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Khetarpal S. Superior Mesenteric Vein Thrombosis in a Pediatric Patient: Case Report and Review of the Literature. Pediatr Emerg Care 2021; 37:e769-e771. [PMID: 31977781 DOI: 10.1097/pec.0000000000001967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Patients with inflammatory bowel disease are at increased risk of thromboembolism. There are various sites for thromboembolism including the cerebral, limbs, abdominal vessels, retina, and lungs. Here, we report a case of a 17-year-old patient with a history of Crohn disease presenting with abdominal pain. Upon further evaluation, the patient was found to have mesenteric vein thrombosis, which was discovered on computed tomographic scan. Potential causes, contributing factors, diagnosis, and treatment are discussed here.
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Huber TS, Björck M, Chandra A, Clouse WD, Dalsing MC, Oderich GS, Smeds MR, Murad MH. Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery. J Vasc Surg 2020; 73:87S-115S. [PMID: 33171195 DOI: 10.1016/j.jvs.2020.10.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic mesenteric ischemia (CMI) results from the inability to achieve adequate postprandial intestinal blood flow, usually from atherosclerotic occlusive disease at the origins of the mesenteric vessels. Patients typically present with postprandial pain, food fear, and weight loss, although they can present with acute mesenteric ischemia and bowel infarction. The diagnosis requires a combination of the appropriate clinical symptoms and significant mesenteric artery occlusive disease, although it is often delayed given the spectrum of gastrointestinal disorders associated with abdominal pain and weight loss. The treatment goals include relieving the presenting symptoms, preventing progression to acute mesenteric ischemia, and improving overall quality of life. These practice guidelines were developed to provide the best possible evidence for the diagnosis and treatment of patients with CMI from atherosclerosis. METHODS The Society for Vascular Surgery established a committee composed of vascular surgeons and individuals experienced with evidence-based reviews. The committee focused on six specific areas, including the diagnostic evaluation, indications for treatment, choice of treatment, perioperative evaluation, endovascular/open revascularization, and surveillance/remediation. A formal systematic review was performed by the evidence team to identify the optimal technique for revascularization. Specific practice recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system based on review of literature, the strength of the data, and consensus. RESULTS Patients with symptoms consistent with CMI should undergo an expedited workup, including a computed tomography arteriogram, to exclude other potential causes. The diagnosis is supported by significant arterial occlusive disease in the mesenteric vessels, particularly the superior mesenteric artery. Treatment requires revascularization with the primary target being the superior mesenteric artery. Endovascular revascularization with a balloon-expandable covered intraluminal stent is the recommended initial treatment with open repair reserved for select younger patients and those who are not endovascular candidates. Long-term follow-up and surveillance are recommended after revascularization and for asymptomatic patients with severe mesenteric occlusive disease. Patient with recurrent symptoms after revascularization owing to recurrent stenoses should be treated with an endovascular-first approach, similar to the de novo lesion. CONCLUSIONS These practice guidelines were developed based on the best available evidence. They should help to optimize the care of patients with CMI. Multiple areas for future research were identified.
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Affiliation(s)
- Thomas S Huber
- University of Florida College of Medicine, Gainesville, Fla.
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ankur Chandra
- Scripps Clinic/Scripps Green Hospital, La Jolla, Calif
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, Va
| | - Michael C Dalsing
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Gustavo S Oderich
- Division of Vascular and Endovascular Surgery, University of Texas Health Science Center at Houston - McGovern Medical School, Houston, Tex
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Saint Louis University School of Medicine, St. Louis, Mo
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minn
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McCarthy E, Little M, Briggs J, Sutcliffe J, Tapping CR, Patel R, Bratby MJ, Uberoi R. Radiology and mesenteric ischaemia. Clin Radiol. 2015;70:698-705. [PMID: 25812475 DOI: 10.1016/j.crad.2015.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 10/29/2014] [Accepted: 02/17/2015] [Indexed: 02/07/2023]
Abstract
This review focuses on the radiology of mesenteric ischaemia. Covering the acute and chronic presentations, both of which result from impaired vascularisation of the gastrointestinal tract, we evaluate the role of radiographs, ultrasound, CT, MRI, and catheter angiography in the diagnosis of these conditions. Looking to the future, we also assess some of the emerging imaging techniques. Across medicine and surgery there has been a significant shift towards minimally invasive interventions. Although percutaneous revascularisation of chronic mesenteric ischaemia has been performed for some time, there has been a developing trend for the use of such techniques in acute mesenteric ischaemia. We evaluate the available evidence for the use of these percutaneous interventions and assess how they compare with or in some instances compliment traditional surgical alternatives.
