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Intestinal Infarction

Intestinal infarction is a medical emergency entailing an ischemic event of the bowel, due to a restriction or obstruction of the blood flow to the organ. It is not a common medical occurrence, but can profoundly endanger the life of an individual.


Presentation

Intestinal infarction usually affects elderly individuals, with an average age of occurrence in the 6th-7th decade of life. Although symptomatology directs the physician towards a severe pathology, the symptoms elicited are not specific for intestinal infarction.

The predominant and profound symptom reported by the vast majority of the patients (94%) is that of intense and constant abdominal pain disproportionate in severity in comparison to the objective findings on a physical exam [1]. Additional symptoms that complete the clinical picture also include nausea, episodes of diarrhea, tachycardia, and vomiting. In a more advanced stage, the ischemic occurrence leads to necrosis of the intestine, sepsis, and peritonitis; symptoms also include hypotension, a distended, painful abdomen, rigidity and guarding [2] [3] [4] [5]. Progression of the ischemia is transmural [6].

Fever
  • Abstract A patient with paroxysmal nocturnal hemoglobinuria of 14 years duration presented with severe abdominal pain and fever.[ncbi.nlm.nih.gov]
  • Symptoms of intestinal infarction are abdominal pain, fever, nausea, and vomiting.[sweeneylawfirm.com]
  • Severe systemic illness with fever and sepsis (spread of infection to the blood stream) can result. Calling your health care provider Call your health care provider if you have any severe abdominal pain.[webmd.com]
  • Some people may become severely ill with fever and a bloodstream infection ( sepsis ). Call your health care provider if you have any severe abdominal pain.[medlineplus.gov]
  • Other symptoms include: Diarrhea Fever Vomiting Laboratory tests may show a high white blood cell (WBC) count (a marker of infection) and increased acid in the bloodstream.[lutheranhealthcare.org]
Coronary Artery Disease
  • It’s a common cause of IC among people who have a history of coronary artery disease or peripheral vascular disease . A blood clot can also block the mesenteric arteries and stop or reduce blood flow.[healthline.com]
  • Causes of Acute Mesenteric Ischemia Occlusion Type Risk Factors Arterial embolus ( 40%) Coronary artery disease , heart failure , valvular heart disease , atrial fibrillation , history of arterial emboli Arterial thrombosis (30%) Generalized atherosclerosis[merckmanuals.com]
  • If you've had other conditions caused by atherosclerosis, such as decreased blood flow to your heart (coronary artery disease), legs (peripheral vascular disease) or the arteries serving your brain (carotid artery disease), you have an increased risk[mayoclinic.org]
Abdominal Pain
  • Abstract A patient with paroxysmal nocturnal hemoglobinuria of 14 years duration presented with severe abdominal pain and fever.[ncbi.nlm.nih.gov]
  • For all the cases with acute abdominal pain, the possibility of thrombophlebitis should be considered as a differential diagnosis.[ncbi.nlm.nih.gov]
  • The ischemic necrosis of the intestine preceded by recurrent abdominal pain was due to an aneurysmal occlusion of superior mesenteric artery, but not entero-Behçet's disease.[ncbi.nlm.nih.gov]
  • Abstract A 57-year-old woman presented with classical symptoms of Henoch-Schönlein purpura including arthralgia, abdominal pain, palpable purpuric rash and abnormalities of the urinary sediments.[ncbi.nlm.nih.gov]
Vomiting
  • Additional symptoms that complete the clinical picture also include nausea, episodes of diarrhea, tachycardia, and vomiting.[symptoma.com]
  • Abstract A 40-year-old HIV-infected woman developed nausea, vomiting, and epigastric pain and died following her third dose (per study protocol) of interleukin (IL)-2. Her HIV infection was diagnosed in 1996.[ncbi.nlm.nih.gov]
  • Symptoms of intestinal infarction are abdominal pain, fever, nausea, and vomiting.[sweeneylawfirm.com]
