Mesenteric infarction refers to the acute occlusion of an intestinal vessel that, if left untreated, leads to the death of intestinal segments. It is a life-threatening condition that is often recognized too late and has a high lethality. It usually affects patients with preexisting cardiovascular disease.
What is mesenteric infarction?
In mesenteric infarction, an intestinal vessel is blocked by an embolism or thrombosis, and both intestinal arteries and veins may be affected. The intestine in the supply area of the affected vessel is no longer sufficiently supplied with blood, so that – without timely countermeasures – the tissue dies (infarction and necrotization). In 85 percent of cases of arterial mesenteric infarction, the superior mesenteric artery, which supplies large parts of the small intestine, colon and pancreas, is affected. The remaining 15 percent is accounted for in roughly equal parts by the truncus coeliacus (“trunk of the abdominal cavity”), in whose supply area the duodenum lies in addition to the stomach, liver, spleen and pancreas, and by the arteria mesenterica inferior (“lower visceral artery“), which supplies the descending colon and the upper rectum. Mesenteric infarction of the inferior mesenteric artery has a better prognosis.
Causes
The cause of mesenteric infarction is either embolism or thrombosis. Emboli typically occur in middle-aged patients. Preexisting cardiac conditions, such as cardiac arrhythmias or artificial heart valves, favor the development of an embolus in the heart, which is carried first to the aorta and eventually to the visceral vessels. Thrombosis in the mesenteric arteries is more likely to occur in older patients due to arteriosclerosis. Fatty deposits, connective tissue proliferation, and inflammatory processes cause the vessel wall to thicken until adequate blood flow is no longer possible. More rarely, mesenteric vein thrombosis is responsible for mesenteric infarction. It is usually preceded by an underlying disease that promotes thrombosis, such as local inflammation, sepsis, or a coagulation disorder.
Symptoms, complaints, and signs
Mesenteric infarction is an extremely life-threatening condition. Generally, the disease progresses in three phases. For example, in phase I, there is a sudden onset of severe abdominal pain that is particularly concentrated in the area around the belly button. However, there is no defensive tension or pressure pain. In addition to the colicky abdominal symptoms, bloody diarrhea and symptoms of circulatory shock often occur. Due to impaired blood flow to the intestine from an embolism or thrombosis, the sections of intestine affected by the obstruction die. Their necrosis begins circ two hours after the vascular occlusion due to the undersupply of the corresponding intestinal segments. On examination of the abdomen, however, nothing is noticeable at first. However, an increasing deterioration of the patient is observed. Approximately six to eight hours after the onset of the initial phase, the pain suddenly disappears and the patient appears to feel better. Sometimes this so-called “deceptive peace” is accompanied by meteorism and flatulence. This apparent improvement in symptoms is due to a decrease in intestinal peristalsis, which is also caused by the reduced supply to the intestine. Phase II with the apparent calming of the complaints is then replaced by phase III with irreparable necrosis of large sections of the intestine. This initially results in [(intestinal paralysis]], which prevents the intestinal contents from being passed on. The consequences are paralytic intestinal obstruction,rupture of the intestine with the development of peritonitis and severe intoxication of the body. The lethality is up to 90 percent.
Diagnosis and course
Mesenteric infarction classically progresses in 3 stages. The leading symptom in the initial stage is acute abdomen: a sudden onset of severe, colicky abdominal pain. Defensive tension is often initially absent. Unfortunately, acute abdomen is a relatively nonspecific sign that can have many causes. Therefore, the emergency diagnosis is often not made quickly enough. In addition, the pain subsides after a few hours due to the cessation of intestinal peristalsis, resulting in an apparent improvement. This second phase is referred to as “rotten peace.” A blood gas test provides important information (metabolic acidosis, lactic acidosis).Increased leukocyte values indicate inflammatory processes. Apparently, mesenteric infarction can be visualized by an x-ray overview of the abdomen, by sonography and/or CT angiography. If the mesenteric infarction is not diagnosed in time, the patient’s condition deteriorates massively after about 12 hours due to advanced intestinal necrosis. The final stage begins: the patient goes into septic shock with intestinal obstruction (ileus) and peritonitis. Left untreated, mesenteric infarction is a sure death sentence.
Complications
Mesenteric infarction causes the patient to die in the worst-case scenario. However, this complication usually occurs only if the mesenteric infarction is not treated. Patients suffer from very severe pain in the stomach and intestines, which leads to considerable restrictions in their quality of life. Likewise, diarrhea and a tense abdomen are not uncommon. The patient’s ability to cope with stress decreases and exhaustion often occurs. It is not uncommon for mesenteric infarction to also lead to a reduced appetite and thus to deficiency symptoms. Due to the permanent pain, many patients also suffer from depression and psychological complaints or moods. In the case of mesenteric infarction, direct surgery is necessary to avoid consequential damage and death of the affected person. This usually has to occur a few hours after the appearance of the mesenteric infarction. In most cases, there are no complications bade, but dead parts of the intestine must be removed. After the procedure, there is a large scar on the abdomen in most cases. Whether life expectancy is reduced by mesenteric infarction usually cannot be predicted.
