MESENTRIC VASCULAR

DISEASE

PRESENTER : VIJAY N
CHAIRPERSON: DR SURENDRA AGARWAL

MESENTRY
ITS DERIVED from the greek word
MESOS in middle
ENTERON intestine

Mesentries

are the two layered

fold of peritoneum connecting
parts of the intestine to the
posterior abdominal wall

The

posterior line of attachment

extends obliquely from the
duodeno jejunal junction at the
left side of the second lumbar
vertebra towards the right side of
the right iliac fossa to terminate
anterior to the sacro iliac
articulation

CELIAC

TRUNK

SUPERIOR MESENTRIC ARTERY

It arises from the 1 cm below the
celiac trunk directly from aorta
At level of intervertebral disc between
first and second lumbar vertebra
Runs inferiorly and anteriorly , anterior
to the uncinate process of pancreas
and third part of the duodenum
Posterior to the spleenic vein and the
body of the pancreas

Left

renal vein separates it from

the aorta
The artery crosses anterior to the
ivc , right ureter and right psoas
major as it descend in the root of
the small bowel mesentry
Supplies the jejunum and ileum
Terminal branches anastomoses
with ileocolic artery

It
1.
2.
3.
4.
5.

gives off
Inferior pancreaticoduodenal
artery
Middle colic
Ileocolic
Jejunal
Ileal branches

SMA

may be the source of the

common hepatic ,
gastroduodenal , accessory right
hepatic , accessory pancreatic
The jejunal and ileal branches
form arcade with in the mesentry
Arcades form the marginal artery

Jejunal branches
5-10 % jejunal branches arise
from the left side of the upper
portion of the SMA
Distribute as a series of short
arcades which forms a single tier
of anastomotic arch before giving
rise to multiple vasa recta
Distribute alternatively to
opposite aspects of it wall

Ileal branches
Arise from the left and anterior
aspect of SMA
More in number
Length of mesentry is greater

Superior mesentric vein

Drains small intestine ,
caecum , ascending and
transverse part of the colon
Formed in the right lower
mesentry of the small bowel
terminal ileum , caecum and
vermiform appendix

It

ascends in the mesentry to the

right of the mesentric artery ,
passes anterior to the right ureter
, ivc , 3rd part of the duodenum
and uncinate process of the neck
of pancreas
It joins with the spleenic vein to
form the portal vein

Tributeries
Jejunal
Ileal
Ileocolic , right colic , middle colic
Right gastroepiploic
Pancreatico duodenal

INFERIOR MESENTRIC ARTERY

it arises from 6-7 cm below sma at
the level of L3
It supplies left transverse colon ,
descending colon , sigmoid colon ,
rectum and upper anal canal
Branches left colic , sigmoid ,
superior rectal artery
The terminal branches divide in to
vasa brevia , vasa longa

Marginal

artery of drummond
vessel which lies close and
parallel to the wall of large
intestine
Formed from the ileocolic , right
, middle , and left colic artery
Marginal artery absent in the
spleenic flexure

Arc

of riolan arterial anastomosis

btw the right side of the
transverse colon and upper
descending colon
Formed from large branch of the
middle colic artery , anastomosis
with ascending branch of left
colic artery

INFERIOR MESENTRIC VEIN

Left part of transverse and
descending colon
Sigmoid
Rectum
Upper anal canal

ACUTE MESENTRIC
INSUFFICIENCY
PRESENT WITH THE ABDOMINAL PAIN

IF UN DIAGNOSED INTESTINAL
INFARCTION

LATER PROCEEDS TO SIGN OF

PERITONITIS

LAB INVESTIGATIONS
CBC leukocytosis ,
haemoconcentration
LFT , AMYLASE , LIPASE to
exclude other condition
Lactic acidosis late features
associated with the poor
prognosis

CT

abdomen emerged as an
imp in diagnosis

Angiography

also done

MESENTRIC ISCHEMIA
ARTERIAL EMBOLISM
ARTERIAL THROMBOSIS
LOW FLOW STATES- NON
OCCLUSIVE
MESENTRIC VENOUS OCCLUSION

Important thing in management

of acute mesentric in sufficiency
is
Effective fluid resusitation
Broad spectrum antibiotics

Acute mesentric
embolization
It

accounts for roughly 50% of all

cases of AMI
CAUSES
1. Atrial fibrillation
2. Myocardial dyskinesia
3. Prosthetic valve
4. Cardioversion
5. Recent mi

Most

common cause is cardiac

origin
Because of the flow character of
the visceral vessel
Most common site is distal to the
first jejunal branches 3-10 cm
Artery is soft and the site of
embolus is readily apparent
Most proximal part of jejunum is
viable

Clinical features
Pain abdomen
Vomiting
bloody diarrhea
Fever
Hypotension
Diffuse or local abdominal
tenderness
Rebound tenderness and rigidity

Diagnosis :
Catheter angiography classic
meniscus sign
CT Angiogram

TREATMENT :
Transverse arteriotomy with
primary repair
Longitudinal arteriotomy with
patch close
If bowel resection required
proximal saphenous vein should
be used for arterial
reconstruction

To

reduce vaso spasm

papaverine or nitroglycerine is
used
Residual distal thrombolysis
urokinase or total plasminogen
activator
Catheter directed thrombolysis
Anticoagulation with heparin

Acute mesentric
thrombosis
Its

life threatening
h/o arterial occlusive disease
stroke , claudication , myocardial
infarction
TAO , atherosclerosis
MC site is origin of the mesentric
vessel

