Chronic mesenteric ischaemia: pain after eating, tests and treatment

The mesenteric arteries are the vessels that supply blood to the stomach, liver, bowel and other abdominal organs. The Society for Vascular Surgery describes mesenteric ischaemia as poor circulation in these vessels, which can be acute (sudden) or chronic (developing over time). In chronic mesenteric ischaemia, the narrowing builds up gradually, which is why symptoms tend to come on slowly.

The gut has a rich network of back-up blood vessels. The Seminars in Interventional Radiology review explains that, because of this collateral circulation, symptoms usually do not appear until two or three major mesenteric vessels are involved. It also notes that blood flow to the intestine rises after eating, which explains why symptoms are more prominent after meals. The old term abdominal angina reflects this: like angina in the heart, the pain comes when demand outstrips supply.

This is a distinct condition from acute mesenteric ischaemia, which is a surgical emergency in which a clot suddenly blocks a mesenteric artery.

The Society for Vascular Surgery describes severe stomach pain starting 15 to 60 minutes after eating, which may last as long as 2 hours and tends to recur with every meal, together with nausea, vomiting, diarrhoea or flatulence. Weight loss and loss of appetite can follow because, although you may feel hungry, you eat less or less often to avoid the pain. The review adds that classic symptoms include postprandial pain with significant weight loss, fear of food, nausea, vomiting or diarrhoea, and that it generally presents in people older than 60 and is more frequent in women.

Because these symptoms can resemble gallstones, peptic ulcer, gastroparesis, irritable bowel or cancer, the condition is often diagnosed late. If you have pain after eating that keeps happening, weight loss you cannot explain, or you have started to fear eating, see your GP.

• Abdominal pain starting within an hour of eating.

• Avoiding food or eating less to prevent the pain.

• Unintended weight loss.

• Nausea, vomiting, diarrhoea or bloating.

The Society for Vascular Surgery lists sudden, severe abdominal or back pain as a symptom requiring immediate medical treatment. In the UK that means calling 999 or going to A&E, particularly if there is vomiting, a very tender or rigid tummy, bloody stools or collapse. Do not drive yourself. A person with known chronic mesenteric ischaemia is at risk of the condition becoming acute, which the review says may result in bowel infarction and death, so a sudden change in pattern needs prompt assessment.

The review says the most common cause is atherosclerosis involving the origins of the coeliac, superior mesenteric or inferior mesenteric artery. Less common causes include dissection, vasculitis, fibromuscular dysplasia, radiation and cocaine use. Factors that predispose to atherosclerosis, such as smoking, high blood pressure, diabetes and high cholesterol, are associated with higher risk.

Many people who are diagnosed also have atherosclerosis elsewhere, including coronary artery disease and peripheral vascular disease, which is why the Society for Vascular Surgery asks about smoking, blood pressure, diabetes and heart disease when taking a history.

The review emphasises that diagnosis requires a high index of suspicion. Blood tests may show effects of malnutrition. To confirm a narrowing, imaging options include duplex ultrasound, CT angiography (CTA), MR angiography and conventional angiography. The Society for Vascular Surgery calls CT scanning the test of choice and describes an angiogram as a more invasive test that may be preferred if a rapid diagnosis is very important.

Duplex ultrasound can be limited by body habitus, bowel gas and operator dependence, according to the review, while CT can also show effects of ischaemia on the bowel wall. MR angiography avoids radiation. In the UK the work-up is usually led by vascular surgery or gastroenterology teams working with radiology.

The Society for Vascular Surgery says the goal of treatment is to re-open the artery so that enough blood reaches the intestine. In chronic cases, minimally invasive endovascular treatment, balloon angioplasty with stenting, has become the first-line approach in most instances; if you are not a candidate for it, bypass surgery is recommended.

The review describes open surgery as effective but associated with significant morbidity and mortality, partly because of weight loss and malnutrition, and endovascular repair as having high technical and clinical success with lower complication rates, although repeat procedures are more common. It says medical treatment such as anticoagulation is usually reserved for people who are not healthy enough for surgery or endovascular treatment, and that it is not curative.

After treatment, regular follow-up is advised, with imaging if symptoms return. The review mentions antiplatelet therapy after stenting and management of risk factors such as smoking, high cholesterol and diabetes; the Society for Vascular Surgery adds a heart-healthy diet, regular exercise and keeping other conditions under control.

No UK patient information page on chronic mesenteric ischaemia could be read for this guide, so it relies on a US vascular surgery society and a US review article. Practice in the NHS follows similar principles, with care coordinated by vascular surgeons and interventional radiologists, but local pathways differ. Ask your specialist team what is planned and what the follow-up arrangements are.