Expert Review of Gastroenterology & Hepatology

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Acute mesenteric ischemia in elderly patients

J. M. Kärkkäinen

To cite this article: J. M. Kärkkäinen (2016) Acute mesenteric ischemia in elderly patients, Expert
Review of Gastroenterology & Hepatology, 10:9, 985-988, DOI: 10.1080/17474124.2016.1212657

To link to this article: https://doi.org/10.1080/17474124.2016.1212657

Published online: 21 Jul 2016.

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EXPERT REVIEW OF GASTROENTEROLOGY & HEPATOLOGY, 2016
VOL. 10, NO. 9, 985–988
http://dx.doi.org/10.1080/17474124.2016.1212657

EDITORIAL

Acute mesenteric ischemia in elderly patients

J. M. Kärkkäinen
Heart Center, Kuopio University Hospital, Kuopio, Finland

ARTICLE HISTORY Received 31 May 2016; accepted 6 July 2016; published online 21 July 2016

KEYWORDS Acute mesenteric ischemia; acute on chronic; elderly; revascularization; computed tomography; diagnosis

1. Introduction the mesentery is currently the most common etiology [6,7].

Unfortunately, population-based studies with high autopsy
Acute mesenteric ischemia (AMI) is more common than gen-
frequency have not been performed in the current century,
erally thought, and the disease is often caused by mesenteric
so there is no definitive proof of any change in the etiological
atherosclerotic occlusive disease especially in the elderly. The
spectrum of AMI. Even so, the population is getting older
atherosclerotic etiology is as common as the embolic etiology,
(which means more atherosclerosis), and the use of anticoa-
if not more so. Approximately half of the patients with ather-
gulation therapy has increased (less embolic events) [8].
osclerotic etiology present with acute thrombotic occlusion of
Nowadays, the classic presentation of AMI, i.e. ‘severe, poorly
the superior mesenteric artery (SMA), while the other half
localized abdominal pain that is out of proportions to the
develop acute ischemia upon chronic occlusive multivessel
physical examination’, is becoming a rarity, while the so-called
disease of the mesenteric arteries. The symptoms and clinical
‘acute on chronic’ presentations of mesenteric ischemia are
findings are often obscure. Clinical suspicion is a major factor
more common, and probably underdiagnosed. The classical
in the correct interpretation of computed tomography (CT)
characterization of AMI seems to apply only when AMI is
findings as some patients develop acute ischemia gradually
caused by acute embolic occlusion of previously unobstructed
from previously symptomatic or asymptomatic chronic mesen-
SMA. Patients who develop AMI upon atherosclerotic occlu-
teric ischemia, and the ischemia-specific signs may not yet
sive disease of the mesenteric arteries often present with
have been developed at the time of the imaging. Patients
insidious onset of obscure symptoms such as vague abdom-
with symptomatic chronic mesenteric ischemia require urgent
inal pain, vomiting, and diarrhea, and the diagnosis can be
treatment before the disease culminates in AMI with much
incredibly difficult.
worse prognosis.
It is important to recognize that there is only ‘a thin red line’
between chronic mesenteric ischemia and AMI. Patients with
2. Acute mesenteric ischemia is more common than symptomatic chronic mesenteric ischemia (abdominal angina)
expected in the elderly are at high risk of developing AMI. In one study, more than 80%
of patients with acute on chronic mesenteric ischemia had been
AMI due to arterial occlusive disease is generally considered a
previously hospitalized or evaluated at hospital for the same com-
rare condition with hospital incidence rates ranging from 4.5
plaints, often within half year before the final admission [9].
to 5.4 per 100,000 person-years [1–3]. On the other hand, it
Therefore, patients with clearly symptomatic chronic mesenteric
has been shown that AMI is 1.5 times more common abdom-
ischemia need to be evaluated and revascularized preferably
inal emergency than ruptured abdominal aortic aneurysm
within days or, if anyhow possible, with equivalent urgency as if
[1,4]. Rare or not, AMI should never be overlooked as a possi-
the patient had acute coronary syndrome. If symptoms persist for
ble cause of acute abdomen especially in the elderly. The
hours after meal, the patient may already have gone into an
incidence of AMI increases exponentially with age. In patients
irreversible state of bowel ischemia, and emergency revasculariza-
aged 75 years or older, AMI is a more prevalent cause of acute
tion may be necessary (even though fluid resuscitation and correc-
abdomen than appendicitis [1]. The incidence of AMI is
tion of anemia may sometimes reverse the acute symptoms). Any
roughly 10-fold in an 80-year-old than in a 60-year-old patient
unnecessary delay will risk the patient developing fulminant AMI.
[1,4].

