The Intestinal ischemia, intestinal infarction or intestinal necrosis Is a rare but potentially life-threatening disease that causes the death of a part of the intestine due to the narrowing or blockage of one or more of the arteries, thus reducing blood flow.
When it affects the small intestine, it is called mesenteric ischemia and when it affects the large intestine or colon is called ischemic colitis.
It was described in 1918 as"abdominal angina"by Goodman, but it was Shaw in 1958 who performed the first successful surgical revascularization of the Superior mesenteric artery (AMS), demonstrating that recovery was attainable.
Therefore, intestinal ischemia is the clinical condition resulting from the deprivation of oxygen and nutrients necessary to maintain intestinal conditions intact.
Three distinct types of ischemia can be given: acute mesenteric ischemia, chronic mesenteric ischemia, and ischemic colitis.
Acute mesenteric ischemia IMA arises as a consequence of the deficit of blood supply that can affect the small intestine and the right colon, and this in turn can provoke Embolism , Non-occlusive and venous thrombosis.
This, therefore, has a vital risk for the patient, and should be treated as soon as possible to reduce the high mortality of this disease.
In the case of chronic intestinal ischemia BMI, which is unusual but clinically relevant, should be submitted to a revascularization procedure, preferably surgical.
At the moment the procedure that is carried out continues being the surgical intervention next to anticoagulant medicines.
According to the data show us, its prevalence continues to increase in people over 60 years due to the progressive aging of the population.
In this article I will explain the details of intestinal ischemia or infarction and what are the risk factors and ways of preventing it.
Diagnosis of intestinal ischemia
CT scan of a small bowel ischemia due to thrombosis of the superior mesenteric vein. The dilated bowel and the thickened wall are shown.
Fortunately, since 1930 the use of magnetic resonance And Doppler flowmetry have made it possible to detect and perform an early diagnosis.
While the prognosis remains severe, with an early diagnosis, recovery is much more likely.
Even so, its diagnosis is usually late for several reasons, such as the symptoms of bowel ischemia, abdominal pain and weight loss.
Before going on to the techniques used for your diagnosis, some of the considerations to keep in mind are:
-Always consider the risk factors that predispose to intestinal ischemia, such as being over 60 years of age with a previous history of atrial fibrillation, having recently suffered a myocardial infarction, arterial embolism or having had a considerable weight loss.
- Do not underestimate the importance of the picture due to the inexpressiveness of the abdominal examination.
- Keep in mind that pain may be absent in up to 25% of cases of non-occlusive ischemia.
The physician will be the one who values what techniques per image to use, based on their signs and symptoms.
Among the techniques used are:
- I take computerized spelling : X-rays that produce images of cross-sections of structures and organs of the body.
- Ultrasonography with Doppler record : Ultrasound that makes use of sound waves of high frequency to thus create images of the organs of the body. This allows to obtain images of great precision, of the glasses of thickness and of small caliber with a specificity of 92-100% respectively.
This has become an essential procedure in view of the clinical suspicion of an acute mesenteric IMA ischemia.
- Nuclear Magnetic Resonance (NMR) : Nuclear magnetic resonance has a high sensitivity and specificity to detect stenosis or occlusion of AMS or celiac trunk. The procedure used is a magnet plus radio waves.
- MRA angiography By magnetic resonance imaging of blood vessels. One of the advantages is that it provides a surgical map suitable for revascularization.
What is done is to inject a dye into the arteries that supply the intestine, and x-rays are taken to show the location of the arterial obstruction.
- Arteriography : A procedure that uses x-rays and a special dye to look inside the blood vessels.
As for its prevalence according to the data, it has increased, due to the progressive aging of the population and at the present moment represents 1 of every 1000 hospital admissions and in some cases up to 5% of hospital mortality.
Causes
There are several possible causes of intestinal ischemia or infarction.
- Hernia : It occurs when the bowel moves in the wrong place or is trapped and therefore can result in an intestinal infarct, as it would cut off the flow of blood.
- Embolism : This occurs when a blood clot in the heart or major blood vessels, block one of the arteries that goes to the intestine. People who have had a heart attack or who have Arrhythmias , as the Atrial fibrillation , Are at risk of suffering from this problem.
- Adhesions : These can occur when the bowel becomes trapped in the scar tissue of a past surgery, which can lead to ischemia if left untreated.
- Arterial thrombosis: May appear when arteries supplying blood to the intestine are narrowed or blocked due to cholesterol buildup. When this happens in the arteries of the heart, a heart attack occurs, while if it occurs in the arteries that go to the intestine, it would cause an intestinal ischemia.
- Venous thrombosis : Is the cause that the veins that carry the blood from the intestines, can be obstructed by clots of blood. It is commonly found in people with liver disease, cancer, or other blood clotting disorders.
