in this presentation me & my colleagues discuss briefly the types of mesenteric ischemia ( acute , chronic , venous ) and its related syndromes (superior mesenteric artery syndrome , celiac trunk syndrome and supply it by good radiologic images ..

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. BY
1. Abdullah Hasan Alhojaili
2. Alhassan Ali Alghamdi
3. Abdulaziz Mosa Hawsawi
Mesenteric ischemia

3. CHRONIC MESENTERIC
ISCHEMIA
Alhassan Ali Alghamdi

4. Anatomy
celiac trunk supplies the foregut

5. Anatomy
SMA & IMA supply midgut and hindgut respectively

6. Anatomy

7. Definition
Mesenteric ischemia is defined as a condition in
which the supply of oxygen or blood is too small to
satisfy the needs of the intestines. Ischemia can
affect the small intestine, the colon or both. It can
be acute and chronic.

8. Mesenteric ischemic syndromes
 Chronic
– Atherosclerotic
– Non-atherosclerotic
 Acute
– Occlusive
• Embolic
• Thrombotic (most common)
– Non-Occlusive
– Mesenteric Venous Thrombosis

9. Chronic mesenteric ischemia
• Relatively Uncommon
• Usually 2-3 vessel disease
• Asymptomatic Mesenteric Stenosis 6-24%

10. Chronic mesenteric ischemia
• Usually Women
• Younger
• Smokers
• 2/3 with Other Vascular Disease
– Half with abdominal bruit
• Classic Symptoms
– Post-prandial Pain
– Weight Loss
– sitophobia??
– GI ulceration

11. Diagnosis
Clinical: “high index of
suspicion”
R/o other causes for atypical
abdominal pain

12. Diagnosis
• PT , aPPT, INR
• CBC  anemia
• Blood Chemistry 
electrolyte abnormalities .
• Urinalysis - to rule out stones
or infection
• (LFTs) – hypoalbuminemia.
• Angiography
• CT & CTA
• MRI & MRA
• US & Duplex us
Lab studies Imaging studies
Electrocardiography (ECG) to rule out cardiac disease

13. angiography
Chronic mesenteric
ischemia Lateral
abdominal aortogram
shows occlusion of
the celiac and IMA
Severe stenosis .

14. CTA
A CT angiogram
showing occlusion of
the coeliac axis and
tight stenosis of the
superior mesenteric
artery

15. Managment
 The main therapy is surgical which is :
open or endovascular revascularization .
 medical management is warranted only when the risks
of revascularization outweigh the benefits. Nitrate
therapy may provide short-term relief but is not curative.
Anticoagulation therapy with warfarin is indicated.

16. Superior mesenteric artery
syndrome (SMAS)
 Superior mesenteric artery syndrome is a rare condition first described by
Rokitansky in1861. The condition results from a reduced angle between the
artery at its origin from the abdominal aorta and the transverse third part of
the duodenum causing duodenal obstruction. Diagnosis of the syndrome
depends on high index of suspicion, augmented by the radiological features
of the syndrome. Treatment can either be conservative or operative,
depending on the severity of the condition.

17. Case report
 A 19-year-old female presented to the out-patient department of
King Fahad Medical City with a two-year history of recurrent
abdominal pain associated with feeling of fullness and vomiting after
meals together with progressive loss of weight (>40kg) in 2 years.
On examination, she was emaciated with a body weight of 22kg.
Her vital signs were within the normal limits. The abdominal
examination revealed a slightly distended abdomen with positive
succession splash. Laboratory investigations were normal. Barium
follow-through showed a grossly distended stomach reaching down
to the pelvis

18. SMAS

19. Treatment
Conservative to
relieve obstruction
(decompression)
Options for surgery
include a
duodenojejunostomy
or gastrojejunostomy
Medical Surgical

20. ACUTE MESENTERIC
ISCHEMIA
Abdullah Hasan Al-hojaili

21. Definition
 Acute mesenteric ischemia (AMI) is a
syndrome caused by inadequate blood flow
through the mesenteric vessels, resulting in
ischemia and eventual gangrene of the bowel
wall. Although relatively rare, it is a potentially
life-threatening condition.

22. Risk Factors & Epidemiology
▪ Atherosclerosis.
▪ Arrhythmias.
▪ Hypovolemia.
▪ CHF.
▪ recent MI.
▪ valvular disease.
▪ advanced age.
▪ intra-abdominal malignancy.
▪ IBD .
▪ AMI is commonly
considered a
disease of the older
population(>60), but
may affect young !!
▪ African American
people and men
might be at higher
risk ??

23. Etiology of AMI
– Occlusive
• Embolic (AMAE)
• Thrombotic
(AMAT)
– Non-Occlusive
– Mesenteric Venous
Thrombosis
AMAE has better
prognosis and
outcome than AMAT ,
why ??

