Angina

Superior mesenteric (mesenteric) artery syndrome. Acute disorders of mesenteric circulation

Thrombosis of the superior mesenteric artery- a disease that can lead to serious circulatory problems. It is the upper artery that is most often susceptible to the formation of blood clots, unlike the lower one. As a result of such a violation, mesenteric thrombosis occurs, ultimately leading to the death of the patient.

What kind of disease is this?

Thrombosis is nothing more than a blockage of a vessel, followed by blockage of blood flow. This is a very serious disease that can lead to serious consequences, including death. It is very difficult to accurately diagnose and just as difficult to treat, especially if the disease is advanced. Therefore, at the first suspicion of thrombosis of the mesenteric arteries, contact our center for a full examination and timely treatment. This disease can occur in different forms, its severity mainly depends on the size of the blocked vessel. In addition, the timeliness of detection of characteristic symptoms, which we will describe below, also affects.

Causes of the disease

Most often, such thrombosis occurs in the following diseases:

. periarteritis nodosa;
Atherosclerosis;
Ulcerative endocarditis;
Vascular injuries;
Infection;
Parietal endocarditis.

Basically, the disease appears as a result of various diseases of the cardiovascular system, including after a myocardial infarction. Also, the causes of thrombosis of the superior mesenteric artery include portal hypertension and pylephlebitis - purulent processes in the abdominal cavity.

Main symptoms

Thrombosis of the upper mesenteric vessels begins unexpectedly, and such an important symptom as abdominal pain appears, as with appendicitis. Sometimes these pains are constant, and sometimes they appear in waves, with periodic attenuation. The next symptoms are vomiting and nausea. They appear already in the first hours of the disease. Over time they become permanent. Frequent stools with blood clots may also be observed. In addition, at the very beginning of the disease the following symptoms may be observed:

. increased heart rate;
Wet tongue;
Soft belly.

The more thrombosis develops, the more severe the symptoms become. Over time, bloating and intestinal obstruction appear, as well as gas and stool retention.

Diagnosis of mesenteric artery thrombosis

Diagnosis of this disease, as well as treatment, is considered extremely difficult. First of all, the recognition of such thrombosis is that it occurs extremely rarely, and most doctors, even if they have heard of it, have probably never encountered it. Our center employs specialists who know first-hand about mesenteric artery thrombosis. Vast experience in diagnosing and treating this disease will greatly increase your chance of successful treatment. When the pathology is in the last stage, an x-ray examination of the abdominal cavity is used for diagnosis. This is especially true in the presence of paralytic intestinal obstruction. Diagnosing this disease is very difficult; exploratory laparotomy is almost always used to clarify it. The most effective diagnostic method today is selective angiography. If there is no contrast on the angiogram of the arterial trunk, as well as its branches, then this indicates the presence of thrombosis of the mesenteric artery.

Treatment of thrombosis

The primary task of the doctor when treating thrombosis of the superior mesenteric artery is to combat the weakening of the functionality of the cardiovascular system. First, the patient, who is in a lying position, is injected with anti-shock liquid, caffeine and camphor. In order to relieve pain, morphine is actively used. If stool with bloody discharge or hemoptysis is observed, the patient is injected intramuscularly with anti-diphtheria serum. A solution of table salt and calcium is also injected into the vein. Ascorbic acid is prescribed.

But all this is relevant only if the disease is at an early stage of development; in more severe forms, thrombosis is treated in other ways. In this case, treatment involves surgery. This is the only effective way to eliminate thrombosis of the superior mesenteric artery, occurring in an acute form. And here it should be remembered that we are talking not only about the health of the patient, but also about saving his life. Reconstructive surgery is performed only if the absence of intestinal necrosis is confirmed. Such surgery can be performed using various techniques, including:

. embolectomy;
Resection of the superior mesenteric artery;
Endarterectomy.

If the patient has intestinal gangrene, artery resection is performed. In some cases, the techniques are combined, for example, reconstructive vascular surgery is used together with resection. If we talk about the treatment of this disease through surgery, it is worth noting that after surgery, deaths are not uncommon. It depends on how advanced the disease is, and the complexity of the operation itself and diagnosing thrombosis. The sooner surgery is performed, the better the result will be.