CLINICAL FEATURES :
PAIN ABDOMEN
VOMITING
BLOODY DIARRHEA
ABSENT PULSE
VASCULAR BRUIT

Diagnosis

is through the
angiography which shows the
atherosclerosis of the aorta and
the visceral vessel

TREATMENT :
Infrarenal bypass saphenous
vein is preferred conduit
Angioplasty and stenting
Bowel resection
To avoid distal embolization lytic
infusion to be given

NON OCCLUSIVE MESENTRIC

ISCHEMIA
Result

of low flow
Causes
1. hypotension
2. severe systemic illness
3. vasospasm
4. Following dialysis
5. Vaso occlusive drug infusion

Mc

site is the sigmoid colon and

the spleenic flexure
Rectum is spared because of the
dual blood supply from the
hemorrhoidal vessel

CLINICAL FEATURES :
Sudden abdominal pain
Vomiting
Constipation
Diarrhea with blood , mucus and
melena
Low BP

Angiography

shows the prunched

arterial tree appearence

TREATMENT :
Treatment of underlying condition
Iv fluids
Antibiotics
Iv papaverine is begun as soon
as the diagnosis is made

Resection

of the infarcted colon

with exteriorization and diversion
laparotomy

Mesentric venous thrombosis

Acute
Predominantly

female
Hyper coagulable

CAUSES:
Def of protein c and s
Apc resistance
Factor 5 leiden mutation
Dehydration
Polycythemia
Cancer
Hormones use

CLINICAL FEATURES :
Vague abdominal discomfort
Distension
Altered bowel habits
Tenderness

Plain

x ray ileus with dilated

loops
Oedematous beefy red bowel
with thrombosis in vein
CT

TREATMENT :
Segmental resection with end to
end anastamosis
Heparin

Chronic mesentric
ischemia
Its

a clinical syndrome
characterized by recurrent
abdominal pain and weight loss
as a result of repeated transient
episodes of insufficient intestinal
blood flow
Seen in middle aged and elderly
people
Predominantly in women

CLINICAL

FEATURES
post prandial pain
weight loss
malabsorption

TREATMENT
Bypass grafting or angioplasty

Focal segmental ischemia

Vascular

insufficiency to short
segments of small intestine
CAUSES
1. Atheromatous emboli
2. Strangulated hernia
3. Blunt abdominal trauma
4. OCP
5. Segmental venous thrombosis

The

most common lesion is

partial bowel wall necrosis with
invasion by intestinal bacteria
Manifest as acute enteritis ,
chronic enteritis , or stricture

CLINICAL FEATURES
Abdominal pain
Diarrhea
Fever
Weight loss

TREATMENT
Resection of involved bowel

Ischemic colitis
Common

disorder of the
largebowel in older persons
Most common form of intestinal
ischemic injury
Its result from the alterations in
the systemic circulation or from
anatomic or functional changes in
mesenteric vasculature

Griffiths

point splenic flexure at

the junction of SMA and IMA
Sudecks critical point mid
portion of sigmoid colon junction
between the IMA and hypogastric
arteries

CAUSES
Surgery
Hypotension
Atherosclerosis , vasculitis ,
polycythemia
OCP , anti hypertensive

CLINICAL FEATURES
Left iliac fossa pain
Bloody diarrhea
Urgent desire to defecate
Fever
Abdominal distension

INVESTIGATION
Colonoscopy colon single strip
sign
Barium enema 1. Early stages- thumb printing
2. Later mucosal erosion and
stricture
.CT mucosal oedema and
thickening
.Biopsy

TREATMENT :
IV fluids
Antibiotics
PROTRACTED case TPN
Surgery resection

TREATMENT :
Operative ligation with resection
of involved bowel
Laparotomy to assess intestinal
viability

Superior mesenteric artery

syndrome
Its

caused by the compression of

the third portion of duodenum
between the superior mesenteric
artery anteriorly and fixed
retroperitoneal structures
posteriorly
Seen
1. who are growing rapidly
2. Position of hyper extension by a
cast after spinal injury or

CLINICAL FEATURES
Postprandial epigastric pain
Distension
Vomiting
Relief of symptoms on knee chest
position or prone position

Barium

contrast studies

TREATMENT
Small feedings
Patient lying prone or on left side
after eating
Duodenal mobilization
Duodeno-jejunal bypass

Superior mesentric artery

aneurysm
MC

associated with the infective

etiology
Others atherosclerosis ,
connective tissue disorder ,
vasculitis , trauma
Rupture in 40-50 %
C/F abdominal pain and
intestinal angina

DEBAKEY

and COOLEY reported

successful resection of mycotic
aneurysm in 1953
Angiography and CT abdomen for
diagnosis
TREATMENT
Ligation with out revascularization
Bypass grafting
Transcatheter embolization

Aneurysms of mesentric
branches
Jejunal

, ileal and colon

aneurysma are small
Often identified during
angiography or ct
Presence of multiple mesentric
aneurysm suggest PAN , septic
emboli , connective tissue
disorder
Rupture m/c in aneurysm
involving the colonic branches

Aneurysm of inferior
mesenteric artery
Its

very rare
Usually managed by the ligation
with the revascularization

REFERENCES
SABISTON

20TH EDITION
MAINGOTS ABDOMINAL
OPERATION 12TH EDITION
SCHWARTZ 9TH EDITION
GRAYS ANATOMY 40TH EDITION