WordNet
- a lack of competence; "pointed out the insufficiencies in my report"; "juvenile offenses often reflect an inadequacy in the parents" (同)inadequacy
- (pathology) inability of a bodily part or organ to function normally
- lack of an adequate quantity or number; "the inadequacy of unemployment benefits" (同)inadequacy, deficiency
- of or relating to or having vessels that conduct and circulate fluids; "vascular constriction"; "a vascular bundle"
- of or relating to or located in a mesentery
PrepTutorEJDIC
- 不十分な[点],不足;不適当,不向き
- (血液・樹液などを運ぶ)管の,導管の,血管の
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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2018/01/28 18:39:11」(JST)
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This article is about ischemia of the small bowel. For ischemia of the large bowel, see ischemic colitis.
| Mesenteric ischemia | |
|---|---|
| Synonyms | Mesenteric ischaemia, mesenteric vascular disease |
| Computer tomography (CT) showing dilated loops of small bowel with thickened walls (black arrow), findings characteristic of ischemic bowel due to thrombosis of the superior mesenteric vein. | |
| Specialty | Gastroenterology |
| Symptoms | Acute: sudden severe pain[1] Chronic: abdominal pain after eating, unintentional weight loss, vomiting[2][1] |
| Usual onset | > 60 years old[3] |
| Types | Acute, chronic[1] |
| Risk factors | Atrial fibrillation, heart failure, chronic renal failure, being prone to forming blood clots, previous myocardial infarction[2] |
| Diagnostic method | Angiography, computer tomography[1] |
| Treatment | Stenting, medications to break down the clot, surgery[1][2] |
| Prognosis | ~80% risk of death[3] |
| Frequency | Acute: 5 per 100,000 per year (developed world)[4] Chronic: 1 per 100,000[5] |
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Mesenteric ischemia is a medical condition in which injury of the small intestine occurs due to not enough blood supply.[2] It can come on suddenly, known as acute mesenteric ischemia, or gradually, known as chronic mesenteric ischemia.[1] Acute disease often presents with sudden severe pain.[1] Symptoms may come on more slowly in those with acute on chronic disease.[2] Signs and symptoms of chronic disease include abdominal pain after eating, unintentional weight loss, vomiting, and being afraid of eating.[1][2]
Risk factors include atrial fibrillation, heart failure, chronic renal failure, being prone to forming blood clots, and previous myocardial infarction.[2] There are four mechanisms by which poor blood flow occurs: a blood clot from elsewhere getting lodged in an artery, a new blood clot forming in an artery, a blood clot forming in the superior mesenteric vein, and insufficient blood flow due to low blood pressure or spasms of arteries.[3][6] Chronic disease is a risk factor for acute disease.[7] The best method of diagnosis is angiography, with computer tomography (CT) being used when that is not available.[1]
Treatment of acute ischemia may include stenting or medications to break down the clot provided at the site of obstruction by interventional radiology.[1] Open surgery may also be used to remove or bypass the obstruction and may be required to remove any intestines that may have died.[2] If not rapidly treated outcomes are often poor.[1] Among those affected even with treatment the risk of death is 70% to 90%.[3] In those with chronic disease bypass surgery is the treatment of choice.[1] Those who have thrombosis of the vein may be treated with anticoagulation such as heparin and warfarin, with surgery used if they do not improve.[2][8]
Acute mesenteric ischemia affects about five per hundred thousand people per year in the developed world.[4] Chronic mesenteric ischemia affects about one per hundred thousand people.[5] Most people affected are over 60 years old.[3] Rates are about equal in males and females of the same age.[3] Mesenteric ischemia was first described in 1895.[1]
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Video explanation
Contents
- 1 Signs and symptoms
- 1.1 Clinical findings
- 1.2 Diagnostic heuristics
- 2 Diagnosis
- 2.1 Blood tests
- 2.2 During endoscopy
- 2.3 Plain X-ray
- 2.4 Computed tomography
- 2.5 Angiography
- 3 Treatment
- 4 Prognosis
- 5 History
- 6 References
- 7 External links
Signs and symptoms
Three progressive phases of mesenteric ischemia have been described:[9][10]
- A hyper active stage occurs first, in which the primary symptoms are severe abdominal pain and the passage of bloody stools. Many patients get better and do not progress beyond this phase.
