History and exam

Key diagnostic factors

common

abdominal pain

The majority of patients with ischemic bowel experience pain, which is poorly localized and can vary depending on the type and segment of bowel involved. The classic presentation of acute mesenteric ischemia is abdominal pain out of proportion to exam.[17] The pain may also be diffuse and have a sudden onset.[17] Chronic symptoms of vague, diffuse abdominal pain may be indicative of chronic mesenteric ischemia.[31] Patients may also report long-standing postprandial abdominal pain and fear of eating.[17][31] The "classic triad" of chronic mesenteric ischemia is postprandial pain, weight loss, and an abdominal bruit; however, this is found in only a minority (around 20%) of patients.[31]

abdominal tenderness

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

Perceived pain may be out of proportion to tenderness appreciated on physical exam in acute mesenteric ischemia.[17]

Other diagnostic factors

common

hematochezia/melena

Intestinal ischemia 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 melena (proximal small bowel).

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

diarrhea

Mucosal sloughing occurs due to intestinal ischemia, frequently causing episodes of diarrhea.

weight loss

This is a notable feature of chronic mesenteric ischemia, which is usually related to sitophobia (food fear) in these patients.[23] The "classic triad" of chronic mesenteric ischemia is postprandial pain, weight loss, and an abdominal bruit; however, this is found in only a minority (around 20%) of patients.[31]

abdominal bruit

Physical examination may reveal an epigastric bruit in 48% to 63% of patients with bowel ischemia, indicative of turbulent flow through an area of vascular narrowing.[23] The "classic triad" of chronic mesenteric ischemia is postprandial pain, weight loss, and an abdominal bruit; however, this is found in only a minority (around 20%) of patients.[31]

uncommon

vasculitis

Rheumatoid arthritis, polyarteritis nodosa, systemic lupus erythematosus, dermatomyositis, Takayasu arteritis, and thromboangiitis obliterans can all result in ischemia of the bowel. The exact clinical picture may vary depending on the size of the mesenteric vessel involved.

light headedness, pallor, dyspnea

Anemia may occur as a result of repeated episodes of melena.

food fear (sitophobia)

Chronic ischemia results in symptoms related to oral intake; patients may report long-standing postprandial pain and may develop fear of eating (sitophobia).[17][31] This should not be confused with acute anorexia due to acute onset of pain or discomfort.

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