What is intestinal thrombosis, what are the causes, symptoms and treatment of mesenteric infarction? Mesothrombosis of intestinal vessels: causes, forms, course, diagnosis and therapy Acute mesenteric thrombosis with intestinal necrosis.

Thrombosis of the mesenteric vessels (ICD-10 code - K55.0) is the blockage of blood clots of the mesenteric arteries and veins of the intestine. This disease mainly affects middle-aged and older people. It refers to very severe pathologies, develops at lightning speed, sometimes death is possible.

The mesentery is a connective tissue cord that attaches the intestine to the posterior wall of the peritoneum. It prevents intestinal loops from twisting.

The intestines are supplied with blood by the superior and inferior arteries of the mesentery. Thrombosis occurs in the superior mesenteric artery more often; it accounts for up to 90% of all cases of this pathology. It supplies blood to most of the body.

This vessel nourishes the following departments:

small, ascending colon, caecum;
hepatic flexure;
two thirds of the transverse colon.

Therefore, with its thrombosis, severe lesions develop.

The inferior mesenteric artery supplies blood to the remaining sections. These include:

colonic descending;
left third of the transverse colic;
sigmoid colon.

This artery accounts for up to 10% of all cases of intestinal thrombosis.

Causes and pathogenesis

The main reason for the development of mesenteric thrombosis is considered to be embolization (closing of the lumen of the vessel) by a thrombus. It is formed in the middle part of the abdominal aorta and gradually spreads down, first narrowing the lumen of the superior mesenteric artery.

Then the thrombus mechanically blocks the lumen of the vessel (artery or vein). The flow of blood through it to the tissues stops. This causes their irreversible destruction. If the blood supply is not restored in a timely manner, a mesenteric infarction develops.

The formation of thrombosis is facilitated by such vascular pathologies as:

mitral valve stenosis;
cardiac aneurysm;
stratification of the intercardiac wall;
arrhythmias;
endocarditis;
cardiosclerosis;
myocardial infarction.

Thrombi, breaking away from the places of their formation, move through the vessels, linger in some of them, and then break the lumen. These diseases are the primary causes of thrombosis. Most often, thrombi in the mesenteric arteries migrate from the aorta.

In addition to cardiovascular pathologies, some other conditions and diseases provoke the appearance of blood clots. They contribute to the formation of secondary mesenteric insufficiency, which causes thrombosis. It can be:

pancreatitis;
acute severe intestinal infections;
heart failure with low blood pressure;
cirrhosis;
stenosis of the lumen of the vessels of the mesenterium due to the formation of an atherosclerotic plaque;
portal hypertension syndrome with a high degree of congestion;
tumors that compress blood vessels;
liver steatosis;
hereditary predisposition;
diabetes;
increased blood clotting.

Increase the risk of developing mesenteric thrombosis of abdominal trauma, abdominal surgery, hormone therapy, smoking, pregnancy and physical inactivity, as well as taking a number of drugs (contraceptives, anticancer drugs).

Characteristics of the stages by narrowing the vessel

Based on the degree of circulatory disorders in the collateral and main vessels, there are three degrees of damage:

Compensation- it is characterized by chronic ischemia of intestinal tissues. Blood circulates only through collateral vessels.
subcompensation- it is characterized by partial blood supply to the tissues of the organ.
Decompensation- this stage is characterized by the onset of irreversible changes, it is considered very difficult. Foci of tissue death are formed, since their blood supply is absent. It is divided into two phases:
- The first is no more than two hours, is considered reversible.
- Four hours later, the second phase begins, with it the gangrene of the affected parts of the intestine develops. If you do not provide the patient with medical care on time, a fatal outcome is possible.

Classification of forms in the table

	Types of mesenteric thrombosis	Characteristic
Process flow	spicy	sudden onset of intestinal infarction followed by necrosis
Process flow	chronic	gradually develop functional disorders of the intestine without necrosis
Localization of circulatory disorders	arterial	the blood flow in the mesenteric arteries is disturbed, which in most cases leads to a bowel infarction in 6-8 hours
	venous	the blood flow in the mesenteric veins is disturbed, the infarction is formed for quite a long time - from several days to several weeks
	mixed	blood flow is disturbed first in the arteries, and then in the veins of the mesentery
The degree of circulatory disorders	with blood flow compensation	blood supply is carried out at the expense of unaffected vessels
	with blood flow subcompensation	blood supply is not complete
	with blood flow decompensation	there is no blood supply to the intestines, intestinal infarction occurs
Prevailing symptoms	ileus	rhythmic and cramping pains, as in intestinal obstruction
	pancreatoid	severe pain above the navel, nausea and vomiting, purple spots on the trunk
	appendicular	symptoms of appendicitis
	holistic-like	pain in the upper right side of the abdomen, nausea
	angiospastic	symptoms of "abdominal toad" that subside after taking nitroglycerin
	ulcerative	similar in symptoms to perforated gastroduodenal ulcer

Clinic: symptoms of development by stages

The clinical manifestations of acute mesenteric thrombosis are characterized by a gradual onset of symptoms. It depends on the stage of the disease.

There are three stages of this disease:

Ischemia- it is distinguished from other stages by the fact that the process is reversible. But clinical manifestations are growing quite rapidly.
There is a process of tissue breakdown, as the blood supply is sharply reduced in the affected areas. The symptoms are growing rapidly.

There is an intense growing pain in the abdominal cavity. The nature of the pain is different, from constant to cramping.

This stage is characterized by the appearance of vomiting. In the vomit, an admixture of bile and blood is found. They have a fecal smell. Patients often have loose stools, provoked by increased peristalsis.