- A paralytic phase can follow if ischemia continues; in this phase, the abdominal pain becomes more widespread, the belly becomes more tender to the touch, and bowel motility decreases, resulting in abdominal bloating, no further bloody stools, and absent bowel sounds on exam.
- Finally, a shock phase can develop as fluids start to leak through the damaged colon lining. This can result in shock and metabolic acidosis with dehydration, low blood pressure, rapid heart rate, and confusion. Patients who progress to this phase are often critically ill and require intensive care.
Clinical findings
Symptoms of mesenteric ischemia vary and can be acute (especially if embolic),[11] subacute, or chronic.[12]
Case series report prevalence of clinical findings and provide the best available, yet biased, estimate of the sensitivity of clinical findings.[13][14] In a series of 58 patients with mesenteric ischemia due to mixed causes:[14]
- abdominal pain was present in 95% (median of 24 hours duration). The other three patients presented with shock and metabolic acidosis.
- nausea in 44%
- vomiting in 35%
- diarrhea in 35%
- heart rate > 100 in 33%
- 'blood per rectum' in 16% (not stated if this number also included occult blood – presumably not)
- constipation in 7%
Diagnostic heuristics
In the absence of adequate quantitative studies to guide diagnosis, various heuristics help guide diagnosis:
- Mesenteric ischemia "should be suspected when individuals, especially those at high risk for acute mesenteric ischemia, develop severe and persisting abdominal pain that is disproportionate to their abdominal findings".[15]
- Regarding mesenteric arterial thrombosis or embolism: "...early symptoms are present and are relative mild in 50% of cases for three to four days before medical attention is sought".[16]
- Regarding mesenteric arterial thrombosis or embolism: "Any patient with an arrhythmia such as atrial fibrillation who complains of abdominal pain is highly suspected of having embolization to the superior mesenteric artery until proved otherwise".[16]
- Regarding nonocclusive intestinal ischemia: "Any patient who takes digitalis and diuretics and who complains of abdominal pain must be considered to have nonocclusive ischemia until proved otherwise".[16]
Diagnosis
It is difficult to diagnose mesenteric ischemia early.[17] One must also differentiate ischemic colitis, which often resolves on its own, from the more immediately life-threatening condition of acute mesenteric ischemia of the small bowel.
Blood tests
In a series of 58 patients with mesenteric ischemia due to mixed causes:[14]
- White blood cell count >10.5 in 98% (probably an overestimate as only tested in 81% of patients)
- Lactic acid elevated 91% (probably an overestimate as only tested in 57% of patients)
During endoscopy
A number of devices have been used to assess the sufficiency of oxygen delivery to the colon. The earliest devices were based on tonometry, and required time to equilibrate and estimate the pHi, roughly an estimate of local CO2 levels. The first device approved by the U.S. FDA (in 2004) used visible light spectroscopy to analyze capillary oxygen levels. Use during aortic aneurysm repair detected when colon oxygen levels fell below sustainable levels, allowing real-time repair. In several studies, specificity has been 83% for chronic mesenteric ischemia and 90% or higher for acute colonic ischemia, with a sensitivity of 71%-92%. This device must be placed using endoscopy, however.[18][19][20]
Plain X-ray
Plain X-rays are often normal or show non-specific findings.[21]
Computed tomography
Computed tomography (CT scan) is often used.[22][23] The accuracy of the CT scan depends on whether a small bowel obstruction (SBO) is present.[24]
SBO absent
- prevalence of mesenteric ischemia 23%
- sensitivity 64%
- specificity 92%
- positive predictive value (at prevalence of 23%) 79%
- negative predictive value (at prevalence of 23%) 95%
SBO present
- prevalence of mesenteric ischemia 62%
- sensitivity 83%
- specificity 93%
- positive predictive value (at prevalence of 62%) 93%
- negative predictive value (at prevalence of 62%) 61%
Findings on CT scan include:
- Mesenteric edema[22]
- Bowel dilatation[22]
- Bowel wall thickening[22]
- Intramural gas[22]
- Mesenteric stranding[25]
Angiography
As the cause of the ischemia can be due to embolic or thrombotic occlusion of the mesenteric vessels or nonocclusive ischemia, the best way to differentiate between the etiologies is through the use of mesenteric angiography. Though it has serious risks, angiography provides the possibility of direct infusion of vasodilators in the setting of nonocclusive ischemia.[26]
Treatment
The treatment of mesenteric ischemia depends on the cause, and can be medical or surgical. However, if bowel has become necrotic, the only treatment is surgical removal of the dead segments of bowel.