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Hagspiel KD, Flors L, Hanley M, Norton PT. Computed tomography angiography and magnetic resonance angiography imaging of the mesenteric vasculature. Tech Vasc Interv Radiol 2014; 18:2-13. [PMID: 25814198 DOI: 10.1053/j.tvir.2014.12.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are highly accurate cross-sectional vascular imaging modalities that have almost completely replaced diagnostic catheter angiography for the evaluation of the mesenteric vasculature. CTA is the technique of choice when evaluating patients with suspected mesenteric ischemia; it permits to differentiate between occlusive and nonocclusive etiologies, to evaluate indirect signs of bowel ischemia, and in some instances, to provide alternative diagnoses. MRA has the advantage of not using ionizing radiation and iodinated contrast agents and can be appropriate in the nonacute setting. Both CTA and MRA are suitable for the assessment of patients with suspected chronic mesenteric ischemia, allowing to evaluate the degree of atherosclerotic steno-occlusive disease and the existence of collateral circulation, as well as other nonatherosclerotic vascular pathologies such as fibromuscular dysplasia and median arcuate ligament syndrome. CTA provides excellent depiction of visceral aneurysms and has an important role to plan therapy for both occlusive and aneurysmal diseases and in the follow-up of patients after open or endovascular mesenteric revascularization procedures. This article provides an introduction to the CTA and MRA imaging protocol to study the mesenteric vasculature, the imaging findings in patients presenting with acute and chronic mesenteric ischemia and visceral aneurysms, and the value of these imaging techniques for therapy planning and follow-up.
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Affiliation(s)
- Klaus D Hagspiel
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA.
| | - Lucia Flors
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - Michael Hanley
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
| | - Patrick T Norton
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, VA
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Abstract
Magnetic resonance (MR) imaging is a robust imaging modality for evaluation of vascular diseases. Technological advances have made MR imaging widely available for accurate and time-efficient vascular assessment. In this article the clinical usefulness of MR imaging techniques and their application are reviewed, using examples of vascular abnormalities commonly encountered in clinical practice, including abdominal, pelvic, and thoracic vessels. Common pitfalls and problem solving in interpretation of vascular findings in body MR imaging are also discussed.
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Affiliation(s)
- Wirana Angthong
- Department of Radiology, University of North Carolina Hospitals, UNC at Chapel Hill, CB 7510, 2001 Old Clinic Building, Chapel Hill, NC 27599-7510, USA; Department of Radiology, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, 62 Moo 7, Khlong Sip, Ongkharak, Nakhon Nayok, Thailand
| | - Richard C Semelka
- Department of Radiology, University of North Carolina Hospitals, UNC at Chapel Hill, CB 7510, 2001 Old Clinic Building, Chapel Hill, NC 27599-7510, USA.
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Abstract
OPINION STATEMENT Acute mesenteric ischemia is caused by a critical reduction in intestinal blood flow that frequently results in bowel necrosis and is associated with a high mortality. Clinicians must maintain a high index of suspicion because a prompt diagnosis and early aggressive treatment before the onset of bowel infarction results in reduced mortality. Medical management includes aggressive rehydration and the use of antibiotics, anticoagulation, vasodilators, and inhibitors of reperfusion injury. If acute mesenteric ischemia is suspected, early angiography is imperative, as it permits accurate diagnosis and possible therapeutic intervention. Therapeutic options during angiography depend on the cause of ischemia and include administering intra-arterial vasodilators and/or thrombolytic agents and angioplasty with or without stent placement. If interventional techniques are not possible or if the patient presents with suspicion of bowel infarction, surgery is warranted. Surgical techniques include superior mesenteric artery embolectomy or visceral artery bypass, which should be used before bowel resection to ensure only resection of nonviable bowel.
