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Acute inferior mesenteric vascular occlusion, a surgical syndrome
Acute Inferior
RICHARD
Mesenteric Vascular a Surgical Syndrome
Occlusion,
M.D., ROBERT VANNIX, M.D., DAVID B. HINSHAW, M.D. AND CLARENCE E. STAFFORD, M.D.,Los Angeles, California
CARTER,
W occlusion
ETIOLOGY
HILE acute inferior mesenteric vascular is generally a lethal disease, it usually produces a clinical picture which may be diagnosed and successfully treated. Occlusion of the inferior mesenteric vessels has seldom been thought of as a separate clinical entity [5,17]. Most discussions of mesenteric vascular occlusion are based almost entirely on involvement of the superior mesenteric artery, which is affected in more than go per cent of cases [12]. Acute occlusion of the iriferior mesenteric vessels accounts for about 2 to 3 per cent of cases of mesenteric infarction [I]. A review of the literature on mesenteric occlusion in general reveaIs that Tiedeman in 1843 reported the first known case and Virchow in I 847 described the salient pathoIogic features of this condition. In 1895, Elliot performed the first successful resection for this disease, and in 1954 Uricchio et al. [20] were able to find only 158 survivals after bowel resection. Significant contributions to the general subject of mesenteric vascular occlusion have been made by Jackson, Porter and Quinby [7] (214 cases) in 1904, Trotter [Ig] (360 cases) in 1913, Loop [II] (500 cases) in 1921, Cokkinis [j] (76 cases) in 1926, Meyer [15] (92 cases) in 1931, and Brown [2] (772 cases) in 1940. Excellent reviews of this subject have appeared recently [6,8]. This is a review of fourteen verified cases of acute inferior mesenteric vascuIar occlusion as seen at the Los Angeles County Hospital during the Iast eight years. There were eleven men and three women in this series; the age range was fifty-nine to eighty-five, with an average age of sixty-five. In this study emphasis is placed on early diagnostic clinical findings and the distinctive features of infarction of the descending colon.
The predominant cause of the mesenteric infarction in this series was arterial thrombosis, which was present in eleven of the fourteen patients or 78.6 per cent. Venous thrombosis accounted for two cases or 14.3 per cent, and both arterial and venous thrombosis appeared likely in one patient. Serious concomitant conditions were present in most instances, with cardiovascular disease and various malignancies being most common. Thrombosis of the inferior mesenteric artery arising from a saccular aortic aneurysm occurred in two cases. The inferior mesenteric vessels were selectively involved in all fourteen patients. All were verified by either operative findings or postmortem examination, and all had hemorrhagic infarcts. Mesenteric occlusion after surgery for unrelated conditions developed in four patients (Table I), and others have reported this associaTABLE POSTOPERATIVE
Surgical
INFERIOR
I MESENTERIC
Time of Onset after Operation (days)
Procedure
Type of Occlusion and Extent of Infarction
4
Hemorrhoidcctomy
Vagotomy-pyloroplasty..
’
7
Ureterosigmoidostomy and sigmoid colostomy
1
IO
Above knee amputation.
INFARCTION
Arterial thrombosis, perforated and gangrenous descending colon Venous thrombosis, hemorrhagic infarction splenic flexure to rectum Arterial thrombosis, gangrenous descending and sigmoid colon Arterial thrombosis secondary to saddIe aortic embolus, gangrenous sigmoid colon and nxx”rn
14
271
American
Journal
of Surgery,
Volume
98, August,
19~9
Carter,
Vannix,
Hinshaw
tion in as high as 30 to 40 per cent of their cases [g,18]. Thrombotic occlusions may be precipitated by operative trauma, blood dyscrasias, atheromatous pIaques, saccuIar aortic aneurysm, aortography, sepsis and after spIenectomy. CLINICAL
and
Stafford
Sigmoidoscopic demonstration of ischemic changes of the rectosigmoid mucosa strongIy suggests the presence of inferior mesenteric vascuIar occlusion. At sigmoidoscopy the mucosa appears bIuish bIack and is accompanied by a bIoody putrid discharge. This finding was observed in the Iast three patients in this series. Experimenta studies have shown that intestina1 mucosa is particuIarIy susceptibIe to ischemic change [IO], making it probabIe that vascuIar insuffIciency wouId appear first in the mucosa. Therefore the sigmoidoscopic findings should appear earIy.
FEATURES
The most striking feature of acute mesenteric infarction is sudden, severe abdominal pain out of proportion to the physica findings. Acute abdomina1 pain was prominent in a11 patients in this series. Sudden occIusion of the inferior mesenteric vesseIs tends to produce Iower abdomina1 pain and tenderness in contrast to the upper or more generahzed abdomina1 pain and tenderness of the superior mesenteric type. Dunphy and ZoIIinger [4] believe this pain is due to anoxemia of the intestina1 muscuIature and is a true viscera1 pain conducted by the sympathetic nervous system. LocaIized tenderness and rigidity in the Ieft Iower quadrant are present earIy in infarction of the descending coIon from occlusion of the inferior mesenteric vesseIs, but findings may Iater be generalized if perforation of the colon occurs. A bIoody recta1 discharge is a prominent feature of infarction of the descending coIon. It was present in thirteen of fourteen patients or in 92.3 per cent of this series. BIood is extravasated into the intestina1 waII, Iumen, mesentery and peritonea1 cavity, and bIoody stooIs are aImost aIways present with occIusion of the inferior mesenteric vesseIs. Litten in I 880 observed that tenesmus accompanied by bright red stooIs should suggest this diagnosis. Shock may deveIop as intestinal infarction progresses, and its severity usuaIIy paraIIeIs the extent of bowe1 invoIvement. Some degree of shock was present in the majority of patients. Venous obstruction intensifies the shock, resuIting in massive sequestration of bIood and ffuid into the bowe1 and peritonea1 cavity which may produce death before gangrene deveIops. Shock appearing Iater may be due to peritonitis. It is unusua1 to have distinctive x-ray findings in mesenteric infarction. EarIy Ieukocytosis is the onIy constant Iaboratory finding, and this rises with progression of tissue necrosis and peritonitis. Bfoody ffuid obtained by peritonea1 aspiration is a heIpfu1 finding in mesenteric infarction, even though it may aIso be present in other acute abdomina1 conditions.
