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Case 19

Chronic mesenteric ischaemia

61 year old lady with post prandial abdominal pain

Li Foong Foo

A 61 year old lady presented at the Gastroenterology Clinic with a 4 month history of central abdominal pain which seemed to occur several hours after eating. She described it as very severe, lasting 3-4 hous at a time, with apparent relief by flatulence. There had not been any vomiting or change in bowel habit. Although she felt hungry, she had been scared to eat and as a result had lost one and a half stone in weight.

Prior to this, she had always enjoyed good health. Her only regular medication was hormone replacement therapy. She smoked 12 cigarettes a day and drank moderate amounts of alcohol only.

Except for evidence of recent marked weight loss, her physical examination was unremarkable.

Ultrasound revealed normal liver, gallbladder, pancreas, spleen and kidneys.

What is the likely diagnosis? What investigation would you perform to confirm it?

The history suggests chronic mesenteric ischaemia. Indeed the radiologist performing the ultrasound noted that despite the patient's thin body habitus, he was unable to identify doppler flow in the superior mesenteric artery or coeliac axis.

Aortography was performed. What do these two images from the AP aortogram show? What other projection is normally performed in this situation, and why?

Findings

The arteriogram shows a narrowed infrarenal aorta due to atheroma. There are two left renal arteries. The right renal artery shows moderate stenosis. No filling is seen of the coeliac axis or superior mesenteric artery (SMA). The inferior mesenteric artery (IMA) arises at L3, above the bifurcation, and is hypertrophic. On the later image, the distal branches of the SMA are seen to fill via collateralisation from the IMA. A blush of small collaterals are also seen in the region of the porta hepatis.

The lateral projection was also performed. confirming occlusion of the coeliac and SMA origins. This projection is important in the investigation of mesenteric ischaemia because stenoses or short occlusions of these vessels may be obscured by contrast in the underlying aorta on the AP view.

Diagnosis

Chronic mesenteric ischaemia or abdominal angina resulting from occlusion of coeliac axis and superior mesenteric artery.

Discussion

Ischaemia of the intestine results from the interruption or reduction of its blood supply. The clinical manifestation depends on the vascular supply involved (eg. arteial vs venous), the extent of the occlusion or ischaemia, (eg. maintrunk or branches of coeliac, superior or inferior mesenteric artery) and rapidity of the process (ie. acute or chronic).

Its aetiology ranges from atheromatous disease, embolic disease, dissecting aortic aneurysm, fibromuscular hyperplasia, vasculitis, endotoxic shock, hypoperfusion (shock, hypovolaemia, cardiac failure, arrhythmia), disseminated intravascular coagulation, direct trauma.

Abdominal angina results from intermittent mesenteric ischaemia in severe arterial stenosis with inadequate collateralisation provoked by food ingestion. It is most commonly caused by atherosclerosis of coeliac and superior mesenteric arteries, and symptoms are unlikely unless at least two vessels are involved. The patient typically complains of intermittent dull or crampy mid abdominal pain 15-30 minutes after a meal, lasting hours postprandially. Significant weight loss usually results from decreased food intake. Chronic mesenteric arterial insufficiency may however produce mucosal damage and malabsorption, which may contribute to weight loss.

Patients with abdominal angina are at risk of acute mesenteric ischaemia/infarction, whcih may be precipitated by thrombosis or an embolic event at an atherosclerotic site (occlusive), or a systemic low flow state (non-occlusive).

Angiography remians the investigation of choice to confirm the diagnosis and assess the extent of disease. Traditional therapy involves surgical revascularisation, although in stenotic disease and some short occlusions (not this case however) angioplasty and vascular stenting are developing a role.

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