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Dewitte A, Biais M, Coquin J, Fleureau C, Cassinotto C, Ouattara A, Janvier G. [Diagnosis and management of acute mesenteric ischemia]. ACTA ACUST UNITED AC 2011; 30:410-20. [PMID: 21481561 DOI: 10.1016/j.annfar.2011.02.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Accepted: 02/09/2011] [Indexed: 12/19/2022]
Abstract
The prevalence of significant splanchnic arterial stenoses is increasing, but remains mostly asymptomatic due to abundant collateral circulation. Acute insufficiency of mesenteric arterial blood flow accounts for 60 to 70% of cases of mesenteric ischemia and results mostly from a superior mesenteric embolus. Despite major advances have been achieved in understanding the pathogenic mechanisms of bowel ischemia, its prognosis remains dismal with mortality rates about 60%. The diagnosis of acute mesenteric ischemia depends upon a high clinical suspicion, especially in patients with known risk factors. Rapid diagnosis is essential to prevent intestinal infarction. However, early signs and symptoms of mesenteric ischemia are non specific, and definitive diagnosis often requires radiologic examinations. Early and liberal implementation of angiography has been the major advance over the past 30 years which allowed increasing diagnostic accuracy of acute mesenteric ischemia. CT and MR-based angiographic techniques have emerged as alternatives less invasive and more accurate to analyse splanchnic vessels and evaluate bowel infarction. The goal of treatment of patients with acute mesenteric ischemia is to restore intestinal oxygenation as quickly as possible after initial management that includes rapid hemodynamic monitoring and support. Surgery should not be delayed in patients suspected of having intestinal necrosis.
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Affiliation(s)
- A Dewitte
- Service d'anesthésie-réanimation II, CHU de Bordeaux, Maison du Haut-Lévêque, groupe hospitalier Sud, université Bordeaux-Segalen, avenue de Magellan, Pessac cedex, France.
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Ersoy H. The role of noninvasive vascular imaging in splanchnic and mesenteric pathology. Clin Gastroenterol Hepatol 2009; 7:270-8. [PMID: 19201388 DOI: 10.1016/j.cgh.2008.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Revised: 12/03/2008] [Accepted: 12/05/2008] [Indexed: 02/07/2023]
Abstract
Traditionally, catheter angiography (CA) has been the mainstay of diagnosis for mesenteric arterial diseases. However, CA is invasive and is associated with complications that result from the procedure itself, depending on the experience of the operators, site of vascular access, ionized radiation that could be significant when combined with interventional procedures, and administered contrast material. During the past 2 decades, technical improvements in computed tomography (CT) and magnetic resonance hardware and methods have contributed new, noninvasive tools, specifically CT angiography (CTA) and 3-dimensional gadolinium-enhanced magnetic resonance angiography (3D Gd-MRA). This article outlines the current applications, strengths, and weaknesses of CTA and 3D Gd-MRA in imaging of the mesenteric vessels.
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Affiliation(s)
- Hale Ersoy
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Abstract
Acute mesenteric ischemia is caused by a critical reduction in intestinal blood flow that frequently results in bowel necrosis and is associated with a high mortality. Clinicians must maintain a high index of suspicion because a prompt diagnosis and early aggressive treatment before the onset of bowel infarction results in reduced mortality. Medical management includes aggressive rehydration and the use of antibiotics, anticoagulation, vasodilators, and inhibitors of reperfusion injury. If acute mesenteric ischemia is suspected, early angiography is imperative, as it permits accurate diagnosis and possible therapeutic intervention. Therapeutic options during angiography depend on the cause of ischemia and include administering intra-arterial vasodilators and/or thrombolytic agents and angioplasty with or without stent placement. If interventional techniques are not possible or if the patient presents with suspicion of bowel infarction, surgery is warranted. Surgical techniques include superior mesenteric artery embolectomy or visceral artery bypass, which should be used before bowel resection to ensure only resection of nonviable bowel.
