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MESENTERIC ANGINA

Introduction:

Mesenteric angina is an uncommon condition, which is underdiagnosed, or diagnosed too late when the patient has a mesenteric infarct. Mesenteric angina is also known as chronic mesenteric ischaemia or intestinal angina. The incidence has increased significantly due to the increasing number of elderly patients with atherosclerotic disease.

The mechanism is believed to be similar to the angina pectoris in coronary artery disease or the intermittent claudication in peripheral vascular disease.

Pathophysiology:

Abdominal angina results from intermittent mesenteric ischaemia in severe arterial stenosis with inadequate collateralisation provoked by food ingestion. Ischaemia of the intestine results from the interruption or reduction of its blood supply. The clinical manifestation depends on the vascular supply involved, 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).

Age:

The mean age of affected individuals is slightly older than 60 years.

It is strongly associated with the presence of coronary artery disease or other vascular diseases.

Risk factor:

Smoking is an associated risk factor.

Sub groups:

Mesenteric ischemia could be acute or chronic.
Acute mesenteric ischemia is a surgical emergency.
Chronic mesenteric ischemia typically presents with a more benign process.

Main complain:

Patients with mesenteric ischemia complain of postprandial colicky abdominal pain, typically starting 20-30 minutes after meal that may last up to 60-90 minutes. The pain gradually increases in intensity then slowly decreases in intensity.
The pain can become so severe that the patient may develop a fear of eating leading to weight loss.
Patients may complain diarrhea or constipation.

Past history:

Past medical history may reveal of atherosclerotic disease such as MI, stroke, or peripheral vascular disease.

Examination:

On physical examination, auscultation of the abdomen may reveal a bruit.

Occult testing of stool may be positive because of the sloughing of dead ischemic bowel.

Once a diagnosis of acute mesenteric ischemia is confirmed, the patient should undergo surgery because of the risk of weight loss, pain, bowel infarction, and possible death.

Investigations:

  • Prothrombin time (PT)

  • Activated partial thromboplastin time (APTT)

  • Complete blood cell count (reveal a leukocytosis and/or hemoconcentration)

  • Chemistries that may show acidosis, increased amylase, or increased
  • lactate dehydrogenase (LDH)

  • If a hypercoagulable state is suspected, additional laboratory studies such as tests for protein C and S deficiencies and antithrombin III deficiency can be sent.
  • Imaging Studies:

  • Chest radiograph.

  • Abdominal x-ray

  • produce a presumptive diagnosis in 20-30% of patients.
  • The CT scan of the abdomen

  • Diagnosis in 95%
  • Aortography

  • Angiography remians the investigation of choice to confirm the diagnosis and assess the extent of disease.
    Because arteriography can precipitate an acute ischemia, ensure that the patient is well hydrated.
  • Obtain an ECG.

  • Medical therapy:

  • Nonocclusive mesenteric ischemia is treated medically.

  • vasospastic disease - direct injection of papaverine into the superior mesenteric artery may resolve the vasospasm. If resolution with papaverine occurs, start an infusion of 30-60 mg/h.
  • In hypovolemic condition - fluid resuscitation is required.

  • Start all patients with suspected bowel ischemia on broad-spectrum antibiotics to cover the possibility of bowel necrosis with contamination.
  • Surgical therapy:

  • Transarterial endarterectomy

  • Embolectomy

  • Prosthetic bypass grafting or autogenous vein grafting
  • Patient Education:

    Patients should be counseled to stop smoking.

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    Dr. Chool Liyanapatabendi


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