History and exam

Key diagnostic factors

common

abdominal pain

The majority of patients with ischaemic bowel experience pain, which is poorly localised and can vary depending on the type and segment of bowel involved. The classic presentation of acute mesenteric ischaemia is abdominal pain out of proportion to examination. 

In patients with chronic mesenteric ischaemia, abdominal pain with postprandial worsening is a typical presenting symptom.[30] Abdominal pain may worsen during exercise and often occurs after meals, gradually resolving over a few hours.[30] 

abdominal tenderness

In colonic ischaemia, tenderness to palpation over the affected bowel may be noticed from early in the course of ischaemia, in contrast to acute mesenteric ischaemia, where tenderness is a relatively late sign.

Perceived pain may be out of proportion to tenderness appreciated on physical examination in acute mesenteric ischaemia.

presence of risk factors

Older age, smoking, and a history of medical conditions such as atrial fibrillation, myocardial infarction, structural heart defects, vasculitis, and hypercoagulable states are risk factors for ischaemic bowel disease.

Other diagnostic factors

common

haematochezia/melaena

Intestinal ischaemia leads to mucosal sloughing that can cause blood loss into the bowel lumen.

Depending on the size of the vessels involved and their position within the bowel, this blood loss may manifest as anything on the spectrum from fresh or partially altered blood (colonic or brisk proximal bleeding) to melaena (proximal small bowel).

If bleeding is severe, this can potentially cause further hypoperfusion and worsening of ischaemia.

diarrhoea

Diarrhoea may occur.[30] Mucosal sloughing occurs due to intestinal ischaemia, frequently causing episodes of diarrhoea.

nausea

Nausea may occur.[30]

weight loss

This is a notable feature of chronic mesenteric ischaemia, which is usually related to avoidance of or a fear of food (sitophobia) in these patients.[19][30]

abdominal bruit

Physical examination may reveal an epigastric bruit in 48% to 63% of patients with bowel ischaemia, indicative of turbulent flow through an area of vascular narrowing.[19]

uncommon

vasculitis

Clinical picture may vary depending on the size of the mesenteric vessel involved.

light headedness, pallor, dyspnoea

Anaemia may occur as a result of repeated episodes of melaena.

food fear (sitophobia)

Chronic ischaemia results in symptoms related to oral intake; food fear and food avoidance may develop.[30] This should not be confused with anorexia due to acute onset of pain or discomfort.

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