TREATMENT
Seven of the fourteen patients were expIored surgicaIIy, but onIy four of these received any definitive treatment. The onIy successfu1 case was treated by wide obstructive resection of the descending coIon. Two other patients were aIso treated in a simiIar manner. One underwent a simpIe exteriorization procedure. The mortaIity rate for this series was 92 per cent. The first step in treatment is vigorous bIood repIacement, concomitant antibiotics, and early surgery with wide obstructive resection of the descending coIon. This procedure consists of resection of the descending coIon from the midtransverse coIon to a viabIe area of sigmoid or rectosigmoid. If a viable portion of rectosigmoid cannot be brought out as a mucous fistula, it may be cIosed and Ieft in an extraperitoneai position with drainage. Later, if the patient’s condition permits, intestinal continuity may be re-estabIished by dismantIing the transverse coIostomy with reanastomosis to the rectosigmoid. If necessary, the patient may be left with a permanent colostomy. AntitoaguIants, particuIarIy heparin, have been advocated in the treatment of this disease in order to minimize thrombotic propagation. Serious associated conditions shouId be corrected prior to operation if possibIe. The direct operative approach has been successfuIIy appIied to occIusive disease of the superior mesenteric artery, but the inferior mesenteric artery seems Iess adaptabIe to such procedures because of its smalIer size and infrequent invoIvement by emboIi. The mortaIity in mesenteric vascuIar occIusion remains high because of deIay in diagnosis, the extensive invoIvement of ‘gangrenous bowe1 and the serious associated diseases. The only factor which it is possibIe to influence sig272
Acute
Inferior
Mesenteric
Occlusion
treated for years for arterioscIerotic heart disease with heart bIock and congestive failure had deveIoped in the month preceding admission. On physica examination, he was in a shock-like state, with a tachycardia of I 20, and was Iying in a poo1 of bloody stoo1. The heart rate was regular, and the bIood pressure was I 10/70 mm. Hg. The abdomen was slightly distended with generalized tenderness and rigidity. There were no abdominal scars or palpable hernial masses. Dark red blood was found in the recta1 ampulla, and there was an exquisitely tender, cystic mass in the cuI-de-sac. Sigmoidoscopy showed mucosa1 necrosis at the 6 inch Ievel, with mottIing, cyanosis and superIicia1 uIceration. Laboratory findings included: hemogIobin, 16.5 gm. per cent; white bIood count, 20,600 per cu. mm. with 81 per cent polymorphonuclear leukocytes; blood urea nitrogen, 108 mm. Hg; and a normal serum amyIase. Abdominal x-ray films showed no evidence of distention of the smaI1 or Iarge bowels. Abdominal paracentesis produced a smaIl amount of putrid, serosanguineous fluid. A diagnosis was made of occlusion of the inferior mesenteric vessels with infarction of the descending colon, and the patient was prepared for surgery with antibiotics, blood and plasma. At surgery the entire descending colon was found to be gangrenous with fresh thrombus occluding the inferior mesenteric artery. Left coIectomy was performed with establishment of a dista1 mucous fistma and the transverse coIon was brought out as a colostomy. Profound shock developed in the patient shortly after the surgical procedure was started, and there were noted abnorma1 neuroIogic signs including pupiIIary inequality and a positive Babinski sign. Tracheostomy was performed immediateIy after closure of the abdomen, but the patient died before he could be removed from the operating table. No autopsy was obtained.
nificantly is the delay in diagnosis. The correct diagnosis in this series was made in only four of the fourteen cases. The use of diagnostic sigmoidoscopy shouId make earher recognition possible. Prompt recognition, vigorous bIood replacement and early aggressive surgery provide the onIy opportunity for reducing the high mortality,. CASE
VascuIar
REPORTS
The clinical picture of acute severe pain in the left Iower part of the abdomen usuahy accompanied by blood in the stoo1 and the demonstration of ischemic mucosa1 changes by sigmoidoscopy is iIIustrated by the foIIowing two case reports.