  • Vomiting , diarrhea , and in some cases, fever, are also seen. Signs and tests Laboratory tests may show an elevated white blood cell (WBC) count (a marker of infection) and increased acid in the bloodstream.[webmd.com]
  • Стр. 72 - Anorexia Vomiting generally occurs in the early stages of the attack, but usually a few hours after the initial pain. Many patients do not vomit, but instead have a sensation of nausea.[books.google.com]
Severe Abdominal Pain
  • Abstract A patient with paroxysmal nocturnal hemoglobinuria of 14 years duration presented with severe abdominal pain and fever.[ncbi.nlm.nih.gov]
  • Calling your health care provider Call your health care provider if you have any severe abdominal pain. Prevention Eating a nutritious diet and avoiding smoking can help prevent this disease.[webmd.com]
  • Call your health care provider if you have any severe abdominal pain.[medlineplus.gov]
  • Call your health care provider if you have any severe abdominal pain. Intestinal infarction may require a colostomy or ileostomy, either temporary or permanent. Peritonitis is common in such cases.[lutheranhealthcare.org]
  • When to Contact a Medical Professional Call your health care provider if you have any severe abdominal pain.[limamemorial.org]
Nausea
  • Additional symptoms that complete the clinical picture also include nausea, episodes of diarrhea, tachycardia, and vomiting.[symptoma.com]
  • Abstract A 40-year-old HIV-infected woman developed nausea, vomiting, and epigastric pain and died following her third dose (per study protocol) of interleukin (IL)-2. Her HIV infection was diagnosed in 1996.[ncbi.nlm.nih.gov]
  • Symptoms of intestinal infarction are abdominal pain, fever, nausea, and vomiting.[sweeneylawfirm.com]
  • The degree of nausea and the frequency of... ‎ Стр. 22 - ... the common mesentery.[books.google.com]
  • However, signs of an acute abdomen with distension, guarding (rigidity), and hypotension may also occur, particularly when diagnosis has been delayed. 1 Fever, diarrhoea, nausea, and anorexia are all commonly reported.[doi.org]
Acute Abdomen
  • This paper documents the first reported case of fatal intestinal infarction in a 49 year old woman with systemic oxalosis and advocates its consideration in the differential diagnosis of an acute abdomen in such patients.[ncbi.nlm.nih.gov]
  • This case also serves to remind physicians that there should always be a high level of suspicion of intestinal infarction in patients with an acute abdomen who are in a hypercoagulable state. Copyright 2009 S. Karger AG, Basel.[ncbi.nlm.nih.gov]
  • abdomen in the tropics -- Diseases that may simulate the acute abdomen -- Acute abdominal pain in the immunocompromised patient -- Abdominal catastrophes when sensation in impaired.[worldcat.org]
  • Four weeks after recommencing haemodialysis she developed an acute abdomen and an urgent laparotomy was performed, which showed extensive infarction of the small intestine with three separate perforations.[jcp.bmj.com]
  • However, signs of an acute abdomen with distension, guarding (rigidity), and hypotension may also occur, particularly when diagnosis has been delayed. 1 Fever, diarrhoea, nausea, and anorexia are all commonly reported.[doi.org]
Chronic Hypotension
  • The infarction was most likely caused by decreased splanchnic perfusion secondary to the chronic hypotension of the nephrotic syndrome and to amyloid deposition within the walls of the small blood vessels supplying the gut.[ncbi.nlm.nih.gov]

Workup

A detailed medical history is certainly the first step towards reaching a diagnosis of intestinal infarction. Intense, persistent pain disproportionate in severity compared to the physical exam is the hallmark of the condition. Nausea, tachycardia, vomiting and diarrhea may complete the clinical picture; signs of peritoneal irritation may also be present if intestinal infarction has already been complicated by gangrenous peritonitis. Peritoneal signs also include abdominal rigidity, a positive rebound sign, hypotension, guarding and a considerable distention in the abdomen.

