A 68-year-old woman presented with a 19-month history of generalized abdominal pain. Initially, she experienced the pain following meals, but subsequently the pain became persistent. Over this period of time, she lost 12 kg in weight. For the last few months before admission, she started having diarrhea once to twice per day. There was no blood or mucus in the stool. Her past medical history included partial gastrectomy 17 years earlier for benign disease. On examination, the patient looked cachectic.Herabdomenwasslightlydistended,andthebowelsoundswereincreased.There was a high-pitched epigastric bruit. Routine blood tests were normal.

Question 1

Which is the likely diagnosis for our patient on the basis of the available information so far?

A.  Cancer of the pancreas B.  Peptic ulcer

C.  Subacute intestinal obstruction secondary to adhesions D.  Mesenteric angina

E.  Cancer of the large bowel

Fecal fat measurement was 17.6 g/day (normal value <6 g/day). Gastroscopy was performed, which showed features compatible with atrophic gastritis. This was followed by computed tomography (CT) scanning of the abdomen, which reported that the pancreas could not be defined well as a result of paucity of retroperitoneal fat. In addition, CT showed non-specific thickening of the small-bowel loops. Endoscopic retrograde cholecystopangreatography (ERCP) was performed, which ruled out pancreatic pathology. A small-bowel enema did not demonstrate any significant findings. A colonoscopy was performed, which showed two isolated ulcers in the ascending colon (Fig. 27.1) and raised the possibility of ischaemic colitis. Figure 27.2 shows the lateral aortogram of our patient, and demonstrates an occlusion of the coeliac artery and 95% stenosis of the superior mesenteric artery. A diagnosis of chronic visceral ischaemia was made.

G. Geroulakos ( )

Imperial College of Science Technology and Medicine,

Charing Cross Hospital, and Ealing Hospital, London, UK

Question 2

Which of the following statements regarding chronic visceral ischaemia is correct?

A.  It has a marked male preponderance.

B.  As described in our patient, it usually takes more than 1 year from the first presentation of the symptoms until the final diagnosis is made.

C.  It presents clinically as an undiagnosed malignancy.

D.  Symptoms occur when at least one of the three visceral arteries has significant disease.

E.  It may cause malabsorption.

The patient underwent antegrade revascularisation, via a ninth rib extraperitoneal thoracoabdominal approach, of the coeliac artery and the revascularisation, superior mesenteric artery. An 8-mm Dacron graft was used approach, as a conduit.

Question 3

Which of the following statements regarding the management of this patient are false?

A.  The best patency can be achieved using a venous conduit.

B.  Revascularisation of the coeliac artery was unnecessary, and equally good results could have been achieved with revascularisation of only the superior mesenteric artery.

C.  Surgical revascularisation should not have been considered in this elderly, frail patient because it has an excessive mortality rate of about 30% in most series.

D.  Percutaneous transluminal angioplasty (PTA) should have been the method of choice.

The postoperative recovery of the patient was uneventful. She was discharged home on the eighth postoperative day. Six months later, she was asymptomatic and had gained 5 kg in weight. However, at 12 months the patient presented to the outpatient clinic with recurrent postprandial abdominal pain. A duplex examination showed that the graft to superior mesenteric artery anastomosis had more than 60% stenosis and the graft to coeliac artery anastomosis was occluded.

Question 4

What would you advise your patient?

A.  Reoperation aiming to revascularise the coeliac artery and place a patch on the graft to superior mesenteric artery anastomosis.

B.  Angioplasty and stenting of the graft to superior mesenteric artery anastomosis. C.  Conservative management advising the patient to take small and frequent meals. D.  Start the patient on Cilostazol 100 mg twice per day.

The patient underwent angioplasty and stenting of the graft to superior mesenteric artery anastomosis with an excellent technical and clinical result. Twenty-four months following this procedure the patient remains asymptomatic.

27.1  Commentary

As described in our patient, the clinical picture of chronic visceral ischaemia includes abdominal pain with or without diarrhea and weight loss. The diagnosis of chronic visceral ischaemia is in doubt if the patient has no significant decrease in total body mass. The abdominal pain occasionally radiates to the back. The pain of visceral ischaemia has similarities to that of carcinoma of the stomach, pancreatic carcinoma and peptic ulceration. Diarrhea may be explained by the increased motility of the bowel induced by the ischaemia; it may also be secondary to malabsorption. [Q1: A, B, D, E]

Other symptoms that may be seen include nausea and vomiting, which have been associated withgastric motility disorders causedby ischaemia.1 Anepigastricbruitmay or may not be present. Our group and others have reported a marked female patient distribution of this condition.2–4 The reason for this peculiar sex distribution remains undetermined. However, it has been suggested that it could be the result of the inclusion of cases of Takayasu’s aortitis in reports of atherosclerotic chronic visceral ischaemia.5 Takayasu’s aortitis closely mimics atherosclerosis of the abdominal aorta and has a marked female predominance. The time from the onset of symptoms to diagnosis is usually more than 12 months.6 The diagnosis of chronic visceral ischaemia is a clinical one. As shown clearly in our case, contrast studies, abdominal ultrasound, endoscopy and CT are not essential to the diagnosis but will prove important in eliminating other sources of abdominal discomfort. Inallinstances,lateralviewsofbiplaneaortographydemonstratevisceralocclusivelesions compatible with the diagnosis. As a result of an abundant network of collateral vessels, clinical symptoms are present when at least two of the three visceral arteries have significant disease. There are known asymptomatic cases with all three visceral arteries thrombosed, thus emphasizing the fact that chronic visceral ischaemia cannot be diagnosed exclusively on the basis of X-rays. [Q2: B, C, E]

Techniques of revascularisation include transection and reimplantation, bypass grafting, endarterectomy and balloon angioplasty with or without stent placement. There is no consensusregardingthebestsurgicalapproachforthetreatmentofchronicvisceralischaemia. This condition is encountered infrequently, and it is unlikely that a single center can treat enough patients and accumulate sufficient experience to develop principles of treatment by demonstrating significant differences between the various mesenteric revascularisation strategies. Bypass grafting is the most common type of visceral revascularisation performed; it may originate from several different locations, including the supracoeliac aorta, the infrarenal aorta and the common iliac arteries. Regardless of the bypass technique used, the status of the donor artery is critical to success.7 The distal thoracic aorta is usually free ofatherosclerotic disease and is anexcellent origin of a short antegrade bypass to the superior mesenteric artery. The bypass is placed in the direction of normal blood flow,thusreducinganastomoticturbulence.Inaddition,thisdesigneliminatesthepossibility of kinking and thrombosis by compression or traction from the overlying intestinal mesentery, which may be observed with retrograde grafts originating from the infrarenal aorta or the iliac arteries. The distal portion of the thoracic aorta may be approached from the abdomen through division of the crura.8