Chronic mesenteric ischemia ischemic colitis

Inadequate blood supply to meet the energy demands of viscera can lead to reports of pain, as occurs with cardiac angina. A similar phenomenon has been noted in the gastrointestinal system whereby severe abdominal pain may be precipitated by the ingestion of a meal.109,110 Fear of eating with subsequent weight loss and poor nutritional status may further compromise patients already in ill health due to atherosclerotic disease in multiple sites. Poor peripheral pulses, abdominal bruits, and arterio-graphic evidence of stenosis or occlusion in the three main mesenteric arteries are all consistent with the diagnosis of abdominal angina. Similar to cardiac disease, abdominal angina may precede infarction which has devastating life-threatening consequences. Arterial thrombosis, embolic events, venous occlusion, and low flow states due to poor cardiac output may all lead to the same disastrous results. Ischemic colitis represents approximately half of the cases of morbidity due to mesenteric vascular disease. Although usually diagnosed by colonoscopy, 20 percent of patients with ischemic colitis develop evidence of peritonitis requiring surgical diagnosis and treatment. Initial presentation may be with persistent diarrhea, rectal bleeding, or weight loss. Diagnostic work-up for mesenteric ischemia has angiography as the gold standard, but the less invasive magnetic resonance angiography and/or tonometry have diagnostic value.111 Surgical revascularization, thrombectomy, thrombolytic therapy, or angioplasty are definitive treatments for mesenteric vasculopathy but, like all patients with widespread vascular disease, comorbidity may dictate outcome as much as the specific procedure performed. Pharmacologically, there can be short-term value of vasodilators such as papverine and, like most chronic processes with some low grade inflammatory component, there appears to be a role for the use of antioxidants and agents acting via cytokine mechanisms, but at present these treatments are experimental.112

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