All these symptoms are similar to an acute intestinal infection, so the wrong diagnosis is often made and the necessary assistance is not provided to the patient.
heart attack- for him, a complete absence of blood flow in the walls is typical, as a result of which there are areas of necrosis of the tissue of this organ. There are signs of severe intoxication. There is incessant vomiting. There is a change from frequent loose stools to constipation. Blood streaks are found in the feces.
Severe pain subsides, which means that the nerve endings die off. Characterized by a thready pulse, unstable pressure. The patient's abdomen is soft, somewhat swollen. In the region of the navel, a local seal is detected. Sometimes patients go into shock.
Peritonitis- characterized by the formation of open defects in the intestinal wall, its contents enter the abdominal cavity. This stage develops in the period from seventeen hours to one and a half days from the onset of the disease. The patient's abdomen is swollen, the abdominal wall is tense. Peristalsis disappears, gases do not leave, body temperature is elevated.

The development of the disease proceeds quickly, so there is no time to waste. You should immediately call an ambulance or see a doctor.

Diagnosis of thrombosis of the mesenteric vessels of the intestine

The patient must be examined by a surgeon. He asks about complaints, finds out how the disease proceeded when it began. Determines the nature of the pain syndrome, the nature of the stool. This makes it possible to suspect the development of mesenteric thrombosis.

The diagnosis is confirmed by the following research methods:

Selective angiography, which helps to identify the level of blockage of the vessel by a thrombus and the nature of the lesion. This further determines the tactics of surgical intervention.
Laparoscopy used to clarify the nature, volume of intestinal damage. In the absence of technical capabilities for its implementation, a diagnostic laparotomy is done.
General blood analysis identifies signs of inflammation. This disease is characterized by leukocytosis, elevated ESR.
Coagulogram is prescribed to determine the indicators of blood coagulability. An increase in the number of platelets and a change in indicators in the coagulation system are revealed.
CT, MRI intestines is carried out to detect tumor processes of the abdominal organs.
At biochemical blood test an increase in reactive protein is detected.

The patient is assigned a urine test for differential diagnosis with kidney disease.

Differential diagnosis with acute pathologies

It is necessary to differentiate mesenteric thrombosis primarily with acute pathologies of the abdomen:

acute appendicitis;
pancreatitis;
cholecystitis;
intestinal obstruction

From these diseases, mesenteric thrombosis is distinguished by the presence of changes in the blood coagulation system and an increased number of platelets in the blood.

Secondly, the disease is differentiated with other acute pathologies that are not related to the gastrointestinal tract:

myocardial infarction (abdominal form);
lower lobe pneumonia;
urolithiasis disease;
pyelonephritis;
adnexitis;
ovarian cyst;
ectopic pregnancy.

The presence of a pathology of blood coagulation, laparoscopy data (the presence of changes in the intestinal wall), the presence of blood clots in the vessels of the mesentery during angiography helps to correctly establish the diagnosis.

Emergency care and standard of care

Mesenteric thrombosis refers to emergency surgical pathologies. Treatment is only surgical, conservative therapy is not carried out.

Relatives of the patient should call an ambulance, which should immediately take the patient to the hospital. The team must deliver the patient to the duty surgical hospital for immediate examination and subsequent surgical intervention.

On the way, hemodynamics and blood pressure are corrected. The patient should absolutely not be given antispasmodics before the doctors arrive, as this will change the picture of the disease and make it difficult to make a correct diagnosis, they also worsen the blood supply through the collateral vessels and aggravate the disease.

Surgical algorithm

Emergency surgery is the only way to save the patient's life. It is carried out as follows:

after performing access to the intestine, it is examined throughout;
then determine the pulsation of the vessels at the boundaries of the lesion;
restore blood flow (remove a blood clot, sew a vessel);
apply techniques to improve the blood supply to the organ of areas with insufficient blood supply (thrombectomy);
the affected areas of the intestine are excised and the fragments are stitched together;
lavage of the abdominal cavity.

According to emergency indications, if necessary, perform reconstructive surgery on the vessels of the abdominal cavity. Shunting is performed, the mesenteric artery is connected to the aorta below the stenotic area.

Rehabilitation after thrombosis of mesenteric arteries and veins

The recovery period after the operation is quite long, it takes up to six months:

After the operation, it is important to restore the patient's blood clotting parameters. To ensure satisfactory hemodynamics in the intestinal vessels, heparin therapy is used for a week, then transferred to indirect anticoagulants.
To reduce diarrhea, the patient is recommended Loperamide and other drugs that reduce peristalsis.
A diet is recommended to adapt the intestines to new conditions. The patient eats fractionally, often and in small portions. Exclude products that cause increased gas formation (milk, legumes, coarse fiber), reduce the content of animal fats, prohibit canned foods, alcohol.
It is forbidden to lift objects weighing more than 5 kilograms for two weeks.

It is allowed to do a gentle massage of the abdomen to improve peristalsis (clockwise).

Mortality statistics, prognosis after surgery

The incidence of thrombosis of the vessels of the mesentery of the intestine has recently been growing, now it is 1: 50,000/year. The outcome of the disease after surgery depends on the severity of the process. In patients with necrotic changes in the intestine, mortality reaches 80%.

Statistical information:

mortality among non-operated patients in the case of acute mesenteric infarction reaches 100%;
among operated patients - 80-90% with a fatal outcome;
the frequency of the disease is 1 person out of 50,000 per year;
2 times more often this disease occurs in older women;
most often thrombosis of the superior mesenteric artery is diagnosed - in 90% of cases, the inferior artery or mesenteric veins are thrombosed ten times less often.

the introduction of direct anticoagulants for blood thinning;
when it is possible to achieve improvement in coagulogram parameters, the patient is transferred to thrombolytics, antiplatelet agents, indirect anticoagulants

With a reversible stage of intestinal ischemia, it is possible to avoid surgery if it is carried out on time.