In non-occlusive mesenteric ischemia, where there is no blockage of the arteries supplying the bowel, the treatment is medical rather than surgical. People are admitted to the hospital for resuscitation with intravenous fluids, careful monitoring of laboratory tests, and optimization of their cardiovascular function. NG tube decompression and heparin anticoagulation may also be used to limit stress on the bowel and optimize perfusion, respectively.
Surgical revascularisation remains the treatment of choice for mesenteric ischaemia related to an occlusion of the vessels supplying the bowel, but thrombolytic medical treatment and vascular interventional radiological techniques have a growing role.[27]
If the ischemia has progressed to the point that the affected intestinal segments are gangrenous, a bowel resection of those segments is called for. Often, obviously dead segments are removed at the first operation, and a second-look operation is planned to assess segments that are borderline that may be savable after revascularization.[28]
Prognosis
The prognosis depends on prompt diagnosis (less than 12–24 hours and before gangrene)[29] and the underlying cause:[30]
- venous thrombosis: 32% mortality
- arterial embolism: 54% mortality
- arterial thrombosis: 77% mortality
- non-occlusive ischemia: 73% mortality.
In the case of prompt diagnosis and therapy, acute mesenteric ischemia can be reversible.[31]
History
Acute mesenteric ischemia was first described in 1895 while chronic disease was first described in the 1940s.[1] Chronic disease was initially known as angina abdominis.[1]
References
- ^ a b c d e f g h i j k l m n o Bobadilla, JL (August 2013). "Mesenteric ischemia". The Surgical clinics of North America. 93 (4): 925–40, ix. doi:10.1016/j.suc.2013.04.002. PMID 23885938.
- ^ a b c d e f g h i Yelon, Jay A. (2014). Geriatric Trauma and Critical Care (Aufl. 2014 ed.). New York: Springer Verlag. p. 182. ISBN 9781461485018. Archived from the original on 2017-09-08.
- ^ a b c d e f Britt, L.D. (2012). Acute care surgery (1st ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 621. ISBN 9781608314287. Archived from the original on 2017-09-08.
- ^ a b Geoffrey D. Rubin (2012). CT and MR Angiography: Comprehensive Vascular Assessment. Lippincott Williams & Wilkins. p. 318. ISBN 9781469801834. Archived from the original on 2017-09-08.
- ^ a b Gustavo S. Oderich (2014). Mesenteric Vascular Disease: Current Therapy. Springer. p. 105. ISBN 9781493918478. Archived from the original on 2017-09-08.
- ^ Creager, Mark A. (2013). Vascular medicine : a companion to Braunwald's heart disease (2nd ed.). Philadelphia, PA: Elsevier/Saunders. pp. 323–324. ISBN 9781437729306. Archived from the original on 2017-09-08.
- ^ Sreenarasimhaiah, J (April 2005). "Chronic mesenteric ischemia". Best practice & research. Clinical gastroenterology. 19 (2): 283–95. doi:10.1016/j.bpg.2004.11.002. PMID 15833694.
- ^ Liapis, C.D. (2007). Vascular surgery. Berlin: Springer. p. 420. ISBN 9783540309567. Archived from the original on 2017-09-08.
- ^ Boley, SJ, Brandt, LJ, Veith, FJ (1978). "Ischemic disorders of the intestines". Curr Probl Surg. 15 (4): 1–85. doi:10.1016/S0011-3840(78)80018-5. PMID 365467. CS1 maint: Multiple names: authors list (link)
- ^ Hunter G, Guernsey J (1988). "Mesenteric ischemia". Med Clin North Am. 72 (5): 1091–115. PMID 3045452.
- ^ Oldenburg WA, Lau LL, Rodenberg TJ, Edmonds HJ, Burger CD (2004). "Acute mesenteric ischemia: a clinical review". Arch. Intern. Med. 164 (10): 1054–62. doi:10.1001/archinte.164.10.1054. PMID 15159262.
- ^ Font VE, Hermann RE, Longworth DL (1989). "Chronic mesenteric venous thrombosis: difficult diagnosis and therapy". Cleveland Clinic journal of medicine. 56 (8): 823–8. doi:10.3949/ccjm.56.8.823. PMID 2691119.