24. Cont.
occlusive
Thrombotic
1-
atherosclerosis
2- Aortic
dissection
3- Aortic
aneurysm
Embolic
1- cardiac
2- ruptured
atheromatous
plaque

25. Cont.
Non occlusive
hypotension
Digitalis !!
Vasopressors
Cocaine

26. Acute mesenteric ischemia
 Relatively Uncommon
 Difficult Diagnosis
 High Complication Rate
 High Mortality Rate 70%

27. Presentation
 “Half” with prior
symptoms of CMI
 Abdominal Pain :
sudden , sever , diffuse ,
non localized , constant.
► AMAT vs AMAE ??
This pain is
disproportionate to
physical examination
findings & not responding
to opioid .
 Nausea and vomiting
are found in 75%.
 Anorexia and diarrhea
progressing to
obstipation.
 Abdominal distention
and gastrointestinal (GI)
bleeding.
In NOMI Symptoms
typically develop over
several days.

28. Examination
 normal abdominal
examination in the
face of severe
abdominal pain.
 No signs of
peritonitis.
 abdominal
tenderness
,guarding , rigidity .
 These signs develop
when bowel become
necrotic or
perforated.
 Sign of septicemia
may be predicted .
Early late

29. Diagnosis
 PT
 aPPT
 INR
 CBC  hi WBCs
 Blood Chemistry  acidosis ,
hi LDH .
N.B.
These laboratory findings are
nonspecific and generally
unreliable.
 AXR
 Angiography
 CT & CTA
 MRI & MRA
 US & Duplex us
N.B.
Positive findings on plain abdominal
radiography are usually late and
nonspecific .
Lab studies Imaging studies

30. AXR
Pneumatosis
intestinalis (black
stripes of air)
in advanced acute
mesenteric ischemia
(AMI) with
gangrenous bowel.

31. AXR
Thumbprinting of
bowel, characteristic
of mesenteric artery
ischemia.

32. angiogram
Aortogram showing
narrowing of
superior mesenteric
artery.

33. CT & CTA
• CTA sagittal view
showing an SMA
thrombus (white
arrow)
• pneumatosis
intestinalis (black
arrow).
• (B) CTA coronal
view showing
pneumatosis

34. CT
CT scan (with
contrast) of
nonocclusive
mesenteric ischemia
with resulting bowel
wall edema (arrows).

35. Management
 Papaverine : is
phosphodiesterase inhibitor,
which acts to relax vascular
smooth muscle.
 Thrombolytics : The infusion
must be started within 8 hours of
symptom onset.
 Antibiotics & pain killer
 Laparotomy
 Revascularization
-embolectomy
-thrombectomy
 Determine viability
 Second-look
Medical Surgical

36. Determine viability
 Inspection: color,
pulses, peristalsis
 Hand-held doppler

37. Second look Laparotomy
A second-look
laparotomy is the most
reliable method of
determining bowel
viability.
Usually within 24 hours
gross specimen showing hemorrhagic dead bowel after
resection from patient with acute mesenteric ischemia.

38. Conclusion
• High index of suspicion
• Rapid preoperative evaluation
• Revascularization with open surgical
techniques
• Resection of non-viable bowel
• Liberal use of second-look

39. Conclusion
• Timely revascularization of symptomatic
patients with C.M.I. Will hopefully reduce
the incidence and subsequent high
morbidity/mortality of A.M.I.

40. MESENTERIC VENOUS
THROMBOSIS
Abdul-Aziz Mosa Hawsawi

41. Portal system
There are three veins that
carry blood from the
intestines:
1. the superior mesenteric
vein
2. the inferior mesenteric
vein
3. the splenic vein

42. Definition
 Mesenteric venous thrombosis occurs when
a blood clot forms in one or more of the major
veins that drain blood from your intestines.
This condition is rare, but it can lead to life-
threatening complications without prompt
treatment.

43. Etiology of MVT
• 20% Idiopathic
• Hypercoagulable States
• Low-flow (CHF, Cirrhosis with PH, Budd-
Chiari)
• Intra-abdominal inflammatory or
suppurative processes and malignancies
• Smoking, prior DVT or thrombosis

44. Diagnosis
• Plain Films
• CT
• Mesenteric Venography

45. CT
Coronal and axial
views of a computed
tomographic scan of
the abdomen
showing enlargement
of the superior
mesenteric vein. An
intraluminal clot is
seen (arrows),
showing extensive
thrombosis of the
superior mesenteric
vein.

46. Treatment
• Systemic Anticoagulation
• Exploration with resection of non-viable bowel for
peritonitis.

47. Median arcuate ligament syndrome
 Celiac Artery
Compression Syndrome
 Etiology - Compression
of CA by the median
arcuate ligament.
 Female 20-40 years old
 Symptom - post-
prandial epigastric
abdominal pain
 Treatment - release the
median arcuate
ligament

48. Angio/CTA

49. Angioplasty