With regard to laboratory findings, most patients display the following, although recent studies have shown that none of them can be relied upon for a definitive diagnosis [7]:

  • Leucocytosis [6]: white cell blood count typically amounts to over 20 x 109/L in the serum. This finding is solely used as an inflammation indicator since it is exhibited in the vast majority of inflammatory processes [8] [9].
  • Acid-base imbalance [10]: although patients are expected to exhibit metabolic acidosis, metabolic alkalosis is sometimes diagnosed, due to vomiting during the initial stages of the disease.
  • Increased D-dimer serum levels, which also cannot be considered pathognomonic for intestinal infarction [11].
  • Increased L-lactate levels

An extremely valuable tool for the definitive diagnosis of intestinal infarction is mesenteric angiography, due to its indisputable accuracy, efficacy and potential to increase the survival rate it is considered as a gold standard [12] [13]. Currently, another imaging modality, computed tomography angiography (CTA) has effectively replaced mesenteric angiography in the diagnosis of intestinal infarction, as it is less invasive and has a specificity and sensitivity of 94% and 96% respectively [14] [15].

Pneumoperitoneum
  • Prolonged pneumoperitoneum at 15 mmHg causes lactic acidosis. Surg Endosc 1998;12:198–201. CrossRef PubMed Google Scholar 43. Windsor MA, Bonham MJ, Rumball M. Splanchnic mucosal ischemia. an unrecognized consequence of routine pneumoperitoneum.[doi.org]
  • […] portalis : gas in the portal vein or in mesenteric vein can be differentiated by pneumobilia because gas usually reaches the periphery of the liver while pneumobilia is usually about 2 cm short of external liver border, and is more clustered at the hilum pneumoperitoneum[radiopaedia.org]
Nephrolithiasis
  • Abstract Primary hyperoxaluria is a rare genetic disorder characterised by calcium oxalate nephrolithiasis and nephrocalcinosis leading to renal failure, often with extra-renal oxalate deposition (systemic oxalosis).[ncbi.nlm.nih.gov]
  • The disorder is characterised by recurrent calcium oxalate nephrolithiasis and nephrocalcinosis, frequently leading to renal failure and death before the age of 20 years.[jcp.bmj.com]
Colitis
  • Ischemic colitis, enteritis, or enterocolitis NOS ICD-9-CM Volume 2 Index entries containing back-references to 557.9 :[icd9data.com]
  • This review aims to help clinicians to understand the features and management of acute and chronic mesenteric ischaemia, mesenteric venous thrombosis, and ischaemic colitis.[doi.org]
  • For ischemia of the large bowel, see ischemic colitis.[en.wikipedia.org]
  • Ischaemic colitis (colonic ischaemia).[patient.info]
  • Definition Intestinal ischemia is classified into three main types: Ischemic colitis ( colonic ischemia ) : hypoperfusion of the large bowel, which is mostly transient and self-limiting ( non-gangrenous form ), but can also lead to severe acute ischemia[amboss.com]

Treatment
  • The treatment should be directed towards the conditions causing intestinal ischaemia.[ncbi.nlm.nih.gov]
  • The patient had acute abdominal pain with tenderness and melena on the 3rd day after appendectomy for the treatment of gangrenous appendicitis.[ncbi.nlm.nih.gov]
  • Symptoms resolved following treatment with prednisolone and cyclophosphamide, and replacement of the aortic valve. The sub-total occlusion produced by endarteritis obliterans may lead to acute end-organ infarction if cardiac output is reduced.[ncbi.nlm.nih.gov]
  • Treatment is described in detail. European adder bites may cause, although uncommonly, severe envenoming with unusual symptoms. The attending doctor must be prepared to face unusual diagnostic and therapeutic problems.[ncbi.nlm.nih.gov]
  • Detection and diagnosis may be obscured and treatment complicated by immunosuppression after cardiac transplantation.[ncbi.nlm.nih.gov]