CASEI. E. S., a sixty-eight year old white man, was admitted to the Los AngeIes County HospitaI on January 30, 1958, with a two-day history of sudden pain in the Ieft Iower part of the abdomen. The pain became increasingly severe, was associated with tenesmus, and the passage of bIoody stooIs. On physical examination the patient was acuteIy ill with cold extremities consistent with incipient shock. He complained of excruciating pain in the Iower part of the abdomen. The temperature was IOI’F., the puIse was 120, and the biood pressure was 144/76 mm. Hg. The Iower part of the abdomen was markedIy tender and rigid, with signs of diffuse peritonitis. Gross blood was noted on recta1 examination, and on sigmoidoscopy there were bIuish black areas of mucosa1 gangrene in the rectosigmoid area. A diagnosis of inferior mesenteric vascuIar occlusion was made, and the patient was prepared for surgery with bIood, plasma, antibiotics and digitalization. At surgery there were patchy areas of greenish bIack gangrene of the entire descending coIon including the extraperitonea1 part of the rectum. Wide obstructive resection of the descending coIon was performed, the distal part of the rectum oversewn, and closed extraperitoneaIIy and drained. Two smaI1 poIythene catheters were inserted into the peIvis for a I per cent neomycin soIution to be irrigated at frequent intervaIs. After surgery the right transverse coIostomy remained viable and functiona1, and the patient’s recovery was uneventfu1. Three months Iater the transverse colon was anastamosed to the rectum, re-estabIishing intestina1 continuity. Two weeks Iater he was discharged from the hospita1 after a satisfactory convalescence.
COMMENTS
WhiIe arterial occIusion due to either emboIism or thrombosis is usuahy more fmminating than venous thrombosis, this cIinica1 distinction is rarely possible. There are two genera1 clinical types of acute mesenteric occIusive disease: sudden, compIete occlusion of a major mesenteric artery, or gradual occIusion of an artery or vein. When massive intestina1 infarction with gangrene resuIts, the cIinica1 picture is about the same no matter how it started. Severity of the symptoms depends more on the size of the occIuded vesse1 and extent of infarction than on the type of occIusion. Trotter observed that perforation of the bowel is more apt to occur when the inferior mesenteric vesseIs are occIuded, and he attributed this to the thinner
CASE II. H. S., a seventy-two year oId Caucasian man, was admitted to the Los Angeles County HospitaI on November 21, 1957, in a state of menta1 confusion. ReIatives stated that he had been compIaining of severe abdominal pain for three days; There was no vomiting. The patient had been 273
Carter,
Vannix,
Hinshaw
and
Stafford
TABLE II COMPARATIVE FEATURES
Data
Frequent etiology. Location of pain. CoIlateraI circulation, ............ Blood in stool. ..... Gangrene. Sigmoidoscopy ..
Superior Mesenteric VascuIar OccIusion
. EmboIism . Mid-abdomen Poor Inconstant Constant ..........
SUMMARY I. Fourteen cases of inferior mesenteric vascular occIusion have been presented. One patient was successfuhy treated by wide obstructive resection of the descending coIon. The over-a11 mortaIity was 92 per cent. 2. Acute inferior mesenteric vascuIar OCCIUsion has distinctive clinica features consisting of sudden, severe pain in the Ieft Iower part of the abdomen, usuaIIy accompanied by blood in the stoo1. Shock is a frequent earIy finding. 3. The demonstration of ischemic mucosa1 changes by sigmoidoscopy faciIitates earIy diagnosis. 4. The reduction of mortaIity in mesenteric vascuIar occIusion depends upon earher diagnosis and prompt, aggressive surgica1 treatment.
Inferior Mesenteric Vascular OccIusion
Thrombosis Left Iower quadrant Abundant Very frequent Less IikeIy Diagnostic vaIue
intestina1 waI1 and more infective feca1 content of the colon. Gradual obIiteration of the mesenteric arteries may aIlow collateral circulation to deveIop and prevent actua1 necrosis of the boweI. Intestinal &hernia resuIting from mesenteric arterial obstruction may present a recognizabIe syndrome and has been aptIy termed “intestina1 angina [r6].” IntestinaI gangrene is Iess frequent foIlowing 0ccIusion of the inferior mesenteric vesseIs than it is when superior mesenteric vesseIs are invoIved. The area of the descending coIon is protected by an adequate coIIatera1 circulation through the middIe colic artery via the margina artery of Drummond above, and through the middle and inferior hemorrhoida arteries beIow. Infarction of the descending colon is rarely abrupt and tends to be patchy. These pathoIogica1 changes may be expIained by the minima1 intramura1 circuIation at the antimesenteric border. The infrequency of ischemic necrosis of the descending colon foIIowing Iigation of the inferior mesenteric artery demonstrates the usual effectiveness of the margina arteries of the coIIatera1 circulation [I?]. Hemorrhagic infarction with gangrene aImost always foIIows sudden cIosure of the superior mesenteric artery. The superior mesenteric artery is of large caliber, about 9 mm. in diameter, and runs paraIIe1 with the aorta. For these reasons it is a trap for emboIi. The inferior mesenteric artery is haIf this size, takes off from the aorta at a greater angIe and is rareIy invoIved by an emboIus. The contrasting features of the superior and inferior mesenteric occIusions are shown in TabIe II.
