Isquemia mesentérica crónica, tratamiento quirúrgico: reporte de dos casos / Chronic mesenteric ischemia: report of two cases

Chronic mesenteric ischemia is uncommon and often not recognized by clinicians. We report two patients with the disease. A 61 years old female with a two years history of abdominal pain, diarrhea, anorexia and weight loss. A mesenteric arteriography showed a critical stenosis of the celiac artery. The patient was operated and a retrograde bypass from the iliac to the mesenteric artery was placed. Digestive symptoms ceased and the patient gained weight. A 49 years old smoker female, with a two years history of abdominal pain and weight loss, without diarrhea. A doppler ultrasonography of abdominal arteries showed a critical stenosis of the celiac artery. The angiography confirmed the stenosis and disclosed also a complete occlusion of the common hepatic artery. The patient was operated placing anterograde aortic-mesenteric and aortic- hepatic bypasses. During the follow up, the patient is in good conditions.

La isquemia mesentérica crónica es una enfermedad que pone en riesgo la vida, que puede provocar la muerte por inanición o infarto mesentérico. El diagnóstico se realiza tardíamente debido a la inespecificidad de sus síntomas. El método diagnóstico no invasivo de elección es la ecografía doppler, por el cual se determina la presencia de estenosis u oclusión de las arterias viscerales comprometidas. La arteriografía se utiliza para definir la anatomía de las lesiones y planificar la cirugía. El tratamiento de elección sigue siendo la revascularización. Presentamos dos pacientes tratadas en nuestro servicio con buenos resultados, las que presentaban historia de síntomas abdominales inespecíficos y baja de peso. En la primera paciente, con antecedentes de hipercolesterolemia, su estudio demostró ateromatosis calcica difusa de aorta abdominal, ilíacas comunes, tronco celíaco, renales y mesentérica superior; se le realizó bypass ilíaco-mesentérico superior. En la segunda paciente, con antecedentes de tabaquismo crónico, su estudio demostró lesiones críticas de tronco celíaco y arteria mesentérica superior e inferior, se le realizó bypass aorto-mesentérico superior y aorto-hepático común. En los controles, ambas pacientes presentan alza de peso sostenida y se mantienen asintomáticas.

Clinical Effectiveness of Percutaneous Angioplasty for Acute and Chronic Mesenteric Ischemia: A Six Case Series / 대한소화기학회지

Intestinal ischemia is divided into three categories, namely, acute mesenteric ischemia (AMI), chronic mesenteric ischemia (CMI), and colonic ischemia. AMI can result from arterial or venous thrombi, emboli, and vasoconstriction secondary to low-flow states. It is an urgent condition which can result in high mortality rate. The predominant causative factor of CMI is stenosis or occlusion of the mesenteric arterial circulation, and it is characterized by postprandial abdominal pain and weight loss. Surgery is the treatment of choice for intestinal ischemia. However, it has been recently reported that percutaneous transluminal angioplasty with stent placement and/or thrombolysis is an effective therapy in various types of mesenteric ischemia. We report six cases of mesenteric ischemia which were successfully treated by percutaneous angioplasty, and review the literature from South Korea.

Clinical Effectiveness of Percutaneous Angioplasty for Acute and Chronic Mesenteric Ischemia: A Six Case Series / 대한소화기학회지

Intestinal ischemia is divided into three categories, namely, acute mesenteric ischemia (AMI), chronic mesenteric ischemia (CMI), and colonic ischemia. AMI can result from arterial or venous thrombi, emboli, and vasoconstriction secondary to low-flow states. It is an urgent condition which can result in high mortality rate. The predominant causative factor of CMI is stenosis or occlusion of the mesenteric arterial circulation, and it is characterized by postprandial abdominal pain and weight loss. Surgery is the treatment of choice for intestinal ischemia. However, it has been recently reported that percutaneous transluminal angioplasty with stent placement and/or thrombolysis is an effective therapy in various types of mesenteric ischemia. We report six cases of mesenteric ischemia which were successfully treated by percutaneous angioplasty, and review the literature from South Korea.

Tratamiento quirúrgico de la isquemia mesentérica crónica: Caso clínico / Surgical treatment of chronic mesenteric ischemia: Report of one case

Although the classic therapy for chronic mesenteric ischemia is surgical revascularization, endovascular therapy is a new therapeutic option. We report a 55 year-old female, with a 2 years history of post prandial abdominal pain, diarrhoea, and weight loss, with occlusion of both mesenteric arteries and critical stenosis of the celiac artery. The initial treatment consisted in angioplasty and celiac artery stent placement in two occasions, with a brief symptomatic relief. Finally, a visceral artery bypass was performed, with good post operative outcome and complete symptomatic resolution at one year follow up. In our opinion endovascular therapy is a good therapeutic option for chronic mesenteric ischemia in high surgical risk patients, specially when dealing with stenotic injuries. It may also be a complement for patients who need to recover their nutritional status prior to revascularization surgery. On the other hand, due to the long term patency and symptomatic relief, surgical treatment is a good option in low risk patients.