Where to find a specialist?

As we have already written, this disease is very difficult to diagnose and treat. An inexperienced specialist can easily confuse it with other diseases, which will result in serious consequences. Therefore, it is extremely important to take your choice of doctor and medical institution seriously. Our center will be happy to provide you with its services for the diagnosis and treatment of thrombosis of the superior mesenteric arteries. We can do this because we employ experienced specialists who are familiar with all manifestations of this disease, and they are ready to apply their knowledge and do everything to help you!

A large number of conservative treatments have been proposed for the treatment of superior mesenteric artery embolism. The results of some of them are quite convincing, for example, after intra-arterial administration of papaverine (the drug is administered through a catheter to perform angiography). There are cases of spontaneous resolution of the symptoms of mesenteric artery embolism after infusion therapy, replenishment of the volume of circulating fluid, and sometimes after the administration of dextran.

Although conservative treatment methods are sometimes successful in patients with acute embolism of the superior mesenteric artery, the best results are observed with surgical intervention. After laparotomy, the superior mesenteric artery is usually opened in a transverse direction at its origin from the aorta behind the pancreas. An embolectomy is performed, and once blood flow is restored through the superior mesenteric artery, the small bowel is carefully examined to determine its viability. To identify irreversible ischemic changes in the intestinal wall, a fairly large number of different tests have been proposed. Most often, a routine examination of the intestine is performed, which is often quite sufficient. The final conclusion about the condition of the intestinal wall is made after the intestine is warmed for 30 minutes, either by lowering it into the abdominal cavity or by covering it with napkins moistened with warm saline solution. If there are signs of necrosis, intestinal resection is performed with end-to-end interintestinal anastomosis using a stapler. After the operation, the patient is sent to the intensive care unit. Typically, in patients who have undergone bowel resection due to bowel necrosis due to acute embolism of the superior mesenteric artery, a repeat operation, the so-called “secondlook,” is undertaken 24 hours later in order to examine the anastomosed edges of the bowel and ensure their viability. During the first operation, some surgeons prefer not to perform an interintestinal anastomosis, but suture both ends of the intestine using staplers. During reoperation, if a viable intestine is present, an interintestinal anastomosis is performed.

There are several reasons for the relatively high mortality rate after embolectomy from the superior mesenteric artery. Such patients often have very severe cardiovascular diseases that do not allow them to undergo major surgical interventions. Sometimes the diagnosis of embolism of the superior mesenteric artery is made late, which leads to the development of extensive intestinal necrosis. Systemic purulent-septic complications and enteral insufficiency due to resection of a large section of intestine also aggravate the condition of patients and often lead to death.

Abdominal pain associated with intestinal obstruction

Indications for surgical intervention for intestinal obstruction
Treatment of superior mesenteric artery embolism

Embolism of the superior mesenteric artery manifests itself as an acute onset of intense abdominal pain, usually localized in the umbilical region, but sometimes in the right lower quadrant of the abdomen. The intensity of pain often does not correspond to the data obtained from an objective examination of such patients. The abdomen remains soft upon palpation, or there is only slight soreness and tension in the muscles of the anterior abdominal wall. Intestinal peristalsis is often heard. Patients with superior mesenteric artery embolism often experience nausea, vomiting, and often diarrhea. In the early stages of the disease, stool examination reveals a positive reaction to occult blood, although, as a rule, there is not a large amount of blood in the stool.

A careful history of the disease can suggest the cause of the embolism. Classically, such patients always have signs of diseases of the cardiovascular system, most often atrial fibrillation, recent myocardial infarction or rheumatic lesions of the heart valves. A careful history often reveals that patients have had previous episodes of embolism, both in the form of strokes and peripheral arterial embolisms. Angiography can identify the following emboli localization options:

Mouth (5.2%)

– the blood supply to the entire small intestine and the right half of the colon is disrupted

I segment (64.5%) – the embolus is localized to the origin of the a.colica media

– just as when the embolus is localized at the mouth of the superior mesenteric artery, the blood supply to the entire small intestine and the right half of the colon is disrupted

