What is the initial management for a patient with mesenteric arteriosclerosis (mesenteric artherosclerosis) and abdominal pain?

Initial Management of Mesenteric Atherosclerosis with Abdominal Pain

For patients with mesenteric atherosclerosis and abdominal pain, the initial management should include rapid diagnostic imaging with CT angiography followed by endovascular intervention with angioplasty and stent placement as the first-line treatment. 1

Diagnostic Approach

• Triple-phase CT of the abdomen and pelvis (non-contrast, arterial, and portal venous phases) should be performed immediately to identify the underlying cause of ischemia, evaluate for possible bowel complications, and exclude other potential diagnoses of acute abdominal pain 1
• CT findings that should prompt immediate surgical intervention include lack of bowel wall enhancement, free intraperitoneal air, pneumatosis intestinalis, and portal venous gas 1
• Laboratory studies including serum lactate levels should be obtained, although these may not be elevated in early stages of mesenteric ischemia 1
• Patients with abdominal pain, known atherosclerotic disease, right-sided colitis or H. pylori-negative duodenitis should undergo CT angiography immediately to identify symptomatic mesenteric atherosclerotic disease 2

Initial Management Algorithm

For Chronic Mesenteric Ischemia (Atherosclerotic Disease)

• Endovascular therapy with angioplasty and stent placement is the preferred first-line treatment for atherosclerotic mesenteric stenosis, with technical success rates of 85-100% and lower perioperative risks compared to open surgical intervention 3, 4
• Systemic anticoagulation should be initiated promptly but is not a substitute for revascularization 1, 5
• Volume resuscitation and empiric antibiotic therapy should be administered concurrently with planning for definitive treatment 1
• Secondary prevention should include:
  • Platelet antiaggregation with low-dose aspirin or clopidogrel 5
  • Blood pressure control to <140/90 mmHg 5
  • LDL-cholesterol reduction to <1.8 mmol/L, preferably with statins 5, 6
  • Smoking cessation for all smokers 5

For Acute Mesenteric Ischemia (Embolic/Thrombotic)

• Rapid restoration of inline arterial flow to the affected bowel is the primary goal of treatment 1
• For embolic occlusion without signs of bowel infarction:
  • Angiography with aspiration embolectomy is the preferred initial approach 1
  • Transcatheter thrombolysis may be used as an adjunct therapy 1
• For patients with signs of peritonitis or bowel infarction:
  • Immediate surgical intervention is necessary 1
  • Revascularization through endovascular techniques or surgical conduits should be performed during surgery 1

For Non-Occlusive Mesenteric Ischemia

• Angiography with infusion of vasodilator (papaverine) is the treatment of choice, with significantly lower 30-day mortality (65.7%) compared to supportive therapy alone (96.8%) 1
• Time from CT to vasodilator infusion significantly impacts patient survival 1
• Systemic anticoagulation may be considered as adjunctive therapy in the setting of decreased cardiac output with a low flow state 1

Special Considerations

• Patients with mesenteric atherosclerosis often have other manifestations of atherosclerotic disease (71% of cases) 2
• Previous hospitalization for the same complaints is common (78% of cases), indicating that the diagnosis is frequently missed 2
• Body mass index <20 kg/m² is found in 37% of patients with symptomatic mesenteric atherosclerotic disease 2
• Endoscopic findings may include duodenitis (38%) and colitis in the right colon (57%), with all duodenal ulcers testing negative for Helicobacter pylori 2

Pitfalls and Caveats

• Delays in diagnosis and intervention can lead to life-threatening bowel infarction with mortality rates approaching 60% 1, 7
• Anticoagulation should not be administered without a definitive plan for revascularization 1
• As many as 70% of patients may need surgical intervention for bowel resection and/or diversion even after endovascular intervention 1
• Endovascular complications include distal mesenteric embolization, branch perforation, dissection, stent dislodgement, and stent thrombosis 1