Chronic Mesenteric Ischaemia

Question 1

What is CMI caused by?

Answer 1

Reduced blood supply to the bowel as a result of atherosclerosis in the coeliac trunk, SMA and or IMA

Question 2

Epidemiology

Answer 2

In those >60y

F>M

Question 3

Pathophysiology

Answer 3

Gradual build-up of an atherosclerotic plaque

This leads to narrowing of mesenteric vessels and impairing the blood flow.

There is usually collateral blood supply which means that at least two of the coelic, SMA and IMA need to be affected to be symptomatic.

At rest patients are usually asymptomatic, but an increase in demand of blood supply like after eating, severe haemorrhage etc… will exacerbate symptoms.

Question 4

Risk factors

Answer 4

Smoking

HTN

DM

Hypercholesterolaemia

Question 5

Clinical features

Answer 5

Postprandial pain 10min-4h after eating and they may even develop fear of eating

Weight loss due to less calorie intake and malabsorption

Concurrent vascular co-morbidities like previous MI, strok or PVD

Change in bowel habits (loose), nausea and vomiting can also occur

Question 6

Examination findings

Answer 6

Often non specific

Malnutrition/cachexia

Generalised abdominal tenderenss

Abdo bruits

Question 7

Dx

Answer 7

Chronic pancreatitis

Gallstone pathology

Peptic ulcer disease

Upper GI malignancy

Question 8

Lab tests

Answer 8

Routine bloods which usually are normal

Magnesium and calcium should be checked for malnutrition

Lipids, blood glucose and haemoglobin count might be abnormal

Question 9

What is the diagnostic test?

Answer 9

CT angiography is providing a good anatomical view of all vessels.

Question 10

Initial management

Answer 10

Modify risk factors

Smoking

Commence anti-platelet threapy + statin therapy

Question 11

Which surgical approaches are avaiable

Answer 11

Endovascular

Open

Question 12

Which approach is generally preferred?

Answer 12

Endovascular as open can be coplex

Also due to the nutritional status of the patient endovascular might be preferred

Question 13

Indications of surgical intervention

Answer 13

Severe disease

Progressive disease

Presence of debilitating symptoms (weight loss malnutrition)

Question 14

Explain endovascular repair

Answer 14

Mesenteric angioplasty with stenting

Question 15

Explain open repair

Answer 15

Endartectomy or bypass

Question 16

Explain mesenteric angioplasty

Answer 16

Percutaneously done through femoral or brachial/axillary artery.

This allows a catheter to be passed through the appropriate vessel under radiological guidance.

A small balloon is expanded to dilate the vessel and stenting is done.

Question 17

Complications

Answer 17

Infarction

Malabsorption