Download national clinical guidelines. All-Russian Surgical Forum, Russian Society of Surgeons, Russian Society of Angiologists and Vascular Surgeons, Russian Scientific Society of Specialists in X-ray Endovascular Diagnosis and Treatment. Moscow, April 6, 2018.

Download . Moscow, 2014.

Download the article, 2017 Authors: Yaroshchuk S.A., Baranov A.I., Katasheva L.Yu., Leshchishin Y.M. GBUZ KO Novokuznetsk City Clinical Hospital No. 29; GBUZ KO Novokuznetsk City Clinical Hospital No. 1;

Possible consequences

Complications of mesenteric thrombosis are intestinal necrosis and peritonitis. There may be complications after bowel surgery:

suppuration of postoperative scars;
postoperative hernia;
adhesions of intestinal loops.

These complications are treated by the surgeon.

Prevention methods

Measures to prevent intestinal thrombosis include:

compliance with the motor regimen and diet;
weight control;
regular check of the coagulogram;
giving up alcohol, smoking;
prevention of infectious diseases;
pressure control;
regular visits to the doctor.

At the direction of the doctor, a life-long intake of indirect anticoagulants, antiplatelet agents is prescribed.

Before using folk remedies, be sure to consult your doctor.. You can use herbs that thin the blood: peppermint, yarrow, lemon balm, immortelle, lingonberry leaves, sage. These drugs should not replace conventional medications.

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Mesenteric thrombosis is a life-threatening disease. If the patient has a tendency to thrombosis, it is necessary to monitor blood counts and visit the doctor regularly.

Mesenteric thrombosis is a violation of blood circulation in the mesenteric vessels of the intestine.

In most cases, this is a complication after myocardial infarction, atrial fibrillation or slow sepsis. The disease occurs due to embolism and thrombosis of the mesenteric vessels.

Pathology affects the elderly and middle-aged, as atherosclerotic changes occur in the vessels throughout life.

A thrombus blocks the lumen of arteries or veins, which disrupts the nutrition of the intestinal walls, leading to a heart attack of the affected tissues.

Venous thrombosis is much less common than arterial thrombosis. In rare cases, blockage of veins and arteries is diagnosed at the same time, this form is called mixed.

ICD-10 code

According to the international classification of diseases (ICD code 10), mesenteric thrombosis is coded as K55.0. Pathology is included in acute vascular bowel disease.

Why is the blood flow disturbed?

The lumen of the vessels may be blocked primary or secondary. In the first case, the causes are trauma, thrombosis and embolism, and in the second case, the disease develops as a result of prolonged changes in the walls of blood vessels or outside them.

Primary reasons include:

Injuries - strong blows to the abdomen;
myocardial infarction;
Aneurysm of the heart and other pathologies of the cardiovascular system.

Pathological factors may be different (embolism, trauma or thrombosis), but they all lead to intestinal ischemia.

Secondary reasons include the following:

Stenosis of atherosclerotic origin;
Decrease in cardiac activity, in parallel there is a drop in blood pressure;
Tumors of the small or large intestine, squeezing the arteries;
Operations on the aorta, carried out for the reconstruction of the vessel.

How is the blood supply

Arteries and veins are almost parallel. Two large vessels depart from the abdominal aorta: the superior and inferior mesenteric arteries. They completely supply blood to the intestines.

The blood supply scheme is distributed as follows:

In 90% of cases, mesenteric thrombosis is observed in the superior mesenteric artery, in 10-15% of the masses the lumen in the inferior artery is closed.

Emboli can close the lumen of the mesenteric artery, having entered it from the heart (if a parietal thrombus breaks off), from the thoracic and abdominal aorta, or in case of injury.

Thrombotic masses can also form in the veins. Inflammatory processes in the intestines, congestion in the underlying vessels, and any other factors that increase blood viscosity lead to their formation.

What are the types of ischemia in mesenteric thrombosis?

In medical practice, there are three degrees of severity of the disease. They depend on the diameter of the lesion of the mesenteric vessels and the disturbance of the collateral flow.

Decompensated form- the most difficult stage. A time interval of up to 2 hours is a reversible time when blood supply can be restored. The interval from 4 to 6 hours is partially reversible, the prognosis is not always favorable, deterioration can occur at any time, since the arterial and venous blood flow is completely disturbed. Over 6 hours there is gangrene of the intestine.
Subcompensated circulatory disorders- this form can be confused with other diseases. Acute vascular insufficiency is expressed by similar symptoms.
Compensated degree- chronic ischemia, in which collaterals take over the function of blood flow.

Symptoms of mesenteric thrombosis

Signs of thrombosis depend on the level at which the mesenteric arteries are blocked and on the form of intestinal ischemia.

Clinical manifestations are characterized by the following symptoms:

Thrombus zone

Diagnostics

The sooner an accurate diagnosis is made, the greater the chance of a positive outcome of the patient's treatment. The doctor needs to collect an anamnesis of the disease, ask the patient about the nature and time of onset of pain, the frequency of stools. This will help determine the choice of surgical treatment.

In the blood test, a pronounced leukocytosis is observed (more than 20 * 10 9 l). Abdominal x-ray shows small intestinal fluid levels.