REFERENCES I. BOWEN, A.
and FELGER, L. Mesenteric vascuIar occIusion. Mississippi Valley M. J., 64: 24, 1942. 2. BROWN, M. J. Mesenteric venous occIusion: a cIinica1 entity. Am. J. Surg., 49: 242, 1940. 2. COKKINIS. A. J. Mesenteric Vascular Occlusion. London; 1926. BaiIIiere, TindaII & Cox. 4. DUNPHY, J. E. and ZOLLINGER, R. Mesenteric vascuIar occlusion. New England J. Med., 21 I: 708, 1934. 5. GAMBEE, L. P. OccIusion of the inferior mesenteric vesseIs. West. J. Surg., 45: 105, 1937. 6. GOLDMAN, W. P. Mesenteric infarction: a cIinica1 study of 4g cases. Canad. M. A. J., 79: 547, 1958. 7. JACKSON, J. M., PORTER, C. H. and QUINBY, W. C. MesentericemboIism and thrombosis. J. A. M. A., 42: I&g;43:2$, 110, 183, 1904. 8. JENSON, C. B. and SMITH, G. A. A cIinic a1 study of 51 cases of mesenteric infarction. Surgery, 40: 930, 1936. g. LAUFMAN, H. and SCHEINBERG, S. ArteriaI and venous mesenteric occIusion. Am. J. Surg., 58: 84, 1942. IO. LILLEHEI, R. C. The intestina1 factor in irreversibIe hemorrhagic shock. Surgery, 42: 1043, 1957. I I. LOOP, R. G. Mesenteric vascuIar occIusion. J. A. M. A., 7: 369, 1921. 12. MAINGOT, R. AbdominaI Operations, p. 1178. New York, 1955. Appleton-Century-Crofts Co., Inc. 13. MCKAIN, J. and SCHUMACHER, H. B., JR. Ischemia of the Ieft coIon associated with abdomina1 aortic aneurysms and their treatment. Arch. Surg., 76: 355. 1958. 14. MERSHEIMER, W. L., WINFIELD, J. M. and FANKHAUSER. R. L. Mesenteric vascuIar occIusion. Arch. S&g., 66: 752, 1953. 15. MEYER, J. L. Mesenteric vascuIar occIusion. Ann. Surg., 94: 88, 1931. 16. MIKKELSON, W. P. IntestinaI angina: its surgicaI significance. Am. J. Surg., 94: 262, 1957. 17. RUSSELL, J. Y. W. Inferior mesenteric vascular occlusion. Brit. J. Surg., 37: 321, rg4g-1950.
274
Acute
Inferior
Mesenteric
18. SEYBOLD, W. D. and MUSGROVE, J. E. SurgicaI aspects of mesenteric vascuIar 0ccIusion. Proc. .StaJ Meet. i2la~‘o Cl&., zg: $35, 19~0. 19. TROTTER, L. B. C. Embohsm and Thrombosis of Mesenteric VesseIs. London, 1913. Cambridge University Press. 20. URICCHIO,J. F., CALENDA, D. G. and FREEDMAN, D. Alesenteric vascuIar occlusion. Ann. Surg., 139: 206, 1954.
GOLD~~AN (San
Francisco,
Calif.):
It
Ocdusion
statement that there must be additiona arteria1 occlusion to that presented in the inferior mesenteric artery itself. Reports and experience indicate that a history of previous attacks preceding the fatal one by weeks, months or years can be elicited in the majority of patients. We agree with the authors that the pain, degree of shock and rapid deterioration of the patient usuaIIy overshadow the abdomina1 iindings. The severity and persistence of pain and this paucity of abdomina1 signs may be the most significant cIinica1 manifestations of this catastrophe, in the earIy stages. Resection in cases of inferior mesenteric artcria1 occIusion is necessary; with the extensive resection required in superior mesenteric arterial block such a short segment of bowe1 is Ieft that the patient succumbs to maInutrition.
DISCUSSION LEON
Vascuhr
is
timeIy that the authors have caIIed to our attention the serious syndrome of mesenteric vascular occIusion, for with increasing Iongevity this problem arises more frequentIy, and present day advances in vascuIar surgery may potentiate certain improvements in surgica1 therapy in the future. EarIy diagnosis is mandatory if we are to reduce
If we can but make the diagnosis during the rev-ersible stage of ischemia, then endartercctomy, by-pass or impIantation of the patent portion of superior mesenteric artery into the aorta may prove life saving, A patient with inferior mesenteric arteria1 occlusion entered the hospita1 ten days after the onset of pain, vomiting and bIack diarrhea1 stooIs. He had had biIatera1 supracondyIar amputations for arterioscIerotic gangrene two years previousIy. The barium enema showed a ragged outline of what was taken to be the descending coIon. At autopsy following a right-sided transverse coIostomy there was a thrombosis of the inferior mesenteric artery and obhteration of the hypogastric arteries with complete necrosis of the descending and pelvic coIon, walled off from the free peritonea1 cavity, so that the patient was stiI1 passing Iiquid stoo1 through this waIIed off channe1.