II segment (27.6%) – the embolus is localized in the area between the points of origin of a.colica media and a.ileocolica

– the blood supply to the ileum and ascending colon to the hepatic flexure is disrupted

III segment (7.9%) – the embolus is localized in the area below the origin of the a.ileocolica

– blood supply to the ileum is disrupted

Combination of segment I embolism with occlusion of the inferior mesenteric artery

– blood supply to the entire small and large intestine is disrupted

Treatment. A large number of conservative treatments have been proposed for the treatment of superior mesenteric artery embolism. Although conservative treatment methods are sometimes successful in patients with acute embolism of the superior mesenteric artery, the best results are observed with surgical intervention. After laparotomy, the superior mesenteric artery is usually opened in a transverse direction at its origin from the aorta behind the pancreas. An embolectomy is performed, and once blood flow is restored through the superior mesenteric artery, the small bowel is carefully examined to determine its viability. To identify irreversible ischemic changes in the intestinal wall, a fairly large number of different tests have been proposed. Most often, a routine examination of the intestine is performed, which is often quite sufficient. The final conclusion about the condition of the intestinal wall is made after the intestine is warmed for 30 minutes, either by lowering it into the abdominal cavity or by covering it with napkins moistened with warm saline solution. If there are signs of necrosis, intestinal resection is performed with end-to-end interintestinal anastomosis using a stapler. After the operation, the patient is sent to the intensive care unit. Sometimes, in patients who have undergone intestinal resection due to its necrosis due to acute embolism of the superior mesenteric artery, a second operation is undertaken after 24 hours, the so-called in order to examine the anastomosed edges of the intestine and ensure their viability. During the first operation, some surgeons prefer not to perform an interintestinal anastomosis, but suture both ends of the intestine using staplers. During reoperation, if a viable intestine is present, an interintestinal anastomosis is performed.

Access- median laparotomy. The mesenteric vessels are inspected, the level and type of occlusion (embolism, thrombosis, atherosclerosis), the state of collateral circulation, the state of the intestine, and the length of the infarction are determined. First, it is recommended (I.V. Spiridonov, 1973) to resect clearly necrotic intestinal loops with economical excision of the mesentery and leaving intestinal loops of questionable viability. Then surgery is performed on the blood vessels.

Usually limited to simple intervention- thromboembolectomy. Indications for longer-term reconstructive interventions (endarterectomy, bypass surgery) arise very rarely due to the severity of the general condition of the patients. A solution of novocaine is injected into the root of the mesentery. After restoration of blood circulation, the viability of “doubtful” areas of the intestine is finally assessed.

The main trunk of the superior mesenteric artery is isolated below the transverse colon or above it through the gastrocolic ligament. Abduction of the transverse colon upward and tension of its mesentery and a. colica media facilitate detection of the superior mesenteric artery.

Accessible and convenient site for embolectomy of the superior mesenteric artery- between the departure of a. pancreaticoduodenalis inferior and a. Colica media. The artery is of sufficiently large diameter and for embolectomy it is opened by a transverse arteriotomy. The embolus and thrombus are removed using blood pressure when clamping the aorta with a hand distal to the mouth of the mesenteric artery, using the milking technique or balloon catheters (I. V. Spiridonov, 1973; D. Glotzer, P. Glotzer, 1966).

In severe condition of the patient, the embolus can be pushed (without arteriotomy using the milking method) into the aorta and internal iliac artery (the corresponding vessels must be clamped) or into one of the main arteries of the pelvis, and then into the femoral artery with its subsequent removal (Eastcott, 1969).

After removing the obstacle, 10,000 units of heparin and 20-30 ml of 0.25% novocaine solution are injected into the artery. The wound is sutured with an atraumatic thread 5-0 or 6-0 or an autovenous patch is used.

After surgery, intestinal gangrene may continue, especially if questionable areas of the intestine remain with high occlusion. In such cases, relaparotomy in the first 24-48 hours after surgery with resection of a segment of intestine can be successful.