The main diagnostic methods are:

Laparoscopy- one of the decisive methods, allows you to quickly examine the intestines, establish mesenteric obstruction and determine the stage of ischemia, because the surgeon has no more than two hours left;
Ultrasound of the abdomen– the procedure assists in differential diagnosis to exclude the possibility of other diseases;
Selective angiography- a procedure that establishes the levels of occlusion of the arteries is necessary for emergency care. But many surgeons agree that it is inappropriate to spend time on angiography; with a rapid course, mesenteric thrombosis will end in death.

Bowel laparoscopy

If it is not possible to perform a laparoscopy, then surgeons perform a laparotomy, an operation during which a large incision is made along the midline of the abdomen.

In the process of laparotomy, doctors perform the following manipulations:

Palpate the vessels to locate the thrombus (each mesenteric artery and vein should be examined by the surgeon);
Reveal the boundaries of viable intestinal tissues;
Completely examine the abdominal organs, assessing their condition;
The pulsation of the arteries is detected, establishing the state of the intestinal blood supply.

Differential Diagnosis

Mesenteric thrombosis is easily confused with other diseases, which is associated with a blurred clinical picture.

Pathology is similar to the following diseases:

Acute pancreatitis;
Acute cholecystitis;
Appendicitis;

Similar signs are characteristic of acute intestinal obstruction.

Diagnosis of mesothrombosis - insertion of a catheter

How is mesothrombosis treated?

The disease is amenable only to surgical methods of treatment. The operation is performed under endotracheal anesthesia. At the first signs of pathology, the patient needs emergency care.

Antispasmodic and analgesic drugs erase the symptoms and make it difficult to make a diagnosis, this delays the possibility of an operation and leads to death.

Surgical intervention consists of important, mandatory parts:

The surgeon examines the intestines, palpates the mesenteric vessels;
The doctor must determine the pulsation in the arteries located on the borders with the affected intestines.

During the operation, the surgeon, if necessary, performs a resection - removes a section of the necrotic intestine, then stitches the upper and lower borders.

If there are no necrotic changes yet, then the doctor must find a way to restore the blood supply to the intestine and relieve ischemia from the affected area.

Restoration of blood supply can take place in two ways:

The surgeon gently squeezes the thrombus out of the vessels (arteries or veins) with his fingers;
A bypass shunt is created between the extreme boundaries of the thrombosed area.

During the recovery period after surgery, the patient is prescribed anticoagulants, blood thinners ("Heparin"). Therapy with these drugs is carried out under regular monitoring of the prothrombotic index and INR.

If the necrotic area of the intestine is removed (for example: part of the ascending or small intestine), and normal blood supply is not restored, then in 80% of cases the situations end in death.

Forecast

The disease is detected during operations much more often than it is recorded. The fact is that the clinic of mesenteric thrombosis is similar to many other pathologies. It masquerades as appendicitis, cholecystitis, intestinal obstruction.. There is not always enough time to make a correct diagnosis.

According to pathologists, mesenteriothrombosis is up to 2.5% of cases. If the operation was performed within the first hours after the onset of a blood clot, then the likelihood of recovery is high.

If surgery was performed after 12 hours, then the probability of death is up to 90%.

Video: Mesenteric thrombosis - intestinal infarction

Thrombosis of the mesenteric vessels is a condition when the arterial or venous bed of the intestine is blocked as a result of getting there or the formation of a blood clot in it. Partial or complete blockage of the vessel lumen by a thrombus disrupts blood circulation in this organ, the so-called ischemia develops.

If the blockage of veins or arteries is not allowed, then a pathological condition arises - intestinal infarction, which requires resection of the organ. But sometimes even surgical intervention can not always save the life of the patient.

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Thrombosis of the mesenteric (mesenteric) veins

Venous thrombosis can occur acutely or have a subacute or chronic course. Previously, this pathology was considered the main cause of ischemia. Nevertheless, over the past decades, the proportion of detected arterial thrombosis of the intestine has increased significantly. This is associated with the widespread introduction of new, more informative research methods, which has improved the differential diagnosis of mesenteric vascular thrombosis.

Three veins (superior and inferior mesenteric and splenic) carry nutrient-rich blood from different parts of the intestine to the liver. A blood clot in any of these veins blocks blood flow, which can lead to tissue damage and death. Clinical manifestations largely depend on the place of blockage - in which part of the intestine ischemia occurred.

Symptoms

The main signs of intestinal vein thrombosis, as a rule, are abdominal pain (especially after eating), bloating and diarrhea. The following symptoms may also appear: vomiting, fever, bloody stools.

As soon as the patient begins to suspect that he has thrombosis of the mesenteric vessels, the clinic of which is usually acute, you should immediately seek medical help. Delay in treatment can lead to serious complications, the development of peritonitis, which sometimes ends fatally.

Causes

Edema of the mesentery, which can occur with various pathologies of the gastrointestinal tract, contributes to the formation of blood clots in the veins.
The mesentery is a duplication of the peritoneum, through which the intestines are attached to the back wall of the abdomen, the arteries and veins of this organ are located here. Most often, mesenteric edema occurs in the following situations:

traumatization of the abdominal cavity;
infectious diseases of the abdominal organs, such as appendicitis, colitis, diverticulitis;
autoimmune intestinal pathology (ulcerative colitis and Crohn's disease);
chronic and acute pancreatitis - inflammation of the pancreas;
cirrhosis of the liver, fatty degeneration of this organ;
hormone replacement therapy or birth control pills;
excessive tobacco smoking;
some cancers of the digestive system.

Diagnostics

Thrombosis of the mesenteric vessels, which is diagnosed on the basis of acute abdominal symptoms and using medical imaging methods, carries a huge risk to human life. CT (computed tomography) is most commonly used, and sonography or MRI (magnetic resonance imaging) is also used.

