VASCULAR ANOMALIES OF THE

INTESTINE

Dr. SAHAL KRAIDY

M.B.CH.B F I C M S DR
LECTURE 4
Mesenteric ischaemia
Mesenteric ischemia can present as one of two distinct clinical syndromes:
acute mesenteric ischemia and chronic mesenteric ischemia.

Four distinct pathophysiologic mechanisms can lead to acute mesenteric

ischemia:

1. Arterial embolus
2. Arterial thrombosis
3. Vasospasm (also known as nonocclusive mesenteric ischemia[NOMI])
4. Venous thrombosis

Occlusion at the origin of the superior mesenteric artery (SMA) is almost

invariably the result of thrombosis, whereas emboli lodge at the origin of
the middle colic artery. Inferior mesenteric involvement is usually clinically
silent because of a better collateral circulation.
Thrombosis Vs. Embolism
?
Possible sources for the embolisation of the SMA include
a left atrium associated with fibrillation, a mural myocardial
infarction, an atheromatous plaque from an aortic
aneurysm and a mitral valve vegetation associated with
endocarditis.
Primary thrombosis is associated with atherosclerosis and
thromboangitis obliterans.
Primary thrombosis of the superior mesenteric veins may
occur in association with factor V Leiden,portal
hypertension, portal pyaemia and sickle cell disease and in
women taking the contraceptive pill.
 Pathology
ACUTE ISCHEMIA

Irrespective of whether the occlusion is arterial or venous,

haemorrhagic infarction occurs. The mucosa is the only layer of
the intestinal wall to have little resistance to ischaemic injury.
The intestine and its mesentery become swollen and oedematous.
Blood-stained fluid exudes into the peritoneal cavity and
bowel lumen.
If the main trunk of the SMA is involved, the
infarction covers an area from just distal to the duodenojejunal
flexure to the splenic flexure. Usually, a branch of the main
trunk is implicated and the area of infarction is less.
Chronic ischemia

In contrast, chronic mesenteric ischemia develops

insidiously,allowing for development of collateral circulation,
and,therefore, rarely leads to intestinal infarction. Chronic
mesenteric arterial ischemia results from atherosclerotic
lesions in the main splanchnic arteries (celiac, superior
mesenteric, and inferior mesenteric arteries). Most patients
with chronic mesenteric venous thrombosis
are asymptomatic because of the presence of extensive
collateral venous drainage routes;
Clinical features

The most important clue to an early diagnosis of acute

mesenteric ischaemia is the sudden onset of severe
abdominal pain in a patient with atrial fibrillation or
atherosclerosis.
Severe abdominal pain, out of proportion to the degree of
tenderness on examination, is the hallmark of acute
mesenteric ischemia, regardless of the pathophysiologic
mechanism.
The pain is typically perceived to be colicky and most severe in
the midabdomen. Associated symptoms can include nausea,
vomiting, and diarrhea. Physical findings are characteristically
absent early in the course of ischemia. With the onset of
bowel infarction, abdominal distension, peritonitis, and
passage of bloody stools occur.
Chronic mesenteric ischemia presents insidiously. Postprandial
abdominal pain is the most prevalent symptom, producing a
characteristic aversion to food (“food fear”) and weight loss.
These patients are often thought to have a malignancy and
suffer a prolonged period of symptoms before the correct
diagnosisis made.
Hypovolaemic shock rapidly ensues. Abdominal tenderness may
be mild initially with rigidity being a late feature
Work up
Investigation will usually reveal a profound neutrophil
leukocytosis
an absence of gas in the thickened small intestine on
abdominal radiographs.
The presence of gas bubbles in the mesenteric veins is
rare but pathognomonic.
Angiography is the gold standard
managment
Treatment needs to be tailored to the individual.

full resuscitation,

embolectomy via the ileocolic artery or revascularisation of the SMA may be

considered in early embolic cases.

The majority of cases, however, are diagnosed late all affected bowel should
be resected,
Anticoagulation should be implemented early in the postoperative
period.
After extensive enterectomy, it is usual for patients to require
intravenous alimentation.

Second look laparotomy

Assesment of bowel viability intaopertive?
Assesment of bowel viability:
Pink serosa
Visible peristalsis
Bleeding from cuting edges
Positive pulsation
Ischaemic colitis

Ischaemic colitis describes the structural changes that

occur in the colon as a result of the deprivation of
blood. They are most common in the splenic flexure,
whose blood supply is particularly tenuous.

Intestinal ischemia occurs most commonly in the colon.

