Acute Mesenteric Infarction

The management of mesenteric ischemia is complicated by diagnostic delays that are often associated with a fatal outcome. An aggressive approach is necessary, as early diagnosis markedly improves the chances of survival.20 The key to making the correct diagnosis is to consider this possibility in the elderly patient with abdominal pain and risk factors for the disease. Superior mesenteric artery occlusion accounts for roughly half of the cases, with embolus and thrombus nearly equal as the source. Nonocclusive infarction accounts for another quarter of the cases, with inferior mesenteric artery occlusion, venous thrombosis, arteritis, and dissection making up the remainder.21

The specific risk factors to be aware of are listed in Table.M69:2.. The principal manifestation of mesenteric infarction is severe abdominal pain, often refractory to narcotic analgesics. Such severe pain combined with a relatively normal abdominal examination is considered the sine qua non of early mesenteric infarction. Despite its vascular nature, the overall spectrum of mesenteric ischemia involves a gradual onset of abdominal pain. If an embolus is the cause, sudden, severe pain may be reported.20 Prior episodes can be reported, particularly if mesenteric arterial thrombosis is the cause. Associated gastrointestinal symptoms are very common and should not lead the physician astray. Nausea, anorexia, and vomiting are common, and up to half of these patients will report diarrhea. Objective findings on physical examination are inevitable and should be considered an indication of intestinal necrosis and possible perforation. Theoretically, the stool should be guaiac-negative early on. Approximately 60 percent will present with guaiac-positive stools.21 Laboratory abnormalities such as metabolic acidosis and extreme leukocytosis are likewise indicators of advanced, perhaps irreversible disease.

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