Mesenteric angiography - X-ray examination, is considered the most informative method, which with a high percentage of probability allows you to determine the localization of a blood clot.

Treatment

Anticoagulants (blood thinners) are the main treatment for this pathology. If a patient has a problem with blood clotting during the examination, for example, thrombophilia, then he will have to take anticoagulants constantly so that venous thrombosis of the mesenteric vessels does not reappear.

Sometimes a drug that "dissolves" a blood clot can be delivered directly to the site of blockage in blood vessels. For this, a procedure called thrombolysis is used, when a drug is injected directly into a vein using a flexible tube (catheter) to a blood clot. And also the thrombus is removed surgically.

Watch the video about mesenteric thrombosis:

Thrombosis of the mesenteric arteries

A blood clot enters the arteries of the intestine as a result of an embolism. A detached fragment of a thrombus, which was originally formed either in the heart or in the vessel itself, moving with the blood flow, gets stuck in a narrow place and clogs the lumen of the artery.

Risk factors

Conditions in which there is an increased tendency to thromboembolism in the arterial bed are referred to as risk factors for this pathology:

elderly age;
smoking;
thrombophilia: antiphospholipid antibodies, etc.;
valvular / cardiac disorders: artificial valves, aneurysm of the ventricle of the heart.

Symptoms

Sudden occlusion of the mesenteric arteries, as a rule, is accompanied by the appearance of the so-called acute abdomen clinic. The following symptoms usually occur:

severe pain in the abdomen;
his bloating and feeling of fullness;
diarrhea;
nausea;
vomit;
heat.

Diagnostics

If the doctor suspected that the intestinal arteries are blocked by a thrombus, there is a suspicion of thrombosis of the mesenteric vessels, he may prescribe the following research methods:

CT scan of the abdominal organs;
ultrasonography;
magnetic resonance imaging;
MRA (magnetic resonance angiography);
arteriography of the abdominal vessels.

Angiography

Treatment

Thrombosis of the mesenteric arteries is a condition requiring emergency medical care, it can be compared in terms of urgency with myocardial infarction or stroke. If treatment is started at the initial stages of the pathological process in the intestine, then the mortality rate according to statistics does not exceed 30%. In the case of starting therapy 8 hours after the onset of symptoms of the disease, with every hour of delay, mortality increases exponentially.

Each patient with suspected acute thrombosis of the intestinal arteries, as a rule, receives treatment in accordance with the principles of intensive care even at the stage of undergoing diagnostic procedures.

To stabilize hemodynamics, large amounts of fluid are administered intravenously (the patient is constantly under a dropper), anticoagulants are prescribed (usually heparin), and antibacterial treatment is also carried out (antibiotics, for example, cephalosporins + metronidazole).

Further treatment of thrombosis of mesenteric vessels largely depends on the patient's condition and diagnostic findings. Once the site of occlusion has been determined (that is, where the thrombus is located in the artery), the following techniques for its removal can be applied:

- Endovascular procedures: transfemoral intraluminal - a large blood clot from the mesenteric artery is removed using a catheter inserted into the femoral;
  - intra-arterial administration of drugs (papaverine, heparin);
- Surgical treatment: immediate surgical intervention is performed when a large occlusion is diagnosed (a large section of the intestine is cut off from the blood supply), the endoscopic procedure has failed, a clinic of peritonitis (inflammation of the peritoneum) has appeared.

As a rule, such an operation is carried out by two teams of surgeons - vascular (removes a blood clot) and abdominal (resects the affected part of the intestine and imposes an anastomosis).

After discharge from the hospital, anticoagulants are usually given to prevent further clots.

Acute thrombosis of the mesenteric vessels of both veins and arteries leads to a sudden onset of intestinal ischemia, which, if treatment is not started on time, ends with a heart attack of this organ. Mortality in this situation can reach 40 - 70%. Timely seeking medical help (the next few hours after the onset of symptoms) significantly improves the poor prognosis of this disease.

Features of the blood supply to the intestines

The intestinal loops are in a "suspended" state and are fixed in place by a dense ligament of the mesentery. Arterial and venous vessels pass between the sheets. They are almost parallel. Arteries (superior and inferior mesenteric) depart from the abdominal aorta and divide the blood supply into sections:

The superior mesenteric artery carries blood to the small intestine, caecum, ascending colon, and most of the transverse colon. It carries out 90% of the blood supply, so the lesion is more common and clinically severe.
The inferior mesenteric artery feeds a much smaller area (30% of the transverse colon, descending, sigmoid, rectus).

Between the main arteries there are "spare" collateral vessels. Their task is to help the blood supply to the damaged area. A feature of the intestinal collaterals is the pumping of blood in only one direction: from the zone of the superior artery to the inferior mesenteric. Therefore, in the case of upper-level thrombosis, help from anastomoses should not be expected.

Venous outflow from the intestine is directed to the portal vein. Difficulty occurs when it narrows from liver disease. Collateral circulation is formed by a group of porto-caval anastomoses between the portal and vena cava. In the worst position is the small intestine. It does not have a developed collateral network.

Where do thrombi and emboli come from?

Through the arterial system, the embolus can reach the mesentery:

from the heart in case of detachment of a parietal thrombus from the wall of a post-infarction aneurysm, during atrial fibrillation, from the inner layer (epicardium) during sepsis, valve destruction;
from the thoracic and abdominal sections of the aorta with vessel dissection, softening of atherosclerotic plaques;
is formed in the mesenteric artery after a traumatic injury to the inner layer.