Unlike small bowel ischemia, colonic ischemia rarely is
associated with major arterial or venous occlusion.
Instead, most colonic ischemia appears to result from
low flow and/or small vessel occlusion.
 Short bowel syndrom
Short-bowel syndrome is a disorder clinically defined by
malabsorption, diarrhea, steatorrhea, fluid and
electrolyte disturbances, and malnutrition
Any disease, traumatic injury, vascular accident, or
other pathology that leaves less than 200 cm of
viable small bowel or results in a loss of 50% or more
of the small intestine places the patient at risk for
developing short-bowel syndrome.
.
Several operative or invasive procedures and therapies
have been designed for and applied to the treatment
of short-bowel syndrome. These include the
establishment of central venous access for delivery
of total parenteral nutrition (TPN), intestinal
transplantation, and nontransplantation abdominal
operations. The history of these various treatment
strategies is discussed in this section
 the ‘watershed’ area
Adjacent branches of the superior and inferior mesenteric
arteries anastomose so there is usually a complete
vascular supply along the colon named the ‘marginal
artery of Drummond’.
The blood flow in the ‘watershed’ area of the splenic
flexure representing the junction between the superior
and inferior mesenteric supply may be quite tenuous.
The consequences of this might be, for example, that
sudden occlusion of the inferior mesenteric artery may
leave the area of the splenic flexure (at the most distal
point of supply from the superior mesenteric artery)
poorly perfused, leading to an ischaemic colitis
•
The young, however, may sometimes develop sufficient
intestinal digestive and absorptive function to lead
relatively normal lives. In selected cases, consideration may
be given to small bowel transplantation.
Infarction of the large intestine alone is relatively rare.

Involvement of the middle colic artery territory should be

treated by transverse colectomy and exteriorisation of both
ends, with an extended right hemicolectomy in selected
cases.
Risk factors
include vascular disease,
diabetes mellitus,
vasculitis,
hypotension,
and tobacco use.
In addition, ligation of the inferior mesenteric artery during
aortic surgery predisposes to colonic ischemia.
Occasionally, thrombosis or embolism may cause
ischemia. Although the splenic flexure is the most
common site of ischemic colitis, any segment of the
colon may be affected. The rectum is relatively spared
because of its rich collateral
Circulation..
Clinical features

Signs and symptoms of ischemic colitis reflect the extent of

bowel ischemia. In mild cases, patients may have diarrhea
(usually bloody) without abdominal pain. With more severe
ischemia, intense abdominal pain (often out of proportion to
the clinical examination), tenderness, fever, and leukocytosis
are present. Peritonitis and/or systemic toxicity are signs of
fullthickness necrosis and perforation.
Work up
The diagnosis of ischemic colitis is often based on the clinical
history and physical examination.
Plain films may reveal thumb printing, which results from
mucosal edema and submucosal hemorrhage.
CT often shows nonspecific colonic wall thickening and pericolic
fat stranding.
Angiography is usually not helpful because major arterial
occlusion is rare.
While sigmoidoscopy may reveal characteristic dark,
hemorrhagic mucosa, the risk of precipitating perforation is
high. For this reason, sigmoidoscopy is relatively
contraindicated in any patient with significant abdominal
tenderness.
Contrast studies (Gastrografin or barium enema) are similarly
contraindicated during the acute phase of ischemic colitis.
managment
Treatment of ischemic colitis depends on clinical
severity.Unlike ischemia of the small bowel, the majority of
patients with ischemic colitis can be treated medically.
Bowel rest and broad-spectrum antibiotics are the mainstay of
therapy, and
80% of patients will recover with this regimen.
Hemodynamic parameters should be optimized, especially if
hypotension and
low flow appear to be the inciting cause.
Long-term sequelae include stricture (10%–15%) and chronic
segmental ischemia
(15%–20%).
Colonoscopy should be performed after recovery to evaluate
strictures and to rule out other diagnoses such as
inflammatory bowel disease or malignancy. Failure to improve
after 2 to 3 days of medical management, progression of
symptoms,
and deterioration in clinical condition are indications for
surgical exploration. In this setting, all necrotic bowel should
be resected. Primary anastomosis should be avoided.
Occasionally,
repeated exploration (a second-look operation) may necessary
THANK YOU
Angiodysplasia
Angiodysplasia is a vascular malformation that is a
cause of
haemorrhage from the colon, typically in patients
over 60 years.
The lesions are also called angiomas,
haemangiomas and arteriovenous
malformations. Angiodysplasias occur
particularly in the ascending colon and caecum of
elderly patients. The malformations consist of
dilated tortuous submucosal veins and in severe
cases the mucosa is replaced by massive dilated
deformed
vessels.
Clinical features
In the majority, the symptoms are subtle and patients can
present with anaemia. About 10–15 per cent of patients have
brisk bleeds, which may present as melaena or significant
rectal
bleeding. It is likely that in many patients in whom rectal
bleeding
has been attributed to diverticular disease, bleeding was in
fact from angiodysplasia. There is an association with aortic
stenosis (Heyde’s syndrome).
Investigation

If the bleeding is not too brisk, colonoscopy may show the

characteristic lesion in the right colon. The lesions are only a few
millimetres in size and appear as reddish, raised areas at endoscopy.
Capsule endoscopy is a relatively new technology that
may detect small bowel lesions.
Selective superior and inferior mesenteric angiography shows the site
and extent of the lesion by a ‘blush’ of contrast provided bleeding is
above 1 mL/min.
If this fails, a technetium-99m (99mTc)-labelled red cell scan may
confirm and localise the source of haemorrhage.
Treatment

The first principle is to stabilise the patient. Following

this,
thebleeding needs to be localised.
Colonoscopy may allow cauterisation to be carried out. In
severe uncontrolled bleeding,
Surgery becomes necessary. On-table colonoscopy is
carried out to confirm the site of bleeding.
Angiodysplastic lesions are sometimes demonstrated by
transillumination through the caecum
If it is still not clear exactly which segment of the colon
is involved, then a subtotal colectomy may be necessary.