When should you see a doctor?
If the affected person suffers from discomfort in the abdominal region, there is an impairment of health. If there is persistent or increasing abdominal as well as lower abdominal pain, a doctor should be consulted. In the event of sudden onset of severe discomfort, a visit to the doctor is required as soon as possible. If colic occurs, an ambulance should be alerted by the affected person or persons present. Since a mesenteric infarction can be fatal in the worst case, immediate consultation with an emergency physician is required. It is imperative to follow the instructions of the emergency physician to ensure the survival of the affected person. Repeated diarrhea or diarrhea that increases in intensity must be clarified by a physician. Disturbances or irregularities of the abdominal muscles indicate a worrying irregularity. A visit to the doctor is advisable so that a diagnosis can be made. If an obstruction of the intestines develops, the usual level of performance gradually decreases further, or if the affected person experiences a general feeling of illness, he or she needs medical help. An inner restlessness, changes in body temperature and a general feeling of malaise are signs of a present illness that should be treated. A collapse of strength or inability to perform daily duties are symptoms that need to be discussed with a physician.
Treatment and therapy
Mesenteric infarction is an internal medicine emergency and requires rapid action. Intestinal necrosis may occur as early as 2 hours after the onset of the infarct. Thus, the affected intestinal tissue can only be saved if early surgery is performed to restore vascular patency. The operation requires a large abdominal incision and is called laparatomy with (attempted) embolectomy. If the tissue is already irreversibly damaged, the dead portions of the intestine must be removed. Often, approximately 12 hours after successful initial surgery, a so-called second-look operation is performed to resect any further necrosis. Postoperative care must counteract sepsis and peritonitis as well as further thrombosis. Especially because of the short time window for promising therapy, mesenteric infarction has an unfavorable prognosis. On average, the lethality of mesenteric infarction is 90%. Patients undergoing surgery have a 50% chance of survival.
Outlook and prognosis
In a large number of patients, the prognosis for mesenteric infarction is unfavorable. It is a life-threatening condition in which the patient’s risk for premature death is significantly increased. The disease progresses in three stages.In most cases, a diagnosis and adequate medical care are only made at a very late stage. This has a negative impact on the further course of the disease and thus on the prognosis. In addition, a large number of patients suffer from other pre-existing conditions. These mostly relate to the cardiovascular area and thus cause an increase in the existing complaints. If the affected person refuses medical care, this inevitably leads to a critical condition and ultimately to the death of the affected person. Extreme caution is also required when seeking medical treatment. Within a few hours, irreversible damage and demise can occur. Patients who have received timely and comprehensive care have an improved outlook. If no other primary diseases are present, there are certainly prospects of recovery despite the critical condition. Nevertheless, it must be taken into account that most patients with a mesenteric infarction suffer from various previous cardiovascular diseases. This leads to the fact that nearly half of all affected patients die prematurely in the further course even after a successful operation.
Prevention
Prevention of mesenteric infarction involves, on the one hand, measures that generally prevent atherosclerosis: abstaining from cigarettes, eating a healthy diet with healthy fats, and getting sufficient exercise. On the other hand, thrombosis prophylaxis with anticoagulants is important in patients at risk, especially in elderly heart patients. Beyond prevention, it is crucial to think about the possible diagnosis of mesenteric infarction, especially in these high-risk patients, in case of an emergency, so as not to let any saving time pass.
Follow-up
Follow-up care for a mesenteric infarction depends primarily on the cause. The patient should decide this individually with his or her attending physician. Each patient should also discuss with his or her primary care physician whether attention should be paid to certain dietary changes. In addition, symptoms such as frequent heartburn, stabbing stomach pain or vomiting blood must be related to the previous history and clarified in the future. Affected individuals should follow a healthy lifestyle that reduces the likelihood of recurrence. A balanced diet and adequate exercise are essential.
What you can do yourself
As a rule, mesenteric infarction cannot be controlled by various self-help treatments. In this disease, it is necessary to see a doctor in any case to avoid complications or, in the worst case, the death of the affected person. Especially in acute emergencies, the hospital should be visited directly or an emergency doctor should be called. This is the case if the affected person suffers from severe tension of the abdomen or intestinal obstruction. These complaints are accompanied by severe pain. Treatment of mesenteric infarction is always performed in a hospital by surgical intervention and usually leads to success if the intervention is performed early. Often a second operation is necessary to prevent further necrosis. Mesenteric infarction can be prevented by a healthy lifestyle. This includes a healthy diet and exercise. Likewise, abstaining from alcohol and cigarettes also has a positive effect on the disease. Patients at risk should take part in regular examinations in order to avoid a mesenteric infarction. If treatment is successful, there is usually no reduction in the patient’s life expectancy.
