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Treatment of Mesenteric Ischemia

Surgery, Revascularization with Bypass, and Anticoagulation

Jul 20, 2009 David Henry

Mesenteric ischemia is a potentially fatal condition in which the intestines and the surrounding fat do not receive enough blood and oxygen.

The Treatment of acute and chronic arterial and venous mesenteric ischemia are discussed below. Other articles discuss the Pathophysiology, Causes, and Effects of mesenteric ischemia and the Symptoms, Diagnosis, and Outcomes.

Overview of Treatment Options for Clotting Disorders

Mesenteric ischemia occurs when the arteries going to the intestines or veins coming from the intestines become blocked, either acutely or chronically. Infarcted (dead) intestines should be removed surgically. Heparin and warfarin are anticoagulants that thin the blood and prevent blood clots. “Thrombolytics,” like streptokinase, urokinase, and tissue plasminogen activator (tPA) break up clots that are already formed. If a blood vessel is blocked, a surgeon can use a vein or a synthetic graft to divert blood around the blocked segment; this is called a “bypass.” Finally, and “endarterectomy” can be performed, in which a surgeon opens up a blood vessel, removes the plaque, and sutures the blood vessel back together. Below, specific treatment options for the different types of mesenteric ischemia are discussed.

Treatment of Mesenteric Ischemia

Peritonitis

If signs of peritonitis are present, which can occur if the bowel infarcts and perforates, then emergent surgery (laparotomy) should be performed. Infarcted intestines should be resected.

Acute Mesenteric Ischemia: Embolus or Thrombus

If an embolus or thrombus (clot) is responsible for the acute mesenteric ischemia, then blood flow should be restored using surgery or medications. The clot can be removed surgically (embolectomy or thrombectomy), or the blocked blood vessel can be bypassed. Medications such as streptokinase, urokinase, and tPA are also effective at breaking up smaller clots within the blood vessels if initiated within 12 hours after symptoms begin.

Nonocclusive Mesenteric Ischemia (Vasospasm)

The treatment for nonocclusive mesenteric ischemia (vasospasm) is to give a vasodilator medication, mostly commonly papaverine hydrochloride. If peritonitis develops, a laparotomy (surgery) should be performed.

Acute Mesenteric Venous Thrombosis

The treatment for acute mesenteric venous thrombosis is intravenous heparin, an anticoagulant that helps to prevent clots. Warfarin, another anticoagulant, should be taken for 6-12 months.

Chronic Arterial Mesenteric Ischemia

The cause of chronic arterial mesenteric ischemia is usually atherosclerosis (narrowing of the blood vessels by plaques). The blocked portions can be bypassed surgically, or the plaque can be removed in the operating room. A stent can also be placed endovascularly (without surgery) to hold the blood vessel open and to prevent further narrowing.

Chronic Venous Mesenteric Thrombosis

If a clotting disorder is present, the patient should be treated with anticoagulation (heparin and/or warfarin). Blood can be diverted around the narrowed segment of the vein using a “portosystemic shunt.” This diverts blood between parts of the portal vein and the inferior vena cava.

References

Acute mesenteric ischemia. Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 8th ed. Saunders, 2006.

Chapter 27: Small intestine. Brunicardi C et al., Eds. Schwartz’s Principles of Surgery. 4th ed. McGraw-Hill, 2005.

eMedicine (Surgery): Mesenteric Artery Ischemia

Levy, Angela D. Mesenteric ischemia. Radiologic Clinics of North America 2007. 45:593-9.

Vascular Web: Mesenteric Ischemia

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