the frightfu1 mortaIity rate and prevent the need for subtota1 enterectomy when the superior mesenteric artery is involved, a surgica1 sequeIIa which is incompatible with Iife. We must think more and more of the possibiIity of abdomina1 symptoms being produced by obliterative vascular disease in eIderIy patients, particuIarIy when they have other manifestations of arterial disease. Clinical differentiation between superior and inferior mesenteric occIusion is not aIways possibIe or necessary. The inferior mesenteric artery was Iigated at its origin in over 120 operations on the abdominal aorta with only one instance of ischemia of the descending colon. This exception occurred in a patient with an aneurysm of the abdomina1 aorta and thrombosis of both hypogastric arteries, requiring resection of the descending colon to the peIvic floor at the same operation. This confirms the authors’
275
RICHARD
Mesenteric Vascular a Surgical Syndrome
Occlusion,
M.D., ROBERT VANNIX, M.D., DAVID B. HINSHAW, M.D. AND CLARENCE E. STAFFORD, M.D.,Los Angeles, California
CARTER,
W occlusion
ETIOLOGY
HILE acute inferior mesenteric vascular is generally a lethal disease, it usually produces a clinical picture which may be diagnosed and successfully treated. Occlusion of the inferior mesenteric vessels has seldom been thought of as a separate clinical entity [5,17]. Most discussions of mesenteric vascular occlusion are based almost entirely on involvement of the superior mesenteric artery, which is affected in more than go per cent of cases [12]. Acute occlusion of the iriferior mesenteric vessels accounts for about 2 to 3 per cent of cases of mesenteric infarction [I]. A review of the literature on mesenteric occlusion in general reveaIs that Tiedeman in 1843 reported the first known case and Virchow in I 847 described the salient pathoIogic features of this condition. In 1895, Elliot performed the first successful resection for this disease, and in 1954 Uricchio et al. [20] were able to find only 158 survivals after bowel resection. Significant contributions to the general subject of mesenteric vascular occlusion have been made by Jackson, Porter and Quinby [7] (214 cases) in 1904, Trotter [Ig] (360 cases) in 1913, Loop [II] (500 cases) in 1921, Cokkinis [j] (76 cases) in 1926, Meyer [15] (92 cases) in 1931, and Brown [2] (772 cases) in 1940. Excellent reviews of this subject have appeared recently [6,8]. This is a review of fourteen verified cases of acute inferior mesenteric vascuIar occlusion as seen at the Los Angeles County Hospital during the Iast eight years. There were eleven men and three women in this series; the age range was fifty-nine to eighty-five, with an average age of sixty-five. In this study emphasis is placed on early diagnostic clinical findings and the distinctive features of infarction of the descending colon.
The predominant cause of the mesenteric infarction in this series was arterial thrombosis, which was present in eleven of the fourteen patients or 78.6 per cent. Venous thrombosis accounted for two cases or 14.3 per cent, and both arterial and venous thrombosis appeared likely in one patient. Serious concomitant conditions were present in most instances, with cardiovascular disease and various malignancies being most common. Thrombosis of the inferior mesenteric artery arising from a saccular aortic aneurysm occurred in two cases. The inferior mesenteric vessels were selectively involved in all fourteen patients. All were verified by either operative findings or postmortem examination, and all had hemorrhagic infarcts. Mesenteric occlusion after surgery for unrelated conditions developed in four patients (Table I), and others have reported this associaTABLE POSTOPERATIVE
Surgical
INFERIOR
I MESENTERIC
Time of Onset after Operation (days)
Procedure
Type of Occlusion and Extent of Infarction
4
Hemorrhoidcctomy
Vagotomy-pyloroplasty..
’
7
Ureterosigmoidostomy and sigmoid colostomy
1
IO
Above knee amputation.
INFARCTION
Arterial thrombosis, perforated and gangrenous descending colon Venous thrombosis, hemorrhagic infarction splenic flexure to rectum Arterial thrombosis, gangrenous descending and sigmoid colon Arterial thrombosis secondary to saddIe aortic embolus, gangrenous sigmoid colon and nxx”rn
14
271
American
Journal
of Surgery,
Volume
98, August,
19~9
Carter,
Vannix,
Hinshaw
tion in as high as 30 to 40 per cent of their cases [g,18]. Thrombotic occlusions may be precipitated by operative trauma, blood dyscrasias, atheromatous pIaques, saccuIar aortic aneurysm, aortography, sepsis and after spIenectomy. CLINICAL
and
Stafford
Sigmoidoscopic demonstration of ischemic changes of the rectosigmoid mucosa strongIy suggests the presence of inferior mesenteric vascuIar occlusion. At sigmoidoscopy the mucosa appears bIuish bIack and is accompanied by a bIoody putrid discharge. This finding was observed in the Iast three patients in this series. Experimenta studies have shown that intestina1 mucosa is particuIarIy susceptibIe to ischemic change [IO], making it probabIe that vascuIar insuffIciency wouId appear first in the mucosa. Therefore the sigmoidoscopic findings should appear earIy.
FEATURES
The most striking feature of acute mesenteric infarction is sudden, severe abdominal pain out of proportion to the physica findings. Acute abdomina1 pain was prominent in a11 patients in this series. Sudden occIusion of the inferior mesenteric vesseIs tends to produce Iower abdomina1 pain and tenderness in contrast to the upper or more generahzed abdomina1 pain and tenderness of the superior mesenteric type. Dunphy and ZoIIinger [4] believe this pain is due to anoxemia of the intestina1 muscuIature and is a true viscera1 pain conducted by the sympathetic nervous system. LocaIized tenderness and rigidity in the Ieft Iower quadrant are present earIy in infarction of the descending coIon from occlusion of the inferior mesenteric vesseIs, but findings may Iater be generalized if perforation of the colon occurs. A bIoody recta1 discharge is a prominent feature of infarction of the descending coIon. It was present in thirteen of fourteen patients or in 92.3 per cent of this series. BIood is extravasated into the intestina1 waII, Iumen, mesentery and peritonea1 cavity, and bIoody stooIs are aImost aIways present with occIusion of the inferior mesenteric vesseIs. Litten in I 880 observed that tenesmus accompanied by bright red stooIs should suggest this diagnosis. Shock may deveIop as intestinal infarction progresses, and its severity usuaIIy paraIIeIs the extent of bowe1 invoIvement. Some degree of shock was present in the majority of patients. Venous obstruction intensifies the shock, resuIting in massive sequestration of bIood and ffuid into the bowe1 and peritonea1 cavity which may produce death before gangrene deveIops. Shock appearing Iater may be due to peritonitis. It is unusua1 to have distinctive x-ray findings in mesenteric infarction. EarIy Ieukocytosis is the onIy constant Iaboratory finding, and this rises with progression of tissue necrosis and peritonitis. Bfoody ffuid obtained by peritonea1 aspiration is a heIpfu1 finding in mesenteric infarction, even though it may aIso be present in other acute abdomina1 conditions.