Prognosis
  • Two models were constructed with/without the cause of intestinal obstruction as a variable, since it might affect the prognosis.[ncbi.nlm.nih.gov]
  • Five patients with favorable cerebral prognosis underwent surgery: one survived with good cerebral and gastrointestinal recovery. Four patients did not have surgery because of a poor cerebral prognosis.[ncbi.nlm.nih.gov]
  • Because of the poor prognosis without appropriate management, a high level of suspicion, early and aggressive diagnostic measures, and swift surgical intervention are essential to survival.[ncbi.nlm.nih.gov]
  • The prognosis of intestinal infarction is still ominous. Our mortality rate is 68%. Both clinical and laboratory data are non-specific and delayed diagnosis is the main cause of this mortality rate.[ncbi.nlm.nih.gov]
  • Intestinal infarction needs to be treated promptly to improve prognosis as it carries with it a very high chance of infection to organs, fluids, and cells surrounding the necrotic gut tissue.[sweeneylawfirm.com]

Etiology
  • Representative intestinal sections were studied from 10 patients with NOMI of the small and/or large bowel and 12 patients, with OMI of varied etiology.[ncbi.nlm.nih.gov]
  • Recent changes in the etiology of this disease have not been examined. A retrospective review of 121 consecutive patients over a 6-year period was undertaken.[jhu.pure.elsevier.com]
  • Pathophysiology Intestinal blood flow of the superior mesenteric artery (SMA) and/or inferior mesenteric artery (IMA) is suddenly compromised (see “Etiology” for causes) intestinal hypoxia intestinal wall damage mucosal inflammation possibly bleeding[amboss.com]
  • Consistent format for all diseases entries walks readers through each step of patient care and treatment, including: Description Symptoms and Signs Patient Screening Etiology Diagnosis Treatment Prognosis Prevention Patient Teaching Pharmacology appendix[books.google.ro]
  • Pathogenesis Etiology Inflammation and damage to the blood supply to the large bowel. This may be due to larval strongyle migration, hence 'Verminous Arteritis'. Predisposing factors General Strongyle infestation.[vetstream.com]

Epidemiology
  • Epidemiology The incidence of ischaemic colitis has risen from 6.1 cases/100 000 person-years in 1976-80 to 22.9/100 000 in 2005-09 [ 5 ]. Many mild cases may go unreported.[patient.info]
  • […] flow to the small intestine (arterial or venous) that can result in bowel infarction Chronic mesenteric ischemia : constant or episodic hypoperfusion of the small intestine, usually due to atherosclerosis References: [1] [2] [3] [4] Ischemic colitis Epidemiology[amboss.com]
  • Acosta S: Epidemiology of mesenteric vascular disease: clinical implications. Semin Vasc Surg 2010; 23: 4–8. CrossRef MEDLINE 2. Kortmann B, Klar E: Warum wird die mesenteriale Ischämie zu spät erkannt? Zentralbl Chir 2005; 130: 223–6.[doi.org]
  • Infarction of omentum and epiploic appendage: diagnosis, epidemiology and natural history. Eur Radiol 1999 ; 9:1886-1892. Crossref , Medline , Google Scholar 19 Lane MJ, Katz DS, Ross BA, Clautice-Engle TL, Mindelzun RE, Jeffrey RB, Jr.[doi.org]
  • Stefan Acosta, Maria Wadman, Ingvar Syk, Sölve Elmståhl and Olle Ekberg , Epidemiology and Prognostic Factors in Acute Superior Mesenteric Artery Occlusion , Journal of Gastrointestinal Surgery , 10.1007/s11605-009-1130-1 , 14 , 4 , (628-635) , (2010)[doi.org]
Sex distribution
Age distribution