Venous blood, having a reverse direction and a tendency to decrease in speed and increase in viscosity, is more susceptible to the formation of its own thrombotic masses. Blood clots in the veins lead to:

inflammatory bowel diseases, affecting the entire wall, also involve venous vessels, local thrombophlebitis is formed;
drop in blood pressure caused by different situations;
portal hypertension in liver diseases;
stagnation in the underlying vessels with thrombosis of the portal vein;
any causes that increase blood viscosity (diseases of the hematopoietic system, condition after splenectomy, long-term use of hormonal drugs to prevent pregnancy).

If the patient has a heart disease in which the right and left chambers communicate with each other (for example, non-closure of the foramen ovale), then a blood clot from the lower extremities can freely pass through the vena cava, the right atrium into the left ventricle and aorta, and then descend to the intestinal arteries .

Types of damage to the intestinal vessels

The classification of pathology includes different aspects of the lesion mechanism.

For reasons distinguish:

arterial thrombosis and embolism;
venous thrombosis;
secondary thrombosis of mesenteric vessels in diseases of the aorta;
violation of the patency of blood vessels due to compression by germinating tumors;
a consequence of ligation of vessels during surgical intervention.

Depending on the degree of violation of blood flow, the stages are distinguished:

compensatory
subcompensation,
decompensation.

Pathological consequences of thrombosis can be:

ischemia of the intestinal wall;
area of infarction;
diffuse peritonitis.

Light areas - viable tissues, dark areas - infarction zone

In surgery, the stage of functional acute obstruction of the mesenteric vessels is distinguished, in which there is no organic lesion, and a temporary spasm causes pathology.

The most damaging factor is abdominal trauma. Compensation does not have time to develop fully. Protective mechanisms for increasing blood clotting are activated, which aggravates the patient's condition.

During operations on the aorta (narrowing of the isthmus, repositioning in case of congenital malformations, replacement of the aneurysm site with a graft), doctors know the possible mechanism of thrombosis of the mesenteric vessels: the restored full blood circulation leads to a high flow rate through the thoracic aorta to the abdominal area and the femoral artery to the legs. In this case, a partial “robbing” of the mesenteric vessels occurs due to the additional suction action of the jet. Perhaps the formation of small blood clots in the capillaries supplying the intestinal wall.

Stages and forms of circulatory disorders

Any circulatory disorders cause intestinal ischemia.

In the compensated stage, there is a complete replacement of the disturbed lumen of the vessel by the flow of blood through the collaterals. This form is typical for chronic ischemia with a gradual course of the disease.

Subcompensation also depends on collaterals, but has clinical manifestations.

With decompensation, the entire period is divided into 2 phases:

in the first 2 hours, reversible changes are possible with a complete restoration of the blood supply to the damaged area;
after 4–6 hours, an irreversible phase of gangrenous changes begins.

Clinical signs of thrombosis

The symptoms of acute thrombosis of mesenteric vessels are determined by the level of circulatory occlusion and the form of ischemia.

Abdominal pain is intense in the stage of subcompensation. It is localized throughout the abdomen or in the navel, lower back. In the transition to decompensation (after 4-6 hours), the nerve endings on the intestinal wall die off, the pain decreases. Such an "improvement" does not correspond to the actual size of the pathology.
Intoxication of the body is manifested by nausea, vomiting, lowering blood pressure. Attention is drawn to the discrepancy between the general severe condition and moderate pain in the abdomen.
Peritoneal phenomena: the abdomen is tense, swollen, dense muscles are felt on palpation. The symptom is more typical of thrombosis of the small intestine. In the stage of decompensation, peristalsis disappears, although in the subcompensated form it retains increased activity.
Stool disorders - frequent diarrhea mixed with blood is possible in the initial stages of ischemia. With decompensation, when there is no intestinal motility, diarrhea stops.
The state of shock is characterized by pallor of the skin, thready pulse, tachycardia, cyanosis of the lips, and a drop in blood pressure.

Any, even short-term, abdominal pain requires attention

Signs of pre-thrombosis caused by arterial insufficiency can be identified by questioning and clarifying the patient's complaints:

pain in the abdomen along the intestine becomes more intense after eating, long walking;
tendency to unstable stool, alternating diarrhea and constipation;
unclear weight loss.

Thrombosis of the mesenteric veins is milder and slower. More often it is a chronic process.

Diagnostics

In order to correctly diagnose, it is important for the doctor to get answers to questions about the initial manifestations, the duration of pain, and the characteristics of the stool.

The decisive method is diagnostic laparoscopy, which allows you to examine the intestines and clarify the stage of ischemic changes, the localization of the site.

Leukocytosis with a shift of the formula to the left does not provide certain information, since it is inherent in many diseases. Elevated levels of the enzyme lactate dehydrogenase indicate the presence of necrotic tissue.

Some assistance in differential diagnosis can be provided by ultrasound of the abdomen, fluoroscopy. Preparing the patient and wasting time on angiography is not rational.

Conducting a revision of the intestine allows you to detect a blood clot or ischemic site

In the absence of the possibility of laparoscopy, doctors proceed to laparotomy - surgery with a large incision in the midline of the abdomen:

examine (carry out an audit) of the abdominal organs, intestines;
palpate the vessels of the mesentery in order to detect a thrombus;
assess the sufficiency of the pulsation of the arteries;
define the boundaries of viable tissues.

Treatment

Treatment of thrombosis of intestinal vessels is possible only by immediate surgical means. The introduction of painkillers and antispasmodics erases the clinic and delays the diagnosis.

With venous thrombosis, fibrinolytic therapy is indicated in the first 6 hours.