- ^ Levy PJ, Krausz MM, Manny J (1990). "Acute mesenteric ischemia: improved results--a retrospective analysis of ninety-two patients". Surgery. 107 (4): 372–80. PMID 2321134.
- ^ a b c Park WM, Gloviczki P, Cherry KJ, Hallett JW, Bower TC, Panneton JM, Schleck C, Ilstrup D, Harmsen WS, Noel AA (2002). "Contemporary management of acute mesenteric ischemia: Factors associated with survival". J. Vasc. Surg. 35 (3): 445–52. doi:10.1067/mva.2002.120373. PMID 11877691. CS1 maint: Multiple names: authors list (link)
- ^ "American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia". Gastroenterology. 118 (5): 951–3. May 2000. doi:10.1016/s0016-5085(00)70182-x. PMID 10784595.
- ^ a b c Cope, Zachary; Silen, William (April 2005). Cope's Early Diagnosis of the Acute Abdomen (21st ed.). New York: Oxford University Press. ISBN 978-0-19-517545-5. LCCN 2004058138. OCLC 56324163.
- ^ Evennett NJ, Petrov MS, Mittal A, Windsor JA (July 2009). "Systematic review and pooled estimates for the diagnostic accuracy of serological markers for intestinal ischemia". World J Surg. 33 (7): 1374–83. doi:10.1007/s00268-009-0074-7. PMID 19424744.
- ^ Lee ES, Bass A, Arko FR, et al. (2006). "Intraoperative colon mucosal oxygen saturation during aortic surgery". The Journal of surgical research. 136 (1): 19–24. doi:10.1016/j.jss.2006.05.014. PMID 16978651.
- ^ Friedland S, Benaron D, Coogan S, et al. (2007). "Diagnosis of chronic mesenteric ischemia by visible light spectroscopy during endoscopy". Gastrointest Endosc. 65 (2): 294–300. doi:10.1016/j.gie.2006.05.007. PMID 17137857.
- ^ Lee ES, Pevec WC, Link DP, et al. (2008). "Use of T-stat to Predict Colonic Ischemia during and after Endovascular Aneurysm Repair: A case report". J Vasc Surg. 47 (3): 632–634. doi:10.1016/j.jvs.2007.09.037. PMC 2707776 . PMID 18295116.
- ^ Smerud M, Johnson C, Stephens D (1990). "Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases". AJR Am J Roentgenol. 154 (1): 99–103. doi:10.2214/ajr.154.1.2104734. PMID 2104734.
- ^ a b c d e Alpern M, Glazer G, Francis I (1988). "Ischemic or infarcted bowel: CT findings". Radiology. 166 (1 Pt 1): 149–52. doi:10.1148/radiology.166.1.3336673. PMID 3336673.
- ^ Taourel P, Deneuville M, Pradel J, Régent D, Bruel J (1996). "Acute mesenteric ischemia: diagnosis with contrast-enhanced CT" (PDF). Radiology. 199 (3): 632–6. doi:10.1148/radiology.199.3.8637978. PMID 8637978. Archived (PDF) from the original on 2008-02-27.
- ^ Staunton M, Malone DE (2005). "Can acute mesenteric ischemia be ruled out using computed tomography? Critically appraised topic |". Canadian Association of Radiologists Journal. 56 (1): 9–12. PMID 15835585. Archived from the original on 2007-09-27.
- ^ Pereira JM, Sirlin CB, Pinto PS, Jeffrey RB, Stella DL, Casola G (2004). "Disproportionate fat stranding: a helpful CT sign in patients with acute abdominal pain". Radiographics : a review publication of the Radiological Society of North America, Inc. 24 (3): 703–15. doi:10.1148/rg.243035084. PMID 15143223.
- ^ Kao, Lillian S., and Tammy Lee. PreTest Surgery: PreTest Self-assessment and Review. New York: McGraw-Hill Medical, 2009.
- ^ Sreenarasimhaiah J (2003). "Diagnosis and management of intestinal ischaemic disorders". BMJ. 326 (7403): 1372–6. doi:10.1136/bmj.326.7403.1372. PMC 1126251 . PMID 12816826.
