MESENTERICMESENTERICISCHEMIAISCHEMIA

THE FORGOTTEN DIAGNOSISTHE FORGOTTEN DIAGNOSIS

Richard M. Gore, MDRichard M. Gore, MDNorth Shore University Health SystemNorth Shore University Health System

University of ChicagoUniversity of ChicagoEvanston, IllinoisEvanston, Illinois

SCBT/MR 2010SCBT/MR 2010San Diego, CaliforniaSan Diego, California

March 8, 2010March 8, 201016:0016:00--16:1016:10

TYPE 1: WHITETYPE 1: WHITE

•• VASODILATION VASODILATION WITH HYPEREMIA WITH HYPEREMIA ACUTE IBDACUTE IBD

•• INJURY TO INTRAINJURY TO INTRA--MURAL VESSELS MURAL VESSELS CONTRAST LEAK: CONTRAST LEAK: SHOCK BOWEL, RESHOCK BOWEL, RE--PERFUSION AFTER PERFUSION AFTER ISCHEMIAISCHEMIA

•• HEMORRHAGEHEMORRHAGE

TYPE 1: WHITETYPE 1: WHITE

•• VASODILATION VASODILATION WITH HYPEREMIA WITH HYPEREMIA ACUTE IBDACUTE IBD

•• INJURY TO INTRAINJURY TO INTRA--MURAL VESSELS MURAL VESSELS CONTRAST LEAK: CONTRAST LEAK: SHOCK BOWEL, RESHOCK BOWEL, RE--PERFUSION AFTER PERFUSION AFTER ISCHEMIAISCHEMIA

•• HEMORRHAGEHEMORRHAGE

TYPE 1: WHITETYPE 1: WHITE

•• VASODILATION VASODILATION WITH HYPEREMIA WITH HYPEREMIA ACUTE IBDACUTE IBD

•• INJURY TO INTRAINJURY TO INTRA--MURAL VESSELS MURAL VESSELS CONTRAST LEAK: CONTRAST LEAK: SHOCK BOWEL, RESHOCK BOWEL, RE--PERFUSION AFTER PERFUSION AFTER ISCHEMIAISCHEMIA

•• HEMORRHAGEHEMORRHAGE

TYPE 1: WHITETYPE 1: WHITE

•• VASODILATION VASODILATION WITH HYPEREMIA WITH HYPEREMIA ACUTE IBDACUTE IBD

•• INJURY TO INTRAINJURY TO INTRA--MURAL VESSELS MURAL VESSELS CONTRAST LEAK: CONTRAST LEAK: SHOCK BOWEL, RESHOCK BOWEL, RE--PERFUSION AFTER PERFUSION AFTER ISCHEMIAISCHEMIA

•• HEMORRHAGEHEMORRHAGE

ARTERIAL INSUFFICIENCYARTERIAL INSUFFICIENCYWITHOUT REPERFUSIONWITHOUT REPERFUSION

ARTERIAL INSUFFICIENCYARTERIAL INSUFFICIENCYWITHOUT REPERFUSIONWITHOUT REPERFUSION

ARTERIAL INSUFFICIENCYARTERIAL INSUFFICIENCYWITH REPERFUSIONWITH REPERFUSION

TYPE 1: WHITETYPE 1: WHITE

•• VASODILATION VASODILATION WITH HYPEREMIA WITH HYPEREMIA ACUTE IBDACUTE IBD

•• INJURY TO INTRAINJURY TO INTRA--MURAL VESSELS MURAL VESSELS CONTRAST LEAK: CONTRAST LEAK: SHOCK BOWEL, RESHOCK BOWEL, RE--PERFUSION AFTER PERFUSION AFTER ISCHEMIAISCHEMIA

