What are the symptoms of mesenteric ischemia?

Symptoms of Mesenteric Ischemia

The hallmark symptom of mesenteric ischemia is severe abdominal pain out of proportion to physical examination findings, which should be assumed to be mesenteric ischemia until proven otherwise. 1

Key Clinical Presentations

Acute Mesenteric Ischemia

• Severe abdominal pain that is disproportionate to physical examination findings (classic presentation) 1
• Nausea (44% of patients) 1
• Vomiting (35% of patients) 1
• Diarrhea (35% of patients) 1
• Blood per rectum (16% of patients) 1
• Approximately one-third of patients present with the triad of abdominal pain, fever, and hemocult-positive stools 1
• In advanced stages, patients may present with signs of peritonitis indicating irreversible intestinal ischemia with bowel necrosis 1
• Some patients, particularly those with delayed diagnosis, may present in extremis with septic shock 1

Symptoms Based on Etiology

Mesenteric Arterial Embolism

• Sudden onset of severe abdominal pain 1
• Often occurs in patients with atrial fibrillation (present in nearly 50% of cases) 1
• Approximately one-third of patients have a prior history of arterial embolus 1

Mesenteric Arterial Thrombosis

• History of chronic postprandial abdominal pain 1
• Progressive weight loss over time 1
• May have previous revascularization procedures for mesenteric arterial occlusion 1

Non-Occlusive Mesenteric Ischemia (NOMI)

• More diffuse and episodic abdominal pain 1
• Associated with poor cardiac performance 1
• More likely to occur in patients with cardiac failure and recent surgery 1
• May represent a cause of secondary worsening in septic shock, particularly in patients treated with high-dose vasoactive drugs 1

Mesenteric Venous Thrombosis

• Mixture of nausea, vomiting, diarrhea, and abdominal cramping 1
• Gastrointestinal bleeding occurs in approximately 10% of cases 1

Laboratory and Imaging Findings

• No laboratory parameters are sufficiently accurate to conclusively identify mesenteric ischemia 1
• Leukocytosis is present in more than 90% of patients 1
• Metabolic acidosis with elevated lactate levels occurs in 88% of cases 1
• Elevated serum lactate levels > 2 mmol/l are associated with irreversible intestinal ischemia 1
• Plain radiographs have limited diagnostic value and should not be relied upon 1
• Radiographic findings are usually nonspecific, late, and associated with a high mortality rate 1
• CT angiography (CTA) of the abdomen and pelvis is the preferred diagnostic imaging modality 1

Clinical Pitfalls and Important Considerations

• Clinical signs of peritonitis may be subtle, requiring a high index of suspicion 1
• Early diagnosis is crucial as mortality rates range between 30% to 90% in acute settings 1
• The incidence of mesenteric ischemia increases exponentially with age, with an 80-year-old having approximately tenfold the risk of a 60-year-old 1, 2
• In patients aged 75 years or older, acute mesenteric ischemia is a more prevalent cause of acute abdomen than appendicitis 1, 2
• The main challenge is differentiating acute mesenteric ischemia from other more common causes of acute abdominal pain, such as appendicitis, diverticulitis, peptic ulcer disease, acute pancreatitis, gastroenterocolitis, nephrolithiasis, cholelithiasis, and cholecystitis 1
• Laboratory findings early in the course of disease are of little value in differentiating mesenteric ischemia from other causes of abdominal pain 1

Warning Signs Requiring Immediate Attention

• Abdominal pain out of proportion to physical examination 1
• Presence of lactic acidosis in combination with abdominal pain when the patient may not otherwise appear clinically ill 1
• Signs of peritonitis indicating possible bowel infarction 1
• Rapid clinical deterioration or development of septic shock 1