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Chronic Mesenteric Ischemia In Severe Atherosclerotic Disease
Abigail E. Keene, OMSIII
University of New England College of Osteopathic Medicine, Biddeford, Maine
Introduction: It is imperative to recognize that chronic mesenteric ischemia may be the
manifestation of diffuse underlying vascular disease. Our patient presented only with
post-prandial abdominal pain, nausea and an associated weight loss. After extensive
work-up, she was found to have diffuse atherosclerotic disease with coronary, aortic and
mesenteric involvement and an extensive collateral circulation.
Case: A 77-year old woman presented to our hospital with a two-month history of postprandial
abdominal pain associated with, nausea, loose stools and a 15 pound weight
loss. This patient had been evaluated at multiple hospitals for the same symptoms with
no definitive diagnosis.Vital signs on admission were temperature 97.9ºF, heart rate 91
and regular, respiratory rate 18, blood pressure 96/54 mmHg, and oxygen saturation
98% on room air. Laboratory studies were significant only for an elevated Troponin I
level of 1.39ug/L to 1.52ug/L and a mildly elevated CK-MB fraction of 3.8. Cardiology
and Surgery consults were obtained. Serial 12-lead EKGs, an echocardiogram with color
Doppler, and a nuclear medicine stress test confirmed the presence of an NSTEMI with
severe coronary artery disease. A Doppler ultrasound of the lower extremities revealed
significant bilateral arterial insufficiency. An MRA with IV contrast of the abdomen was
performed and the results were impressive. The test revealed complete occlusion of the
infra-renal aorta, superior mesenteric artery and inferior mesenteric artery with the entire
small and large bowel being perfused by collaterals from the celiac axis which was itself
narrowed. Due to these findings, the patient was a poor candidate for open surgery.The
patient was kept nothing by mouth (NPO), kept on Acute Coronary Syndrome (ACS)
protocol and was sent to the cardiac catheterization lab where angiography of the
coronaries and other major vessels was done. At this time, percutaneous transluminal
angioplasty (PTA) of the right subclavian artery was also performed. On day three,
vascular surgery attempted angioplasty with stent placement of the celiac artery but was
not successful due to severe stenosis of the aorta. During her stay, she continued to
have periodic, resolving, supraventricular contractions with mild hypotensive episodes
that the patient was unaware of. Upon stabilization, the patient was discharged to followup
as an outpatient and to return for angioplasty. A repeat attempt to stent the celiac
artery was successfully completed one month later. The patient is currently reported to
be stable with improved symptoms. Future procedures to relieve extensive stenosis may
be required but medical management is preferred at this point in time.
Discussion: Diffuse and severe atherosclerotic disease may present with few
symptoms but poses a large risk of future vascular events including; myocardial
infarction, mesenteric ischemia, cerebrovascular accidents, ischemic extremity and
organ hypo-perfusion, necrosis and failure. Furthermore, Coronary artery disease with
reduced cardiac function may decrease blood perfusion to already narrowed vessels,
exacerbating tissue hypoxia. In patients like this, who present with post-prandial
abdominal pain, extensive work-up must be done with a high index of suspicion for
mesenteric ischemia. If stenosis is severe, revascularization procedures may be
performed to avoid potential bowel infarction and death.