•• HEMORRHAGEHEMORRHAGE

WHITEWHITE GRAYGRAY TARGETTARGETWATERWATER

TARGETTARGETFATFAT

GASGAS

TYPE 2: GRAYTYPE 2: GRAY

•• HOMOGENEOUS HOMOGENEOUS ENHANCEMENT ENHANCEMENT ~SK MUSCLE~SK MUSCLE

•• CHRONIC CROHNCHRONIC CROHN’’S S DISEASEDISEASE

•• ISCHEMIAISCHEMIA•• NEOPLASMNEOPLASM

ARTERIAL INSUFFICIENCYARTERIAL INSUFFICIENCYWITHOUT REPERFUSIONWITHOUT REPERFUSION

TYPE 3: TARGETTYPE 3: TARGET--WATERWATER

•• MOST COMMON MOST COMMON PATTERNPATTERN

•• IBDIBD•• INFECTIONINFECTION•• ISCHEMIAISCHEMIA

•• RADIATIONRADIATION

ISCHEMIAISCHEMIA

INFARCTION INFARCTION

MESENTERIC ISCHEMIAMESENTERIC ISCHEMIA

•• Mesenteric ischemia is a complex, Mesenteric ischemia is a complex, multifaceted conditionmultifaceted condition

•• State of the systemic circulationState of the systemic circulation•• Degree of functional or anatomic vascular Degree of functional or anatomic vascular

compromisecompromise•• Number and caliber of vessels affectedNumber and caliber of vessels affected

MESENTERIC ISCHEMIAMESENTERIC ISCHEMIA

•• Response of the vascular bed to diminished Response of the vascular bed to diminished perfusionperfusion

•• Nature and capacity of the collateral Nature and capacity of the collateral circulationcirculation

•• Duration of the ischemic insultDuration of the ischemic insult•• Metabolic requirements of the involved Metabolic requirements of the involved

segment of gutsegment of gut

ACUTE MESENTERIC ACUTE MESENTERIC ISCHEMIAISCHEMIA

Superior mesenteric artery embolism (SMAE)Superior mesenteric artery embolism (SMAE)Nonocclusive mesenteric ischemia (NOMI)Nonocclusive mesenteric ischemia (NOMI)Superior mesenteric artery thrombosis Superior mesenteric artery thrombosis (SMAT)(SMAT)

Superior mesenteric vein thrombosis (SMVT)Superior mesenteric vein thrombosis (SMVT)

ACUTE MESENTERIC ACUTE MESENTERIC ISCHEMIAISCHEMIA

SMA embolism (50%)SMA embolism (50%)NOMI (20NOMI (20--30%)30%)SMA thrombosis (15SMA thrombosis (15--25%)25%)SMV thrombosis (5%)SMV thrombosis (5%)

PATHOLOGIC DAMAGEPATHOLOGIC DAMAGE MDCT FINDINGSMDCT FINDINGS

VASODILATIONVASODILATION MURAL HYPERDENSITYMURAL HYPERDENSITY

VASOCONSTRICTIONVASOCONSTRICTION ABSENT OR ABSENT OR ↓↓MURAL MURAL ENHANCEMENTENHANCEMENT

↑↑ MURAL PERMEABILITYMURAL PERMEABILITY MURAL THICKENING MURAL THICKENING BOWEL DISTENTIONBOWEL DISTENTION

MUCOSAL CELLULAR MUCOSAL CELLULAR NECROSISNECROSIS

PNEUMATOSISPNEUMATOSISPORTPORT--MES VEIN GASMES VEIN GAS

TRANSMURAL TRANSMURAL NECROSISNECROSIS

PNEUMOPERITONEUMPNEUMOPERITONEUMPNEUMORETROPERITONEUMPNEUMORETROPERITONEUM

SMAESMAE

•• The wide caliber and The wide caliber and narrow take off angle of narrow take off angle of the SMA off the aorta the SMA off the aorta make it particularly make it particularly vulnerable to embolic vulnerable to embolic events.events.

