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Chronic mesenteric ischaemia
Chronic mesenteric ischaemia presents as the triad of postprandial pain in the abdomen, "food fear" and weight loss, usually when at least 2 of the 3 intestinal arteries are occluded or narrowed; diagnosis is by CTA, and treatment is revascularisation — usually an SMA stent, and in some patients surgical bypass — to prevent progression to acute ischaemia.
Why it matters in the exam
The intestine has three main arteries — the celiac, the SMA and the IMA — with connections between them, so occlusion of one artery usually causes no symptoms. When 2 or more arteries are occluded, flow cannot meet the increased demand after a meal. The classic exam picture: a female smoker in her 60s, with dull abdominal pain starting about 15–30 minutes after eating and lasting an hour or two, who learns to eat less and loses much weight, and has sometimes had many gastrointestinal work-ups that found nothing. There may be an epigastric bruit. Duplex can serve as a screening test (high peak velocity in the SMA or celiac), but CTA is the central test and shows the number of arteries, the site of stenosis and calcification. The differential diagnosis includes pancreatic or gastric cancer, peptic ulcer and biliary disease.
A symptomatic patient with proven disease needs revascularisation, because without it there is a risk of acute-on-chronic ischaemia — a condition with high mortality — and advanced malnutrition. According to ESVS, endovascular treatment (an SMA stent, sometimes also celiac) is the first choice in most patients, with rapid recovery; restenosis is more frequent than after bypass, so duplex surveillance is done. Surgical bypass — from the aorta or the iliac artery to the SMA — suits younger patients in good condition, lesions unsuitable for stenting or repeated failure. An asymptomatic patient with stenosis is not treated routinely. A related condition is median arcuate ligament syndrome — compression of the celiac on expiration, usually in a young woman with postprandial pain and weight loss; diagnosis is by imaging in inspiration and expiration, and treatment is division of the ligament (sometimes laparoscopically), not a stent.
Before revascularisation in a severely malnourished patient the nutritional state is improved carefully, but treatment is not delayed for long.
Key points
- Postprandial pain, food fear, weight loss.
- Usually 2 or more arteries.
- CTA for diagnosis.
- SMA stent first in most patients; bypass in selected.
- Median arcuate ligament — division, not a stent.
Summary table
| Situation | Finding | Treatment |
|---|---|---|
| Chronic mesenteric ischaemia | Postprandial pain, food fear, weight loss; 2 or more arteries | SMA stent or bypass |
| Asymptomatic stenosis | Incidental finding on CT | Surveillance, risk factor treatment |
| Acute-on-chronic ischaemia | Sudden severe pain, acidosis | Emergency — revascularisation and bowel inspection |
| Median arcuate ligament | Celiac compression on expiration, young woman | Division of the ligament |
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Sources
- ESVS Clinical Practice Guidelines on the Management of Diseases of Mesenteric Arteries and Veins, 2017 — Chronic mesenteric ischaemia
- ACR Appropriateness Criteria: Imaging of mesenteric ischemia, 2018 — Chronic mesenteric ischemia
- Rutherford's Vascular Surgery and Endovascular Therapy, 10th edition (2022) — Chronic mesenteric ischemia and median arcuate ligament syndrome
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.