Side-to-side aorto-mesenteric anastomosis for management of abdominal angina.

Abdominal angina and fear of eating are manifestations of mesenteric ischemia. This infrequent cause of abdominal pain was diagnosed in a 60-year-old female smoker. We performed a novel side-to-side aorto-mesenteric anastomosis for mesenteric revascularization, with good short-term (6 months) result.

Trombosis venosa mesentérica: manifestaciones clínicas, terapia y evolución / Mesenteric vein thrombosis: clinical manifestations, treatment and outcome

Background: Mesenteric vein thrombosis (MVT) is uncommon and accounts for 5-10percent of all mesenteric ischemic events. In 80percent of cases, an etiologic factor is found. The clinical presentation varies and the diagnosis is made based on imaging studies. The treatment involves anticoagulation alone or in combination with surgery. Aim: To describe the clinical characteristics of patients with MVT. Patients and methods: Retrospective and prospective review of all cases with MVT, treated between 1995-2001. The clinical presentation, imaging studies, treatment and outcome were evaluated. Results: 29 cases of MVT were reviewed (14 females, age 56 ± 15 years). Twenty two patients (76percent) had recognizable risk factors. The main symptoms were abdomianl pain (86percent) and vomiting (55percent). The diagnosis of acute mesenteric ischemia was suspected on admission only in 6 patients (21percent). Thirteen patients underwent transabdominal color Doppler ultrasonography and the diagnosis was confirmed for 11 of these (85percent). Twenty out of 24 patients (85percent) studied with computed tomography, had positive signs of MVT. Twenty one patients (72percent) recieved anticoagulation, 10 of whom also underwent surgery. Four patients (14percent) received surgical treatment alone. Four patients were not treated. Seven patients (24percent) died. Conclusions: MVT is difficult to identify. It is necessary to have a high degree of suspicion in patients who have risk factors. The diagnosis is made with imaging studies. The treatment consists of early anticoagulation and surgical intervention when indicated.