TREATMENT
Seven of the fourteen patients were expIored surgicaIIy, but onIy four of these received any definitive treatment. The onIy successfu1 case was treated by wide obstructive resection of the descending coIon. Two other patients were aIso treated in a simiIar manner. One underwent a simpIe exteriorization procedure. The mortaIity rate for this series was 92 per cent. The first step in treatment is vigorous bIood repIacement, concomitant antibiotics, and early surgery with wide obstructive resection of the descending coIon. This procedure consists of resection of the descending coIon from the midtransverse coIon to a viabIe area of sigmoid or rectosigmoid. If a viable portion of rectosigmoid cannot be brought out as a mucous fistula, it may be cIosed and Ieft in an extraperitoneai position with drainage. Later, if the patient’s condition permits, intestinal continuity may be re-estabIished by dismantIing the transverse coIostomy with reanastomosis to the rectosigmoid. If necessary, the patient may be left with a permanent colostomy. AntitoaguIants, particuIarIy heparin, have been advocated in the treatment of this disease in order to minimize thrombotic propagation. Serious associated conditions shouId be corrected prior to operation if possibIe. The direct operative approach has been successfuIIy appIied to occIusive disease of the superior mesenteric artery, but the inferior mesenteric artery seems Iess adaptabIe to such procedures because of its smalIer size and infrequent invoIvement by emboIi. The mortaIity in mesenteric vascuIar occIusion remains high because of deIay in diagnosis, the extensive invoIvement of ‘gangrenous bowe1 and the serious associated diseases. The only factor which it is possibIe to influence sig272
Acute
Inferior
Mesenteric
Occlusion
treated for years for arterioscIerotic heart disease with heart bIock and congestive failure had deveIoped in the month preceding admission. On physica examination, he was in a shock-like state, with a tachycardia of I 20, and was Iying in a poo1 of bloody stoo1. The heart rate was regular, and the bIood pressure was I 10/70 mm. Hg. The abdomen was slightly distended with generalized tenderness and rigidity. There were no abdominal scars or palpable hernial masses. Dark red blood was found in the recta1 ampulla, and there was an exquisitely tender, cystic mass in the cuI-de-sac. Sigmoidoscopy showed mucosa1 necrosis at the 6 inch Ievel, with mottIing, cyanosis and superIicia1 uIceration. Laboratory findings included: hemogIobin, 16.5 gm. per cent; white bIood count, 20,600 per cu. mm. with 81 per cent polymorphonuclear leukocytes; blood urea nitrogen, 108 mm. Hg; and a normal serum amyIase. Abdominal x-ray films showed no evidence of distention of the smaI1 or Iarge bowels. Abdominal paracentesis produced a smaIl amount of putrid, serosanguineous fluid. A diagnosis was made of occlusion of the inferior mesenteric vessels with infarction of the descending colon, and the patient was prepared for surgery with antibiotics, blood and plasma. At surgery the entire descending colon was found to be gangrenous with fresh thrombus occluding the inferior mesenteric artery. Left coIectomy was performed with establishment of a dista1 mucous fistma and the transverse coIon was brought out as a colostomy. Profound shock developed in the patient shortly after the surgical procedure was started, and there were noted abnorma1 neuroIogic signs including pupiIIary inequality and a positive Babinski sign. Tracheostomy was performed immediateIy after closure of the abdomen, but the patient died before he could be removed from the operating table. No autopsy was obtained.
nificantly is the delay in diagnosis. The correct diagnosis in this series was made in only four of the fourteen cases. The use of diagnostic sigmoidoscopy shouId make earher recognition possible. Prompt recognition, vigorous bIood replacement and early aggressive surgery provide the onIy opportunity for reducing the high mortality,. CASE
VascuIar
REPORTS
The clinical picture of acute severe pain in the left Iower part of the abdomen usuahy accompanied by blood in the stoo1 and the demonstration of ischemic mucosa1 changes by sigmoidoscopy is iIIustrated by the foIIowing two case reports.