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Affiliation(s)
- Todd Berland
- Mayo Clinic Jacksonville, Jacksonville, FL 32224, USA
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Shih MCP, Angle JF, Leung DA, Cherry KJ, Harthun NL, Matsumoto AH, Hagspiel KD. CTA and MRA in Mesenteric Ischemia: Part 2, Normal Findings and Complications After Surgical and Endovascular Treatment. AJR Am J Roentgenol 2007; 188:462-71. [PMID: 17242256 DOI: 10.2214/ajr.05.1168] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A number of surgical and endovascular options exist for the treatment of acute and chronic mesenteric ischemia. Both surgical and endovascular treatments necessitate close clinical and imaging follow-up because the consequences of acute occlusions can be catastrophic. MDCT angiography (CTA) and contrast-enhanced MR angiography (MRA) are the preferred imaging techniques in this setting. CONCLUSION We review the appearance of the normal and complicated surgical and endovascular treatment on CTA and MRA.
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Affiliation(s)
- Ming-Chen Paul Shih
- Division of Noninvasive Cardiovascular Imaging, University of Virginia Health System, 1215 Lee St., PO Box 800170, Charlottesville, VA 22908, USA
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Abstract
OBJECTIVE CT angiography and MR angiography are the main techniques for the noninvasive diagnosis of mesenteric ischemia. High clinical suspicion and knowledge of the differential diagnostic possibilities in this clinical setting are essential for the correct interpretation of the scans. CONCLUSION CT angiography and MR angiography are well suited for the workup of patients when mesenteric ischemia is suspected.
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Affiliation(s)
- Ming-Chen Paul Shih
- Division of Non-invasive Cardiovascular Imaging, Department of Radiology, University of Virginia Health System, 1215 Lee St., PO Box 800170, Charlottesville, VA 22908, USA
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Affiliation(s)
- Elizabeth A McGuigan
- Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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Lauenstein TC, Ajaj W, Narin B, Göhde SC, Kröger K, Debatin JF, Rühm SG. MR imaging of apparent small-bowel perfusion for diagnosing mesenteric ischemia: feasibility study. Radiology 2004; 234:569-75. [PMID: 15601890 DOI: 10.1148/radiol.2342031002] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The purpose of this study, which was approved by the institutional review board, was to assess the differentiation of individuals with from those without mesenteric ischemia. All subjects provided written informed consent. Six healthy volunteers and six patients with documented chronic mesenteric ischemia underwent magnetic resonance (MR) imaging with and without oral caloric stimulation. After intravenous administration of paramagnetic contrast material, signal intensity values of the small-bowel wall were measured up to 130 seconds after contrast material injection. Volunteers and patients, respectively, had maximum enhancement of the bowel wall between 70 and 85 seconds after contrast material administration that amounted to 269% and 267% without and 425% and 333% with caloric stimulation. MR imaging assessment of small-bowel perfusion is possible and seems feasible for differentiating individuals with from those without mesenteric ischemia.
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Affiliation(s)
- Thomas C Lauenstein
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, Hufelandstrasse 55, D-45122 Essen, Germany.
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Abstract
BACKGROUND Atherosclerotic disease of the peripheral vasculature is a prevalent condition for which catheter-based techniques have been considered to be the gold standard for diagnosis. However, because of their invasive nature, these techniques inherently have the potential for complications. Non-invasive diagnostic techniques have historically been limited by low accuracy and high operator dependence. Magnetic resonance angiography (MRA) is a new approach that has diagnostic accuracy comparable with invasive angiography. METHODS The literature on MRA for evaluation of carotid, mesenteric, renal, and lower-extremity arterial disease was extensively reviewed. Helpful diagnostic algorithms on the basis of the literature are also provided. RESULTS MRA is both sensitive and specific when compared with invasive angiography for the evaluation of peripheral arterial disease and avoids the potential for complications resulting from arterial puncture and use of iodinated contrast. CONCLUSION Current MRA techniques are diagnostically robust and have proven to be a highly accurate, safe, and convenient means of diagnosing atherosclerotic disease of the peripheral vascular system.
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Affiliation(s)
- Eric G Auerbach
- Oklahoma Heart Institute, University of Oklahoma, Tulsa, Okla 74133, USA
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