Acute mesenteric ischemia

Acute mesenteric ischemia [AMI] is a morbid condition with a difficult diagnosis and a high rate of complications, which is associated with a high mortality rate. For the evaluation of the hospital results of diagnosis and treatment of acute mesenteric ischemia we reviewed our experience. The clinical data of 24 patients diagnosed with acute mesenteric ischemia between 2001 and 2004 were reviewed, assessed and hospital results analyzed. The dominant population were males [83%] whereas females were only [17%]. The median age was 61.5, and cases increased with age. Smoking had been studied as a causative factor for acute mesenteric ischemia. 18 patients in the study were regular smokers [75%]. 22 patients [92%] had previous medical or surgical problems, and the most frequent were respectively heart disease [62%], recent surgical procedures [26%], DM [13%], CVA [11%], and previous digestive problems [11%]. 11 patients [46%] had previous thrombosis events. 6 patients [25%] had recent stress [acute illness] associated with mesenteric ischemia. The most common symptoms and signs were respectively: abdominal pain [91%], nausea and vomiting [79%], intestinal obstrucion [58%], gastrointestinal bleeding [33%]. The Median time of pain was 45.6 h, and the most frequent duration was 24 h and less. Abdominal distension was the the most frequent sign [71%], followed by peritoneal irritation [58%]. On ECG series at the time of admission an Atrial Fibration was found in 33% of cases, heart ischemia signs in 66, 67% of cases, enlargment of heart in 17.5%, and arrhythmias in 17.5%. 11 patient [45%] had problems of the chest at the time of admission, and [96%] had cardiopulmonary problems. laboratory findings were non-specific, and the most important signs were:- increased WBC, and the mean value was 18604 mm3-decreased blood PH, and the mean value was 7.2. -the other findings were not helpful in diagnosing acute mesenteric ischemia. Abdominal scanning by AXR and U/S were not helpful and showed some non-specific finding. Angiography was not performed for any cases. CT scan was performed in 6 cases of those had high suspision of acute mesenteric ischemia, 3 of them were diagnosed [and included in this study], it showed specific signs [embolism] in 2 patients [8%], nothing in one case [4%]. The predictive value, sensitivity, and specificity were 67%, 67%, 67%, respectively. All patients underwent open surgery [100%] without any case of laparoscopic, and the indications were: explorative laparotomy [7 cases] 29%, intestinal obstruction [2 cases] 8%, peritoneal irritation [14 cases] 59%, fecal fistula after previous surgery [1 case] 4%. The surgery was performed after admision 31 h as a mean. Surgery showed that there is one or more foci of gangrenous lesions in all patient [100%], these lesions were supplied by SMA in 23 cases [96%], and 1 case was supplied by IMA. and the median leangth of its was 282 cm. Selected procedure to the gangrenous intestine was done in 21 cases [87%], which was colointestinal resection with primary anastomosis in 19 cases and with stoma in 2 cases, while only 2 patient [8%]underwent revascularization procedures [thromboembolectomy] Secound operation was done in 3 cases [12.5%], the indication was fecal fistula [2 cases] and intestinal obstruction [1 case]. The cause of occlusion was determined by clinical and imaging study and the results: 19 cases [79%] were arterial occlusion [14 cases [58%] embolism, and 5 cases [21%] thrombosis], 3 cases [13%] were mesenteric venous thrombosis, and 2 cases [8%] were non-occlusive mesenteric ischemia [NOMI]. Mortality associated with surgery was 14 cases [58%], and higher mortality rate occured in:-Mesenteric venous thrombosis patients [67% of this group], arterial thrombosis [60%], and embolism [5 7%]-At the group of late surgery-The patient at advanced age-Patients having recent heart or chest problems. Most cases of death were at the first 24 h after operation, and less by the time. Multiorgan failure [MOF] was the most frequent cause of death in this group of patients [71.5%], then hemorrhagic shock [2 1%], then heart failure [7%]. Complications occurred in 14 cases of total amount of patient [58%], and in 8 of surviving patients [80%]. -The complications in survived cases were: wound infection in [2], sepsis in [3], gastrointestinal bleeding in [1], short bowel syndrome in [2], bowel obstruction in[1], faecal fistula in [I], multiorgan failure in 2. Total Parenteral nutrition [TPN] was necessary in 60% of survived patients

Prognostic factors in acute mesenteric ischemia

The objective of the study was to explore the prognostic factors by comparing survivor from non-survivor group with the diagnosis of acute mesenteric ischemia. This study was conducted at the Aga Khan University Hospital, Karachi over six and half years. Eighteen patients were hospitalized with the diagnosis of acute mesenteric ischemia [AMI]. Survivor and non-survivor groups had 8 and 10 patients respectively, giving the overall mortality rate of 56%. The surviving patients had significantly shorter length of bowel necrosis, i.e. 176 cm [mean] compared to 525cm [mean] in non-survivor group [P-value 0.0003]. The surviving patients also had less number of "re-look" laparotomies as compared to non-survival group; mean 1.1 and 2 respectively [P-value 0.0002]. The higher number of "re-look" laparotomies were attributed to incorrect visual determination of bowel viability at the time of first laparotomy. The duration of symptoms and interval between arrival to hospital and operation were not different between the two groups [P values 0.98 and 0.65 respectively]. Length of bowel necrosis and number of surgical procedures are the prognostic factors in acute mesenteric ischemia. Comparing the two groups also showed that difference in age, sex and symptoms were insignificant

Dolor abdominal atípico en paciente con estenosis crítica de arteria mesentérica superior: resolución con angioplastía / Atypical abdominal pain in a patient with critical upper mesenteric artery stenosis: resolution with angioplasty

Se presenta el caso de una paciente con dolor abdominal, de carácter atípico. Tras amplio estudio, se realizó angiografía que demostró estenosis crítica en origen de arteria mesentérica. Se procedió a instalar stent, con óptimo flujo posterior. Este caso ilustra la efectividad y seguridad de la angioplastía con stent en el tratamiento de la isquemia mesentérica crónica y su creciente aplicación, antes reservada sólo a casos de alto riesgo quirúrgico

Lesión obstructiva de arteria mesentérica superior / Obstructive lesion of superior mesenteric artery: case report

Se presenta un caso de lesión obstructiva de la arteria mesentérica superior, que se presentó como un abdomen agudo, requirió un completo estudio diagnóstico y dos intervenciones quirúrgicas. Se discute la escasa literatura disponible