CASEI. E. S., a sixty-eight year old white man, was admitted to the Los AngeIes County HospitaI on January 30, 1958, with a two-day history of sudden pain in the Ieft Iower part of the abdomen. The pain became increasingly severe, was associated with tenesmus, and the passage of bIoody stooIs. On physical examination the patient was acuteIy ill with cold extremities consistent with incipient shock. He complained of excruciating pain in the Iower part of the abdomen. The temperature was IOI’F., the puIse was 120, and the biood pressure was 144/76 mm. Hg. The Iower part of the abdomen was markedIy tender and rigid, with signs of diffuse peritonitis. Gross blood was noted on recta1 examination, and on sigmoidoscopy there were bIuish black areas of mucosa1 gangrene in the rectosigmoid area. A diagnosis of inferior mesenteric vascuIar occlusion was made, and the patient was prepared for surgery with bIood, plasma, antibiotics and digitalization. At surgery there were patchy areas of greenish bIack gangrene of the entire descending coIon including the extraperitonea1 part of the rectum. Wide obstructive resection of the descending coIon was performed, the distal part of the rectum oversewn, and closed extraperitoneaIIy and drained. Two smaI1 poIythene catheters were inserted into the peIvis for a I per cent neomycin soIution to be irrigated at frequent intervaIs. After surgery the right transverse coIostomy remained viable and functiona1, and the patient’s recovery was uneventfu1. Three months Iater the transverse colon was anastamosed to the rectum, re-estabIishing intestina1 continuity. Two weeks Iater he was discharged from the hospita1 after a satisfactory convalescence.
COMMENTS
WhiIe arterial occIusion due to either emboIism or thrombosis is usuahy more fmminating than venous thrombosis, this cIinica1 distinction is rarely possible. There are two genera1 clinical types of acute mesenteric occIusive disease: sudden, compIete occlusion of a major mesenteric artery, or gradual occIusion of an artery or vein. When massive intestina1 infarction with gangrene resuIts, the cIinica1 picture is about the same no matter how it started. Severity of the symptoms depends more on the size of the occIuded vesse1 and extent of infarction than on the type of occIusion. Trotter observed that perforation of the bowel is more apt to occur when the inferior mesenteric vesseIs are occIuded, and he attributed this to the thinner
CASE II. H. S., a seventy-two year oId Caucasian man, was admitted to the Los Angeles County HospitaI on November 21, 1957, in a state of menta1 confusion. ReIatives stated that he had been compIaining of severe abdominal pain for three days; There was no vomiting. The patient had been 273
Carter,
Vannix,
Hinshaw
and
Stafford
TABLE II COMPARATIVE FEATURES
Data
Frequent etiology. Location of pain. CoIlateraI circulation, ............ Blood in stool. ..... Gangrene. Sigmoidoscopy ..
Superior Mesenteric VascuIar OccIusion
. EmboIism . Mid-abdomen Poor Inconstant Constant ..........
SUMMARY I. Fourteen cases of inferior mesenteric vascular occIusion have been presented. One patient was successfuhy treated by wide obstructive resection of the descending coIon. The over-a11 mortaIity was 92 per cent. 2. Acute inferior mesenteric vascuIar OCCIUsion has distinctive clinica features consisting of sudden, severe pain in the Ieft Iower part of the abdomen, usuaIIy accompanied by blood in the stoo1. Shock is a frequent earIy finding. 3. The demonstration of ischemic mucosa1 changes by sigmoidoscopy faciIitates earIy diagnosis. 4. The reduction of mortaIity in mesenteric vascuIar occIusion depends upon earher diagnosis and prompt, aggressive surgica1 treatment.
Inferior Mesenteric Vascular OccIusion
Thrombosis Left Iower quadrant Abundant Very frequent Less IikeIy Diagnostic vaIue
intestina1 waI1 and more infective feca1 content of the colon. Gradual obIiteration of the mesenteric arteries may aIlow collateral circulation to deveIop and prevent actua1 necrosis of the boweI. Intestinal &hernia resuIting from mesenteric arterial obstruction may present a recognizabIe syndrome and has been aptIy termed “intestina1 angina [r6].” IntestinaI gangrene is Iess frequent foIlowing 0ccIusion of the inferior mesenteric vesseIs than it is when superior mesenteric vesseIs are invoIved. The area of the descending coIon is protected by an adequate coIIatera1 circulation through the middIe colic artery via the margina artery of Drummond above, and through the middle and inferior hemorrhoida arteries beIow. Infarction of the descending colon is rarely abrupt and tends to be patchy. These pathoIogica1 changes may be expIained by the minima1 intramura1 circuIation at the antimesenteric border. The infrequency of ischemic necrosis of the descending colon foIIowing Iigation of the inferior mesenteric artery demonstrates the usual effectiveness of the margina arteries of the coIIatera1 circulation [I?]. Hemorrhagic infarction with gangrene aImost always foIIows sudden cIosure of the superior mesenteric artery. The superior mesenteric artery is of large caliber, about 9 mm. in diameter, and runs paraIIe1 with the aorta. For these reasons it is a trap for emboIi. The inferior mesenteric artery is haIf this size, takes off from the aorta at a greater angIe and is rareIy invoIved by an emboIus. The contrasting features of the superior and inferior mesenteric occIusions are shown in TabIe II.