Pathophysiology
  • The clinical history and microscopic findings are consistent with the hypothesis of a direct action of absorbed iron on vascular walls as the pathophysiologic mechanism for the toxic effects of iron on the gastrointestinal tract.[ncbi.nlm.nih.gov]
  • This article reviews the pathophysiology, clinical features, diagnostic, and therapeutic options applicable to patients with acute intestinal ischemia.[ncbi.nlm.nih.gov]
  • Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management . 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 118. Eslami MH. Acute mesenteric ischemia. In: Cameron JL, Cameron AM, eds.[medlineplus.gov]
  • Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 118. Eslami MH. Acute mesenteric ischemia. In: Cameron JL, Cameron AM, eds.[limamemorial.org]
  • Accepted 15 May 2003 Although intestinal ischaemia is an infrequent event, early recognition and appropriate treatment can reduce the potential for a devastating outcome Introduction Acute or chronic abdominal pain can be the result of many different pathophysiological[doi.org]

Prevention
  • Although amyloidosis was suspected prior to death, a fixation artifact probably prevented the correct antemortem biopsy diagnosis.[ncbi.nlm.nih.gov]
  • BACKGROUND/AIMS: In patients with acute mesenteric ischemia, early diagnosis is considered to improve the prognosis by preventing the occurrence of systemic inflammatory response syndrome (SIRS).[ncbi.nlm.nih.gov]
  • Prevention Eating a nutritious diet and avoiding smoking can help prevent this disease. Prompt treatment of hernias and control of risk factors such as heart arrhythmias, high blood pressure , and cholesterol may also help.[webmd.com]
  • Prevention Preventive measures include: Controlling risk factors, such as irregular heartbeat, high blood pressure, and high cholesterol Not smoking Eating a nutritious diet Quickly treating hernias References Brandt LJ, Feuerstadt P.[limamemorial.org]
  • Preventive measures include: Controlling risk factors, such as irregular heartbeat, high blood pressure, and high cholesterol Not smoking Eating a nutritious diet Quickly treating hernias Intestinal necrosis; Ischemic bowel - small intestine; Dead bowel[medlineplus.gov]

References

Article

  1. Gore RM, Yaghmai V, Thakrar KH, et al. Imaging in Intestinal Ischemic Disorders. Radiologic Clinics of North America. 2008;46(5):845–875.
  2. Paterno F, Longo WE. The etiology and pathogenesis of vascular disorders of the intestine. Radiol Clin North Am. 2008;46(5):877–85. Sep.
  3. Brandt LJ, Feldman M, Friedman LS, Brandt LJ. Gastrointestinal and liver disease. 8. Philadelphia: Saunders; 2006. Intestinal ischemia; pp. 2563–88.
  4. Yasuhara H. Acute mesenteric ischemia: the challenge of gastroenterology. Surgery today. 2005;35(3):185–95.
  5. Martinez JP, Hogan GJ. Mesenteric ischemia. Emerg Med Clin North Am. 2004;22:909–28.
  6. Oldenburg WA, Lau LL, Rodenberg TJ, et al. Acute mesenteric ischemia: a clinical review. Arch Intern Med. 2004;164:1054–1062
  7. Thuijls G, van Wijck K, Grootjans J, et al. Early diagnosis of intestinal ischemia using urinary and plasma fatty acid binding proteins. Ann Surg. 2011;253:303–308.
  8. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology. 2000;118:954–968
  9. Block T, Nilsson TK, Björck M, Acosta S. Diagnostic accuracy of plasma biomarkers for intestinal ischaemia. Scand J Clin Lab Invest. 2008;68:242–248.
  10. Sise MJ. Mesenteric ischemia: the whole spectrum. Scand J Surg. 2010;99:106–110
  11. Acosta S, Björck M. Acute thrombo-embolic occlusion of the superior mesenteric artery: a prospective study in a well defined population. Eur J Vasc Endovasc Surg. 2003;26:179–183
  12. Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology. 2000;118:954–968
  13. Clark RA, Gallant TE. Acute mesenteric ischemia: angiographic spectrum. AJR Am J Roentgenol. 1984;142:555–562.
  14. Kirkpatrick ID, Kroeker MA, Greenberg HM. Biphasic CT with mesenteric CT angiography in the evaluation of acute mesenteric ischemia: initial experience. Radiology. 2003;229:91–98
  15. Wyers MC. Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010;23:9–20.

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Last updated: 2017-08-09 14:18