During the operation, the doctor must find ways to:

in the absence of necrotic changes, restore the patency of blood flow through the vessel to relieve ischemia from the affected area of the intestine;
remove the modified intestine or part of it and sew the upper and lower ends.

Restoration of blood supply is carried out in this way:

squeezing a blood clot with your fingers;
creation of a bypass shunt between the upper and lower levels of stenosis, bypassing the thrombosed area.

In the postoperative period, the patient is prescribed large doses of Heparin to thin the blood.

Angiogram of the intestinal arteries in an emergency is difficult because it requires patient preparation

How does chronic thrombosis manifest?

The chronic form of thrombosis should be considered in patients with heart failure complicated by myocardial infarction. The clinic distinguishes 4 stages:

I - the patient does not complain, the thrombus is an accidental finding during angiography;
II - typical complaints of pain along the intestines after eating, a person refuses to eat because of this;
III - constant pain, flatulence, violation of the absorption capacity of the small intestine, diarrhea;
IV - the occurrence of intestinal obstruction, which is manifested by an "acute abdomen", with peritonitis and gangrene.

Forecast

Mesenteric thrombosis, according to clinical studies, is observed much more often than cases with a diagnosis are recorded. This pathology is masked by various acute conditions: cholecystitis, renal colic, appendicitis. Limited time for diagnosis does not always allow detection of the disease.

Fatal cases, according to pathologists, are 1–2.5% in general hospital mortality. These are thromboses in the stage of infarction and diffuse peritonitis. Late operation (after 12 hours) means high mortality (up to 90%).

A good prognosis for recovery in the surgical treatment of the chronic form of thrombosis in the first two stages. Timely seeking surgical help for abdominal pain allows you to operate the patient in a favorable time, to prevent perforation of the intestinal wall.

Mesenteric thrombosis is a serious condition of the body that occurs as a result of blockage of blood flow in the mesenteric vessels by blood clots.

The mesentery, or mesentery, is the strands in the abdominal cavity that hold the organs attached to the wall. If a blood clot occurs in an artery or other vessel, the entire area stops receiving blood supply, which can lead to peritonitis and even be fatal.

This disease usually occurs in older people due to atherosclerosis of the walls of blood vessels. But it can also occur in children if they have other diseases in the body that provoke increased thrombosis.

In 90% of cases, a thrombus forms in the superior artery, which is responsible for the "delivery" of blood to the ascending colon, small intestine, and caecum.

Blockage of this vessel has serious consequences - extensive damage to the abdominal organs and even necrosis of the intestine are possible.

In the lower region, the mesenteric artery is blocked by blood clots in only 10% of cases.

As a result, tissue damage occurs in such places:

left side of the transverse colon;
descending colon;
sigmoid colon.

How are the intestines and heart related?

Thrombosis of the mesenteric vessels of the intestine is a condition that occurs suddenly, but has prerequisites for its manifestation.

The primary causes include heart disease and the general condition of the body's vessels - thromboembolism, atrial fibrillation and other disorders in cardiac activity.

In all these conditions, the blood flow through the vessels is disturbed in one way or another. Blood clots can form in any part of the body, but they also tend to move.

As a result, clots settle in a certain vascular area, causing an overlap of further blood supply to the organs located there. As a result, there is no necessary nutrition of the walls of blood vessels, blood circulation in the area is slowed down or even stops.

If a blood clot breaks off, then on its way it can block several vessels - once in a certain area, it does not allow oxygen and nutrients to reach the organs.

Because of this, there is a risk of death, as the organs in this area begin to die without a normal blood supply, and their further problematic functioning affects the entire body.

Causes of the disease

Mesenteric thrombosis (otherwise, mesothrombosis) occurs in patients who have just suffered acute or chronic forms of cardiovascular pathologies.

Clots and blood clots form after damage to the heart muscle and vessel walls - in acute conditions, arrhythmias, inflammation, infections and aneurysms.

One of the severe manifestations is an embolism of the mesenteric vessels (the formation of a clot and its detachment), which occurs as a result of such heart diseases:

A heart attack, due to which the blood is more prone to clotting, and there are changes in the speed of its flow through the vessels.
Aneurysm.
Mitral valve stenosis.
Violation of the heart rhythm.

Such violations lead to the formation of an embolus - a blood clot that breaks off and moves along the vascular branches of the body. As a result, it enters the mesenteric region, clogging large vessels (veins, arteries) and stopping the blood supply to the abdominal organs.

Thrombosis of the superior mesenteric artery is more common than its inferior sister artery and is due to physical trauma and secondary mesenteric insufficiency.

Among injuries, it can be caused by blows to the stomach, followed by peeling of the inner walls of blood vessels and intima, which block further blood flow.

Causes of secondary vascular (both venous and arterial) insufficiency include the following pathologies:

Stenosis arising from atherosclerosis at the attachment points of the arteries to the aorta (branching at an angle): the blood flow velocity changes (decreases), the plaque that closes the vessel is damaged. The final condition is extensive necrosis.
Deterioration of the heart with a decrease in pressure in the arteries. The result is congestion in the vessels.
The steal syndrome that occurs during aortic repair operations; accelerated blood flow after the release of the vessel from the thrombus is directed downward, sucking blood from the mesenteric branches into the main artery. The result is intestinal necrosis due to intestinal infarction.
Tumors in the womb, squeezing the vessels - mainly the upper artery. The inferior artery of this area is damaged much less frequently.

