Although mesenteric ischaemia is associated with a high morbidity and mortality, rapid diagnosis and anticoagulation of MVT has excellent outcomes.1
The literature suggests that of all the causes of mesenteric ischaemia, venous thrombosis carries the best prognosis.2
Patients with non-specific abdominal pain related to eating should be considered for mesenteric ischaemia, and a rapid contrast enhanced CT scan has been shown to have a high diagnostic specificity (100%) and sensitivity (90%).3
While there is much to learn about the natural history of the disease, MVT has been shown to be associated with hypercoagulable states—for example, polycythaemia vera and protein C and S deficiencies. Visceral infection, trauma, surgery, pancreatitis, malignancy and portal hypertension are also linked with MVT, although between 25–50% of cases have no attributable cause.4
Patients with signs of peritonism or extending thrombus have been shown to benefit from endovascular intervention and direct or indirect thrombolysis,5
although thrombolytics carry a higher mortality rate. Signs of extending thrombus are clinical and include haemodynamic instability, failure of symptoms to resolve despite anticoagulation, and peritonism. Surgery is a mandatory option where bowel necrosis is suspected or where frank peritonitis is evident, although this has poorer outcomes.5
The rarity of the disease means there is a lack of consensus in management. Thrombolysis is a development that needs further investigation, and could be useful in MVT that extends or fails to resolve. However, we advocate relatively safe conservative management with rapid and long term anticoagulation with bowel rest, and parenteral nutritional support when early diagnosis is achieved.
- Non-specific abdominal pain related to eating should be considered for mesenteric ischaemia.
- Contrast enhanced CT is the investigation of choice.
- Rapid diagnosis and anticoagulation make conservative treatment possible. Surgery is otherwise indicated where bowel necrosis is suspected.