Clinical Practice Guidelines on the Diagnosis and Treatment of Chronic Mesenteric Ischemia (UEG, 2020)

United European Gastroenterology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

May 12, 2020

European clinical practice guidelines on the diagnosis and treatment of patients with chronic mesenteric ischemia were released by United European Gastroenterology.[1]

Presentation

Consider a diagnosis of chronic mesenteric ischemia in patients with the following:

  • Unexplained postprandial abdominal pain

  • Weight loss greater than 5% body weight

  • Adapted eating pattern (to avoid abdominal symptoms)

  • Diarrhea

The classic triad of chronic mesenteric ischemia is postprandial pain, weight loss, and abdominal bruit. The absence of this triad does not exclude a diagnosis of chronic mesenteric ischemia.

Diagnosis

To exclude alternative diagnoses, perform (at minimum) upper gastrointestinal endoscopy and abdominal imaging (CT scan/MRI). Colonoscopy should be considered depending on patient age and symptoms; however, it is considered mandatory in patients with diarrhea.

Findings that should lead to a presumptive diagnosis of occlusive chronic mesenteric ischemia include a combination of compatible history, radiological imaging showing significant mesenteric artery stenosis, and positive findings on a functional test. Expert multidisciplinary consultation, to include at minimum a gastroenterologist, vascular surgeon, and interventional radiologist, should review test results.

The probability of chronic mesenteric ischemia is high in patients with unexplained abdominal symptoms and significant stenoses of the celiac artery and superior mesenteric artery; therefore, a functional test is not required.

CT angiography (1-mm acquisition slice thickness, arterial and venous/portal venous phase) should be performed in patients with suspected chronic mesenteric ischemia.

If contraindications exist for CT angiography, the diagnostic test of choice is MR angiography.

Reserve angiography for therapeutic purposes.

Normal findings on the following examinations do not exclude chronic mesenteric ischemia:

  • Lactate value

  • Lactate dehydrogenase value

  • Leukocyte level

  • Gastrointestinal endoscopy findings

Treatment

Consider reserving mesenteric bypass procedures for patients who are not suitable for endovascular revascularization.

Increasing oral intake, starting enteral tube feeding, or starting total parenteral nutrition prior to revascularization may prove disadvantageous in patients with chronic mesenteric ischemia.

The femoral artery, followed by the left brachial or radial artery, is the preferred entry site for mesenteric artery revascularization; base the decision on practitioner expertise.

When addressing atherosclerotic mesenteric artery lesions, percutaneous transluminal angioplasty and stenting is recommended over percutaneous transluminal angioplasty alone.

Consider attempting endovascular revascularization of both vessels in patients with occlusive disease of both the celiac artery and the superior mesenteric artery. The preferred target artery is the superior mesenteric artery, followed by the celiac artery.

Post endovascular mesenteric artery stenting, it is suggested that dual antiplatelet therapy be administered for at least 1 month, followed by lifelong antiplatelet monotherapy.

For those patients with symptoms and radiological signs of vasculitis, expert referral for vasculitis treatment is indicated before proceeding to endovascular revascularization.

It is suggested that in patients with symptomatic atherosclerotic chronic mesenteric ischemia, start cardiovascular secondary prevention as soon as the diagnosis is made. In those patients with asymptomatic atherosclerotic stenosis of the mesenteric arteries, it is suggested to assess the cardiovascular risk profile.

Recurrence of symptoms warrants duplex ultrasonography and/or CT angiography to assess in-stent stenosis.

For more information see the Chronic Mesenteric Ischemia and Mesenteric Ischemia Imaging.

For more Clinical Practice Guidelines, go to Guidelines.

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