•• The offending emboli The offending emboli usually originate from a left usually originate from a left atrial or ventricular mural atrial or ventricular mural thrombus or vegetations thrombus or vegetations on a heart valveon a heart valve

SMAESMAE

•• Nearly one half of Nearly one half of patients with SMAE patients with SMAE will have synchronous will have synchronous extramesenteric extramesenteric emboli including emboli including peripheral artery peripheral artery emboli and 20% have emboli and 20% have synchronous emboli synchronous emboli to the spleen, kidneys to the spleen, kidneys or other organsor other organs

SMAESMAE

•• Nearly one half of Nearly one half of patients with SMAE patients with SMAE will have synchronous will have synchronous extramesenteric extramesenteric emboli including emboli including peripheral artery peripheral artery emboli and 20% have emboli and 20% have synchronous emboli synchronous emboli to the spleen, kidneys to the spleen, kidneys or other organsor other organs

SAME: CLINICAL FEATURESSAME: CLINICAL FEATURES

•• Sudden onset of severe periumbilical or right Sudden onset of severe periumbilical or right umbilical fossa abdominal pain.umbilical fossa abdominal pain.

•• Severe pain is usually out of proportion to an often Severe pain is usually out of proportion to an often innocent physical examination which may reveal a innocent physical examination which may reveal a soft abdomen with some tenderness on palpation.soft abdomen with some tenderness on palpation.

•• Nausea, vomiting, or diarrhea may occur.Nausea, vomiting, or diarrhea may occur.•• Query patient about cardiac disease such as Query patient about cardiac disease such as

previous myocardial infarction, arrythmias, cardiac previous myocardial infarction, arrythmias, cardiac valve disease, and previous arterial and venous valve disease, and previous arterial and venous embolism. embolism.

IMPAIRED VENOUS IMPAIRED VENOUS DRAINAGEDRAINAGE

IMPAIRED VENOUS IMPAIRED VENOUS DRAINAGEDRAINAGE

IMPAIRED VENOUS IMPAIRED VENOUS DRAINAGE WITHDRAINAGE WITHREPERFUSIONREPERFUSION

IMPAIRED VENOUS IMPAIRED VENOUS DRAINAGE WITHDRAINAGE WITH

INFARCTIONINFARCTION

ISCHEMIC COLITISISCHEMIC COLITIS

•• LOW FLOW: CHF, HYPOVOLEMIA 80%LOW FLOW: CHF, HYPOVOLEMIA 80%•• ARTERIAL THROMBUS OR EMB 10%ARTERIAL THROMBUS OR EMB 10%•• VENOUS THROMBOSIS 5%VENOUS THROMBOSIS 5%•• VASCULITIS (SLE) 5%VASCULITIS (SLE) 5%

ISCHEMIC COLITISISCHEMIC COLITIS

•• PAIN OUT OF PROPORTION TO PHYSICAL PAIN OUT OF PROPORTION TO PHYSICAL EXAM, BLOODY DIARRHEA, NAUSEA, EXAM, BLOODY DIARRHEA, NAUSEA, VOMITINGVOMITING

•• ELDERLY: LEFT SIDED INVOLVEMENT DUE TO ELDERLY: LEFT SIDED INVOLVEMENT DUE TO HYPOVOLEMIAHYPOVOLEMIA

•• YOUNG: RIGHT SIDED INVOLVEMENT DUE TO YOUNG: RIGHT SIDED INVOLVEMENT DUE TO HEMORRHAGIC SHOCK OR TRAUMA HEMORRHAGIC SHOCK OR TRAUMA (POOR COLLATERAL BLOOD FLOW, INCON(POOR COLLATERAL BLOOD FLOW, INCON--SISTENT MARGINAL ARTERY OF RT COLON) SISTENT MARGINAL ARTERY OF RT COLON)

TYPE 5TYPE 5-- PNEUMATOSISPNEUMATOSIS

•• ISCHEMIAISCHEMIA•• INFECTIONINFECTION•• TRAUMATRAUMA•• BENIGN CAUSES BENIGN CAUSES

CONNECTIVE TISSUE CONNECTIVE TISSUE IBD IBD OBSTRUCTION OBSTRUCTION COPDCOPD