- ^ Meng, X; Liu, L; Jiang, H (August 2010). "Indications and procedures for second-look surgery in acute mesenteric ischemia". Surgery today. 40 (8): 700–5. doi:10.1007/s00595-009-4140-4. PMID 20676851.
- ^ Brandt, LJ; Boley, SJ (May 2000). "AGA technical review on intestinal ischemia. American Gastrointestinal Association". Gastroenterology. 118 (5): 954–968. doi:10.1016/s0016-5085(00)70183-1. PMID 10784596.
- ^ Schoots IG, Koffeman GI, Legemate DA, Levi M, van Gulik TM (2004). "Systematic review of survival after acute mesenteric ischaemia according to disease aetiology". The British journal of surgery. 91 (1): 17–27. doi:10.1002/bjs.4459. PMID 14716789.
- ^ Nuzzo, Alexandre; Corcos, Olivier (13 October 2016). "Reversible Acute Mesenteric Ischemia". New England Journal of Medicine. 375 (15): e31. doi:10.1056/NEJMicm1509318.
External links
| Classification |
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Diseases of the digestive system (primarily K20–K93, 530–579)
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Disorders of blood flow
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UpToDate Contents
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- 1. 成人における腸虚血の概要 overview of intestinal ischemia in adults
- 2. 非閉塞性腸間膜虚血 nonocclusive mesenteric ischemia
- 3. 麻酔後回復室（PACU）における心血管の障害 cardiovascular problems in the post anesthesia care unit pacu
- 4. 成人における確定診断を得られていない低血圧やショックの評価および初期アプローチ evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock
- 5. 成人における副腎不全の診断 diagnosis of adrenal insufficiency in adults
English Journal
- Duplex ultrasound in the early diagnosis of acute mesenteric ischemia: a longitudinal cohort multicentric study.
- Sartini S1, Calosi G, Granai C, Harris T, Bruni F, Pastorelli M.
- European journal of emergency medicine : official journal of the European Society for Emergency Medicine.Eur J Emerg Med.2017 Dec;24(6):e21-e26. doi: 10.1097/MEJ.0000000000000378.
- PMID 26891086
- Non-occlusive mesenteric ischemia localized in the transverse colon: a case report.
- Murono K1, Ishihara S2, Kawai K2, Kaneko M2, Sasaki K2, Yasuda K2, Otani K2, Nishikawa T2, Tanaka T2, Kiyomatsu T2, Hata K2, Nozawa H2, Hayashi A3, Ushiku T3, Fukayama M3, Watanabe T2.
- Surgical case reports.Surg Case Rep.2017 Dec;3(1):23. doi: 10.1186/s40792-017-0299-x. Epub 2017 Feb 10.
- PMID 28188511
- Agmatine attenuates intestinal ischemia and reperfusion injury by reducing oxidative stress and inflammatory reaction in rats.
- Turan I1, Ozacmak HS2, Ozacmak VH2, Barut F3, Araslı M4.
- Life sciences.Life Sci.2017 Nov 15;189:23-28. doi: 10.1016/j.lfs.2017.08.032. Epub 2017 Sep 8.
- PMID 28893640
Japanese Journal
- 腹部臓器虚血を伴う急性IIIb型大動脈解離の治療戦略
- 日本血管外科学会雑誌 = The Japanese journal of vascular
- NAID 10020366550
- The importance of mesenteric vascular insufficiency in meconium peritonitis
- Hum Pathol 17, 411-416, 1986
- NAID 30029400649
- 連合弁置換術後遠隔期に発生した非閉塞性腸間膜血行不全症
- 日本臨床外科医学会雑誌 43(7), 847-853, 1982
- NAID 130003595697
Related Pictures
★リンクテーブル★
| リンク元 | 「腸間膜血行不全」 |
| 関連記事 | 「insufficiency」「vascular」「mesenteric」 |
「腸間膜血行不全」
「insufficiency」
- n.
- 関
- dearth、deficient、deficit、dysfunction、failing、failure、hypofunction、imperfecta、in short、inadequate、incompetence、insufficient、insufficiently、lack、low、malfunction、paucity、poorly、regurgitation、scanty、scarce、scarcity、short、shortage、shortness、stun
「vascular」
- adj.
- (生物・解剖)導管の、脈管の、血管の
「mesenteric」
- adj.
- 腸間膜の