4. Clinical suspicion is a key factor in early diagnosis

3. Atherosclerotic occlusive disease may currently
of AMI
be the most common cause of AMI
The diagnostic accuracy of imaging alone in AMI should not be
Decades ago, SMA embolism was determined as the most
overestimated. In two systematic reviews, CT was associated with
common cause of AMI [5]. Based on contemporary data, how-
as high as 89–100% sensitivity and specificity in AMI [10,11].
ever, it would seem that atherosclerotic occlusive disease of

CONTACT J. M. Kärkkäinen jkarkkai@gmail.com Heart Center, Kuopio University Hospital, P.O. Box 100 Kuopio 70029, Finland
© 2016 Informa UK Limited, trading as Taylor & Francis Group
986 J. M. KÄRKKÄINEN
Unfortunately, there is a discrepancy between the study setting
and practice. First, the studies were performed exclusively on
patients with clinical suspicion of AMI prior to the imaging, and
the CTs were performed in optimal (biphasic) imaging protocols.
Second, the majority of the study patients seemed to have
advanced intestinal ischemia (proving to be fatal or requiring
bowel surgery). These factors make the CT findings in AMI more
prominent and easier to detect, but the reality is different in the
daily life of the emergency department where AMI is found unex-
pectedly in the CT (without prior clinical suspicion) in two-thirds of
the cases, and the CTs of acute abdominal pain are often per-
formed in venous phase alone unless the clinician has specifically
inquired for AMI [7]. Furthermore, we should aim to detect AMI
before irreversible bowel injury has occurred. In ‘still reversible’
phase of bowel ischemia, the CT findings are more subtle and
difficult to detect, and especially because of this, clinical suspicion
is a major factor in the correct CT interpretation [7,12].
There are few studies on the diagnostic accuracy of CT in AMI
that have been performed in patients with unclear acute or sub-
acute abdominal pain in the clinical routine (based on the duty
radiologist’s report) [7,12,13]. These studies showed no more than
67–86% rate of correct CT diagnosis, and roughly half of the AMI
patients in these studies had advanced bowel ischemia, whereas
the other half had reversible ischemia.
5. Disregarding the elderly in patient selection is a
major bias in the literature on AMI
The treatment outcome in AMI depends highly on patient selec-
tion. If you treat only relatively young and low-risk patients with
mild peritoneal signs, you obviously get better results than if you
would treat all the high-risk elderly patients and those with severe
peritonitis. The problem with many reports regarding AMI treat-
ment outcomes is that, too often, it is not clearly disclosed what
percentage of all patients with AMI in the population was actively
treated with revascularization, and how many patients were trea-
ted with bowel resection alone, or with mere comfort care.
Currently, the most often referred papers regarding open and
endovascular therapy in AMI are probably the studies by
Schermerhorn and Arthurs [8,14]. The paper by Schermerhorn
et al. provided outcomes of endovascular and open therapy in
acute and chronic mesenteric ischemia based on the National
Inpatient Sample. It is a database that contains a 20% sample of
hospital stays in approximately 1000 hospitals in the United States;
thus, the huge numbers of patients in that study actually repre-
sented weighted estimates for the entire population. Nevertheless,
the study showed lower mortality rate after endovascular therapy
than after open revascularization for patients with AMI (16% vs.
28%). The problem, however, was that the overall revascularization
rate of all patients with AMI in that study was probably very low.
Although this was not discussed directly in the paper, the suspicion
was raised by another study based on the same database by
Bealieu et al.; the total revascularization rate in AMI in the
National Inpatient Sample was less than 3%, while 17% were
treated with bowel resection alone, and disturbingly, 80% received
no intervention whatsoever [15].
In the single-center report by Arthurs et al., 70 consecutive
patients received primarily endovascular (n = 56) or open
(n = 14) revascularization for AMI with commendable results
(39% overall mortality) [14]. However, the mean age of the
patients, 64 years, was very low compared to the mean age of