And also there are general conditions of the body that can give impetus to the formation of blood clots:

hereditary vascular pathologies - thrombophilia;
increased blood viscosity due to long-term use of drugs;
change in endothelial cells due to chemotherapy, radiation, etc.;
pregnancy;
obesity;
smoking;
diabetes;
Coxsackie virus leading to heart failure.

Forms and stages of development

The clinic of the condition includes three degrees of its development:

Ischemia with severe symptoms - pain, vomiting, frequent loose stools.
Intestinal infarction with symptoms such as: constipation, severe pain, bloating, pale skin and bluish lips.
Peritonitis is a severe intoxication due to inflammation of the peritoneum with high fever, sharp pain and tension in the abdominal wall.

The classification of thrombosis at the stage of ischemia also includes several forms and types of severity:

Decompensation - complete ischemia, the most severe form of the disease, progressing within a couple of hours.
Subcompensation - there is collateral blood flow, the overlap is not complete.
Compensation is a chronic form, the main blood flow is carried out through collaterals.

The states of infarction and peritonitis are more severe and almost always lead to severe tissue necrosis, and can also end in the death of the patient.

And also thrombosis has a division into arterial and venous forms.

Venous insufficiencies (eg, thrombophlebitis) are usually segmental in nature - they affect the entire area of the mesentery. Nevertheless, this type of thrombosis is eliminated more easily than arterial thrombosis and rarely leads to death.

A mixed form is also possible - blood clots form both in a vein and in one of the arteries of the region at the same time. This phenomenon is very rare, and it can be detected only during the surgical intervention.

Ischemia

Ischemia is an acute lack of blood circulation due to the blockage of a vessel by a thrombus by more than 70 percent.

Intestinal ischemia has the following manifestations and symptoms:

bouts of pain that develop into a permanent painful state;
severe diarrhea;
vomiting with bile - bile impurities occur immediately, during the first day after clogging of the vessel.

These signs are typical of ordinary food poisoning, so the patient, as a rule, is in no hurry to see a doctor. Delaying treatment leads to serious consequences in the form of serious operations and disability.

heart attack

Intestinal infarction - necrosis of its site, caused by impaired blood circulation.

Symptoms of this stage include:

Constipation due to intestinal obstruction - pathological changes occur in the walls of the intestines, their functions are inhibited.
Blood in the stool is a negligible amount for this form of thrombosis.
Pain shock or just a strong pain syndrome in the area.
Bloating and violent vomiting.
Mondor's symptom - is detected when probing the area below the navel and is an accumulation of blood in the intestinal loops.
There may be an increase in pressure when the upper artery is affected.
The person turns pale, his lips turn blue.

At this stage, the patient feels some relief when the vessel ruptures. However, this condition is even more dangerous than the ischemia stage, as it leads to the development of peritonitis.

Most often, ischemia develops into an intestinal infarction after a patient's myocardial infarction. The formation of a thrombus during this state leads to its further rapid movement into the mesenteric zone. After that, there is a total blockage of the artery or vein, so the blood, accumulating in front of the "obstruction", breaks the vessel with its pressure. Because of this, some areas of the intestine begin to die.

Thrombosis of the mesenteric vessels can quickly lead to peritonitis - the last and most dangerous stage of the condition.

Her signs include:

elevated body temperature;
sharp pain in the abdominal cavity - goes away for several hours, then returns;
tension in the abdominal wall.

Usually, peritonitis occurs during thrombosis of the small intestine - gangrene develops in the area, perforation of the intestines occurs. This condition has an increased risk of death for the patient.

Diagnostic methods

Mesothrombosis requires an early and accurate diagnosis:

A complete examination by the doctor of the patient - taking an anamnesis, analyzing symptoms, determining the exact diagnosis according to the degree of symptoms.
Manual inspection allows you to diagnose intestinal damage.
Angiography is a type of computed tomography that allows you to quickly get an image of the vessels of the abdominal cavity. Emergency procedure.
A blood clotting test is ordered.
It is possible to have an ultrasound.
If it is difficult to make a diagnosis, laparoscopy is used under anesthesia - an endoscope is inserted through the incision, allowing you to examine the affected area "from the inside".

How is the operation carried out?

Thrombosis of the mesenteric arteries requires invasive methods of treatment - surgery is mandatory.

The need for surgical intervention is due to the high mortality rate if the thrombus is not removed on time. It is impossible to influence him with medication or alternative medical methods in such an acute condition, since complications arise within a couple of hours.

The patient is rushed to the hospital as a matter of urgency because the condition develops very quickly and death can occur within the first 5 to 12 hours after the onset of symptoms.

Surgical intervention includes:

Removal of the clot itself, which blocks the blood flow.
Reconstruction of a vessel affected by the consequences of thrombosis.
Removal of dead parts of organs - only at stage 2 (infarction), when the lesion has already led to necrosis.
Drainage of the abdominal cavity - if the operation is performed at the stage of peritonitis, and the inflammatory process has spread to the entire abdominal cavity.

Prognosis and possible complications

Timely treatment of symptoms and accurate diagnosis of the condition helps to avoid serious complications.

Thrombosis of the mesenteric artery in 70 percent of cases costs the patient's life if the treatment occurred at the stages of infarction or peritonitis.

Even after surgery, the patient runs the risk of dying from too rapid restoration of blood flow or the spread of damage to internal organs (necrosis).

Among elderly patients, death is not uncommon, even if rehabilitation has already been completed.

This is due to the fact that the recovery processes of the body at this age are too slow.

Preventive measures

Prevention of mesothrombosis includes the full treatment of diseases - the causes of this condition.

In addition to medicines, it necessarily includes: good nutrition, quitting smoking and alcohol, physical education. Compliance with the frequency of medical examinations is mandatory.