After restoration of blood circulation in the intestines, patients undergo intensive therapy, and often resuscitation measures in case of collapse due to acutely developing metabolic acidosis and hyperkalemia. 5-10 minutes before restoration of pulsating blood flow in the mesenteric artery, as well as in the postoperative period, a solution of sodium bicarbonate and dextrans are poured into a vein. If blood pressure drops, blood transfusion, polyglucin, and hydrocortisone are administered. A prolonged decrease in pressure can cause re-thrombosis of the vessel and progression of ischemic damage to the intestine.

“Surgery of the aorta and great vessels”, A.A. Shalimov

Acute occlusion of mesenteric vessels is a relatively rare disease and occurs, according to D. F. Skripnichenko (1970), in 3% of patients with acute intestinal obstruction. Most often, intestinal infarction is caused by blockage of the superior mesenteric artery branches due to embolism (60-90%) or acute thrombosis (10-30%). The main source of embolism is heart clots in rheumatic and atherosclerotic lesions, myocardial infarction, endocarditis,…

Acute intestinal ischemia causes progressive changes in the absence of collateral blood flow, which become irreversible after 2-4-6 hours. Intestinal viability can be restored if blood flow disturbances are corrected during this period. However, even if intestinal resection is not required, the consequences of ischemic infarction remain in the form of fibrosis with disruption of the absorptive and motor-secretory functions of the intestine with a normal macroscopic picture. At…

The clinical picture of acute obstruction of the mesenteric arteries is in many ways similar to acute abdominal syndrome of another etiology. An acutely progressive course and at the same time, especially in the initial period, scant objective data are very characteristic. Abdominal pain - the first and main symptom - occurs suddenly. The pain is severe, usually constant, in the umbilical region, and then throughout the abdomen, ...

The disease must be differentiated from a perforated gastric ulcer, acute pancreatitis, cholecystitis, myocardial infarction occurring with pseudo-abdominal angina syndrome. Early timely diagnosis of the disease is difficult even in typical cases. In approximately 6% of patients it is diagnosed in a timely manner (Schlosser et al., 1975). Difficulties in diagnosis, on the one hand, lie in the rarity of the disease, and on the other hand, in a very short period from...

Treatment of acute obstruction of mesenteric vessels is surgical. Preoperative preparation includes premedication, nasogastric intubation with constant aspiration of gastric contents, catheterization of a vein to measure venous pressure and intravenous infusions, determination of blood type, Rh factor and electrolytes (it is especially important to determine the level of potassium in the blood serum, which can be significantly elevated), intravenous transfusion of glucose solution with insulin, plasma, hemodez, rheopolyglucin,...

Superior mesenteric syndrome (mesenteric) arteries is a rare pathology caused by partial compression of the lower horizontal part of the duodenum by the superior mesenteric artery.

Synonyms

Wilkie syndrome(Wilkie)
superior mesenteric artery syndrome

Epidemiology

Rarely encountered, but easily recognized. About 400 cases have been described in the English-language literature. It is more common in women and usually begins in childhood and adolescence.

Anatomy

Superior mesenteric artery originates at the level of the first lumbar vertebra and departs from the aorta at an acute angle. The horizontal (lower) part of the duodenum ( pars horizontalis /inferior/), crosses the aorto-mesenteric angle at the level of the third lumbar vertebra, the left renal vein passes below the duodenum. Normally, the aorto-mesenteric angle is 38–65°, and the distance between the vessels is in the range of 13–34 mm.

Pathology

Anatomical causes of the syndrome include pronounced lumbar lordosis, an abnormally high attachment of the duodenojejunal flexure of the ligament of Treitz, an abnormally low origin of the SMA, or a decrease in the amount of fatty tissue in the aorto-mesenteric angle.

Diagnostics

Diagnosis of superior mesenteric artery syndrome is based on a combination of clinical presentation and imaging findings indicating obstruction. Diagnostic criteria for SMA syndrome include a decrease in angle to 6–16° and a decrease in distance to 5–11 mm.

CT/MRI

CT and MR angiography can visualize compression of the superior mesenteric artery of the duodenum by measuring the angle of origin and the distance between the SMA and the aorta:

Normally, the angle between the SMA and the aorta ranges from 38–65°, and the distance between the vessels is 13–34 mm
with superior mesenteric artery syndrome, both values are reduced and range from 6°-16° and 5-11 mm.