Isquemia intestinal aguda de origen mesentérico / Acute mesenteric ischemia

Se analizan 29 pacientes con diagnóstico de isquemia mesentérica aguda. El dolor abdominal agudo, intenso y persistente, fue el motivo de consulta en todos los casos. Los signos humorales como leucocitos, hemoconcentración e hiperlactacidemia, no son específicos. La arteriografía selectiva de la arteria mesentérica superior permite el diagnóstico y el tratamiento de la isquemia mesentérica extensa, lo que nos llevó a efectuar la revascularización en cuatro de nuestros casos. Las tácticas quirúrgicas empleadas fueron: revascularización y/o resección intestinal. La amyoría de los pacientes desarrollaron complicaciones graves como: shock perioperatorio en 10 casos, sepsis en 10, dehiscencia anastomática en 5, evisceración en 2 y síndrome de malabsorción en uno. La mortalidad alcanzó a 20 pacientes, 69 por ciento, en un gran porcentaje de casos antes de la primer semana de postoperatorio. No falleció ningún revascularizado, mientras que un revascularizado y resecado falleció (50 por ciento), la mortalidad de la resección fue de 13 casos (68 por ciento) y murieron los 6 pacientes a los que sólo se les efectuó una laparotomía exploratoria. El criterio diagnóstico fundado en la "sospecha clínica" y la arteriografía a partir del cual se puede efectuar un tratamiento enérgico y oportuno, puede mejorar de manera importante el pronóstico de esta enfermedad

Isquemia intestinal / Intestinal ischemia

La isquemia intestinal constituye una catástrofe mayor, que se asocia con alta letalidad. Con la creciente proporción de poblaciones añosas en la sociedad moderna, la enfermedad vascular abdominal adquiere preponderante importancia epidemiológica. La gravedad y extensión de la necrosis intestinal isquémica dependen del vaso principal afectado, de la calidad de la circulación colateral y de su capacidad de respuesta, del estado de la circulación general y del grado de hipoperfusión. La isquemia resulta en la liberación de una gran variedad de agentes tóxicos endógenos, que son productos normales y anormales del metabolismo celular, que se generan primero con la hipoperfusión y anoxia y luego con la reperfusión de los tejidos afectados. Dichos productos tóxicos ejercen tanto acción local como acción sistémica deletérea. Hoy se emplea un manejo dinámico de la isquemia mesentérica, tanto para las modalidades agudas como para las crónicas, comenzando con la fase de reanimación y restablecimiento de la volemia, el uso de papaverina como vasodilatador preferencial, la trombólisis y angioplastia en casos seleccionados, y la cirugía como modalidad principal de tratamiento definitivo en cuanto a revascularización y resección del intestino necrótico.

Síndrome do intestino curto: análise retrospectiva de 42 pacientes internados no Hospital das Clínicas de Ribeiräo Preto / Short-bowel syndrome: follow-up of 42 hospitalized patients at the Hospital das Clínicas de Ribeiräo Preto

Foram analisados os prontuários de 42 pacientes (26 homens e 16 mulheres) submetidos à ressecçäo intestinal durante o período de 1979-1987. A causa mais freqüente de ressecçäo intestinal foi a trombose mesentérica seguida pelo volvo. A maior incidência ocorreu aos 30-50 anos. A taxa global de mortalidade foi 57% e as principais "causas de mortalidade" foram os distúrbios metabólicos (56%) e a sepse (30%)

Isquemia mesentérica crónica: caso clínico / Chronic mesenteric ischemia: a clinical case

Se presenta un caso clínico de isquemia mesentérica crónica, catalogado como "Angina Intestinal" típica, diagnosticado y tratado en el Hospital Naval de Valparaíso. Se discute sobre la forma de presentación clínica de estos pacientes, analizando en forma breve los principales síntomas que caracterizan esta enfermedad y se comentan aspectos importantes a considerar en la reparación quirúrgica. Consideramos como excelente el resultado inicial del tratamiento en este caso, ya que nuestra paciente se encuentra libre de síntomas, a los diez meses de operación

Abdome agudo vascular; estudo de 27 casos e revisäo da literatura / Vascular acute abdomen: a study of 27 cases and literature review

A Isquemia Visceral Aguda é patologia rara e invariavelmente fatal (16). Foram analisados retrospectivamente 27 pacientes portadores de Abdome Agudo Vascular, nos últimos 10 anos na Disciplina de Gastroenterologia Cirúrgica da Escola Paulista de Medicina. O quadro clínico é insidioso e incaractéristico dificultando o diagnóstico, a indicaçäo da artériografia e, consequentemente, retardando a terapêutica. Artériografia é método propedêutico de valor inestimável para o diagnóstico e planejamento terapêutico da Isquemia Visceral Aguda