provides a shorter hospital stay with faster mobilisation for the patient
What are the main complications of endovascular intervention?
- Haematoma at the arterial punch site
- Risk of embolisation
- Vessel perforation
What are the main complications of chronic mesenteric ischaemia?
- Bowel infarction with necrosis
What is an important consideration when patients present with chronic mesenteric ischaemia?
They will likely have concurrent cardiovascular disease, which will also require suitable medical management and optimisation
What is the prognosis of chronic mesenteric ischaemia after intervention?
How does the prognosis of chronic mesenteric ischaemia differ between open surgery and endovascular methods?
Comparable results in terms of relief of symptoms