REFERENCES I. BOWEN, A.
and FELGER, L. Mesenteric vascuIar occIusion. Mississippi Valley M. J., 64: 24, 1942. 2. BROWN, M. J. Mesenteric venous occIusion: a cIinica1 entity. Am. J. Surg., 49: 242, 1940. 2. COKKINIS. A. J. Mesenteric Vascular Occlusion. London; 1926. BaiIIiere, TindaII & Cox. 4. DUNPHY, J. E. and ZOLLINGER, R. Mesenteric vascuIar occlusion. New England J. Med., 21 I: 708, 1934. 5. GAMBEE, L. P. OccIusion of the inferior mesenteric vesseIs. West. J. Surg., 45: 105, 1937. 6. GOLDMAN, W. P. Mesenteric infarction: a cIinica1 study of 4g cases. Canad. M. A. J., 79: 547, 1958. 7. JACKSON, J. M., PORTER, C. H. and QUINBY, W. C. MesentericemboIism and thrombosis. J. A. M. A., 42: I&g;43:2$, 110, 183, 1904. 8. JENSON, C. B. and SMITH, G. A. A cIinic a1 study of 51 cases of mesenteric infarction. Surgery, 40: 930, 1936. g. LAUFMAN, H. and SCHEINBERG, S. ArteriaI and venous mesenteric occIusion. Am. J. Surg., 58: 84, 1942. IO. LILLEHEI, R. C. The intestina1 factor in irreversibIe hemorrhagic shock. Surgery, 42: 1043, 1957. I I. LOOP, R. G. Mesenteric vascuIar occIusion. J. A. M. A., 7: 369, 1921. 12. MAINGOT, R. AbdominaI Operations, p. 1178. New York, 1955. Appleton-Century-Crofts Co., Inc. 13. MCKAIN, J. and SCHUMACHER, H. B., JR. Ischemia of the Ieft coIon associated with abdomina1 aortic aneurysms and their treatment. Arch. Surg., 76: 355. 1958. 14. MERSHEIMER, W. L., WINFIELD, J. M. and FANKHAUSER. R. L. Mesenteric vascuIar occIusion. Arch. S&g., 66: 752, 1953. 15. MEYER, J. L. Mesenteric vascuIar occIusion. Ann. Surg., 94: 88, 1931. 16. MIKKELSON, W. P. IntestinaI angina: its surgicaI significance. Am. J. Surg., 94: 262, 1957. 17. RUSSELL, J. Y. W. Inferior mesenteric vascular occlusion. Brit. J. Surg., 37: 321, rg4g-1950.
274
Acute
Inferior
Mesenteric
18. SEYBOLD, W. D. and MUSGROVE, J. E. SurgicaI aspects of mesenteric vascuIar 0ccIusion. Proc. .StaJ Meet. i2la~‘o Cl&., zg: $35, 19~0. 19. TROTTER, L. B. C. Embohsm and Thrombosis of Mesenteric VesseIs. London, 1913. Cambridge University Press. 20. URICCHIO,J. F., CALENDA, D. G. and FREEDMAN, D. Alesenteric vascuIar occlusion. Ann. Surg., 139: 206, 1954.
GOLD~~AN (San
Francisco,
Calif.):
It
Ocdusion
statement that there must be additiona arteria1 occlusion to that presented in the inferior mesenteric artery itself. Reports and experience indicate that a history of previous attacks preceding the fatal one by weeks, months or years can be elicited in the majority of patients. We agree with the authors that the pain, degree of shock and rapid deterioration of the patient usuaIIy overshadow the abdomina1 iindings. The severity and persistence of pain and this paucity of abdomina1 signs may be the most significant cIinica1 manifestations of this catastrophe, in the earIy stages. Resection in cases of inferior mesenteric artcria1 occIusion is necessary; with the extensive resection required in superior mesenteric arterial block such a short segment of bowe1 is Ieft that the patient succumbs to maInutrition.
DISCUSSION LEON
Vascuhr
is
timeIy that the authors have caIIed to our attention the serious syndrome of mesenteric vascular occIusion, for with increasing Iongevity this problem arises more frequentIy, and present day advances in vascuIar surgery may potentiate certain improvements in surgica1 therapy in the future. EarIy diagnosis is mandatory if we are to reduce
If we can but make the diagnosis during the rev-ersible stage of ischemia, then endartercctomy, by-pass or impIantation of the patent portion of superior mesenteric artery into the aorta may prove life saving, A patient with inferior mesenteric arteria1 occlusion entered the hospita1 ten days after the onset of pain, vomiting and bIack diarrhea1 stooIs. He had had biIatera1 supracondyIar amputations for arterioscIerotic gangrene two years previousIy. The barium enema showed a ragged outline of what was taken to be the descending coIon. At autopsy following a right-sided transverse coIostomy there was a thrombosis of the inferior mesenteric artery and obhteration of the hypogastric arteries with complete necrosis of the descending and pelvic coIon, walled off from the free peritonea1 cavity, so that the patient was stiI1 passing Iiquid stoo1 through this waIIed off channe1.
the frightfu1 mortaIity rate and prevent the need for subtota1 enterectomy when the superior mesenteric artery is involved, a surgica1 sequeIIa which is incompatible with Iife. We must think more and more of the possibiIity of abdomina1 symptoms being produced by obliterative vascular disease in eIderIy patients, particuIarIy when they have other manifestations of arterial disease. Clinical differentiation between superior and inferior mesenteric occIusion is not aIways possibIe or necessary. The inferior mesenteric artery was Iigated at its origin in over 120 operations on the abdominal aorta with only one instance of ischemia of the descending colon. This exception occurred in a patient with an aneurysm of the abdomina1 aorta and thrombosis of both hypogastric arteries, requiring resection of the descending colon to the peIvic floor at the same operation. This confirms the authors’
275