approximately 80 years in other studies that include unselected
patients with AMI (due to arterial occlusive etiology) [1,4]. Thus, the
patient population in the Arthurs’ study does not represent the
majority of AMI patients.
This problem is uniform in the current literature on AMI, and the
Arthurs’ and Schermerhorn’s papers are just two examples of
extremely well-performed studies, but even so, these factors
must be taken into account when interpreting the results of AMI
treatment modalities.
6. When publishing outcomes of AMI treatment, it is
mandatory that all cases with AMI are reported, not
just those selected for active treatment
In our institution, we see nearly all patients with acute abdomen
from a well-defined population of 250,000 inhabitants. Between
the years 2009 and 2013, we treated 66 patients with arterial
occlusive AMI of whom 50 (mean age 79 ± 9 years) received
attempt at endovascular therapy constituting a 76% revasculariza-
tion rate and proving technically successful in 44 (88%) of the
cases. Thus, these were fairly unselected AMI patients. The 30-
day mortality of the 50 patients who received either successful or
failed attempt at endovascular revascularization was 32%, and the
overall mortality of all 66 patients with AMI was 42%. Resection of
gangrenous bowel was required in one-third of the patients, and
more than half avoided laparotomy altogether [16]. Our current
treatment algorithm is presented in Figure 1.
During our 5-year study period, only half of the patients with
atherosclerotic occlusive etiology of AMI presented with a clearly
visible thrombotic clot in the contrast-enhanced CT. Thus, half of
the patients developed AMI upon chronic mesenteric ischemia
either due to microthrombosis (that is not clearly visualized in
CT) or due to some other sudden decrease in the bowel perfusion
(dehydration, hypovolemia, and anemia). Although all our AMI
patients with atherosclerotic etiology had severe occlusive disease
of the mesentery, oftentimes, it could only be speculated why the
chronic state suddenly manifested as AMI; in some cases, even the
thrombotic clot that was clearly seen in the CT proved to be a
chronic thrombus (based on earlier CT scans), and yet, the patient
had acute bowel necrosis [7]. If this is not confusing enough, one-
third of our patients with atherosclerotic AMI presented without
any specific CT sign (defined as thrombotic clot of the SMA,
decreased bowel wall enhancement, or pneumatosis). But if it is
of any comfort, all patients did have at least some abnormal,
however, unspecific intestinal signs in their CT examinations such
as luminal dilatation (i.e. paralysis), bowel wall thickening, and
mesenteric fat stranding (i.e. mesenteric edema), and these find-
ings together with occlusion or subtotal occlusion of the SMA
might help the clinician to make the diagnosis [17].
Finally, the diagnosis of AMI must be based on clinical findings,
laboratory findings, and CT findings, all together. High suspicion of
AMI is encouraged in elderly patients with acute or subacute
abdominal pain, especially in those with prior cardiovascular risk
factors, occlusive mesenteric atherosclerosis, and abnormal intest-
inal signs (specific or unspecific) in contrast-enhanced CT. Patients
who slowly develop AMI upon chronic mesenteric ischemia are
difficult to diagnose but seem to have very good survival after

Figure 1. The current treatment algorithm of AMI in our hospital. In stable patients, we seek to revascularize by endovascular means first; we convert to laparotomy
if the endovascular approach is unsuccessful or unfeasible, or if the symptoms do not resolve soon after successful endovascular revascularization. In patients with
septic peritonitis, laparotomy is always required.
(endovascular) revascularization even despite several days’ dura-
tion of symptoms and high inflammatory marker values [9,16,17].
In contrast, decreased bowel wall enhancement, pneumatosis, and
metabolic acidosis are strong signs of advanced bowel ischemia
and indicate the need for surgical intervention.
Acknowledgments
The author was funded by the Interventional Radiologists of Finland society.
Funding
This paper was not funded.
Declaration of interest
The authors have no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
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