- Low blood pressure : Those patients who, in addition to having a low blood pressure, have a preexisting narrowing of the arteries, can cause an intestinal infarction.
symptom
The symptoms that accompany intestinal ischemia or infarction are:
Sudden and severe stomach pain
It is acute mesenteric ischemia which can cause sudden and severe stomach pain, sometimes accompanied by nausea and vomiting.
- Stomach pain after eating
In this case chronic ischemic mesenteric ischemia often causes severe stomach pain 15-60 minutes after eating.
The pain can last up to 2 hours, and unfortunately has to be repeated with each meal. It can also be accompanied by nausea, vomiting, diarrhea or flatulence.
-Weightloss
It is chronic mesenteric ischemia that sometimes leads to weight loss, because although you feel the need to eat, you eat less or less often to avoid the pain it causes.
Treatments
Treatment usually requires surgical intervention. In this case the section of the dead intestine is removed, and the remaining healthy ends are reconnected.
The Colostomy Or ileostomy is necessary in some cases.
In cases where mesenteric ischemia is acute the treatment to follow is as follows:
-Treatment is usually an emergency procedure since intestinal damage can occur quickly.
-If you find an early clot, your vascular surgeon may recommend thrombolytic therapy. This treatment involves the injection of medications that help dissolve the clots in the blood vessels.
- Use of narcotics can be given to relieve pain.
-When there is evidence of intestinal damage or there is not much time to work against the thrombolytic agent, surgery may be necessary to remove the clot and restore the flow of blood to the arteries of the intestine.
In more chronic cases, the treatment would be as follows:
In most cases, the first-line approach would be minimally invasive endovascular treatment.
Sometimes it is carried out at the same time a Angioplasty With the ball and the placement of a Stent . This procedure involves placing a small balloon that the surgeon swells and deflates to push the plaque against the wall of the artery. Once the artery has widened, the surgeon inserts a stent, which is a small metal mesh tube to keep the blood vessels open.
-In case the person is not a candidate for an angioplasty and placement of a stent, it would be advisable in this case for a bypass surgery.
The surgeon does with bypass surgery is to create a detour around the obstruction or narrow the artery that has been affected.
To create this diversion, either your own veins or a synthetic tube, which is sewn above and below the blocked area, is used to restore blood flow to the intestines.
Finally, although surgery is most advisable, it is always necessary to make adjustments in lifestyle that can help reverse the Atherosclerosis of natural form. As a dietary change, include a diet low in fat and sodium to help reduce cholesterol levels and blood pressure.
Daily exercise can also lower cholesterol and also regulate the pressure and therefore increase the health of your heart.
Some of the medications used in the treatment of intestinal ischemia are the following:
-antibiotics in case it was an infection which caused the blockage in the intestinal arteries.
Vasodilatory drugs such as Hydrazaline To cause dilation of the blood vessels.
-heparin the Warfarin Anticoagulants to prevent future blood clots that block their passage through the arteries.
Risk factor's
Factors that may increase the risk of a bowel disease include:
- The accumulation of fatty deposits in the arteries (atherosclerosis). If you have had other diseases because of atherosclerosis, such as a decrease in blood flow to the heart, legs, or arteries to the brain, you are more likely to have intestinal ischemia.
- Being over 50, smoking high blood pressure, diabetes or high cholesterol, increase the risk of atherosclerosis, and therefore a stroke.
-Another risk factor is certain medications, including birth control pills and medications that cause blood vessels to expand or contract, such as medicines used for migraine or allergies.
- Have blood clotting problems.
- Use of drugs such as cocaine and methamphetamine have been linked to intestinal ischemia.
- Cardiac problems, such as congestive heart failure or irregular heart lice.
Prevention
For the prevention of future intestinal ischemia, it is advisable to follow the following indications:
Eat a nutritious and balanced diet low in fat.
- Exercise regularly.
-Avoid smoking.
-Control heart arrhythmias, blood pressure, diabetes and cholesterol, as it can also help prevent a bowel infarct.
- Stay hydrated, drink 1l of water a day.
Before any signs or severe and recurrent abdominal pain you should seek professional health care.
References
- Chaer, D.R. (s.f.). Society for vascular surgery . Obtained from Society for vascular surgery.
- Chatea V Dang, M. P., & Clinic Professor of the Department of Medicine, University of California, L.A. (16 December 2015). Medscape . Obtained from Medscape.
- Miguel A. Montoro Huguet, J.G. (s.f.). Intestinal ischemia . Obtained from Aegastro.
- Castellví Valls J, Espinosa Cofiño J, Barranco Pons R, Pí Siqués F. Chronic intestinal angina and acute intestinal ischemia. Cir Esp. 2010 [cited 23 Dec 2012]; 87 (5): 318.
- An analysis of the incidence and outcomes of mesenteric ischemia in Maryland, 2009-2013. Donald Harris, Robert S. Crawford, Elena Klyushnenkova, Ronald Tesoriero, Rajabrata Sarkar, Joseph Rabin, Hegang Chen, José Díaz. Journal of Vascular Surgery, Vol. 62, Number 3, P791. Published in the edition: September the year 2015.