Vasküler Nedenli Karın Ağrıları: Mezenter Arter İskemi ve Enfarktı
Özet
Mezenter arter iskemisi (MAİ), bağırsak dokusunun akut veya kronik perfüzyon yetersizliği sonucu gelişen, yüksek morbidite ve mortalite oranlarına sahip bir vasküler patolojidir. Bu durum, superior mezenterik arter (SMA), inferior mezenterik arter (İMA) ve çölyak trunk gibi ana mezenterik damarların etkilenmesiyle karakterizedir. Akut mezenter iskemisi (AMİ), ani başlangıçlı bir acil durum olup, bağırsak nekrozu ve septik şoka yol açabilir; kronik mezenter iskemisi (KMİ) ise yavaş ilerleyen semptomlarla seyreder ve genellikle aterosklerotik stenozla ilişkilidir. Bu bölümde, MAİ'nin etiyolojisi, patofizyolojisi, klinik prezentasyonu, tanısal yaklaşımları, tedavi stratejileri ve prognostik faktörleri, güncel uluslararası kılavuzlar temelinde incelenmektedir. Etiyolojik faktörler bakımından, AMİ'nin başlıca nedenleri arteriyel emboli (%40-50), arteriyel tromboz (%20-30), non-oklüzif mezenter iskemisi (NOMİ) (%20-30) ve mezenter ven trombozu (%5-15) olarak sınıflandırılır. Arteriyel emboli, atrial fibrilasyon gibi kardiyak kaynaklıdır; tromboz ateroskleroz zemininde gelişir. NOMİ hipoperfüzyonla, venöz tromboz hiperkoagülabiliteyle ilişkilidir. KMİ genellikle aterosklerotik daralmaya bağlıdır. Patofizyolojik süreçte, iskemi mukozal hasarla başlar ve transmural nekroza ilerler; KMİ'de kollateral dolaşım kısmi koruma sağlar. Klinik bulgular nonspesifiktir: AMİ'de ani şiddetli ağrı, KMİ'de postprandiyal ağrı ve kilo kaybı. Tanısal stratejilerde bilgisayarlı tomografi anjiyografisi (BTA) altın standarttır; dupleks ultrason ve manyetik rezonans anjiyografi alternatiflerdir. Tedavi multidisiplinerdir: AMİ'de revaskülarizasyon ve cerrahi, KMİ'de stentleme. Prognoz erken müdahaleye bağlıdır; tedavi edilmeyen AMİ'de mortalite %80-90'dır. Gelecek çalışmalar yapay zeka destekli görüntüleme ve biyobelirteçlere odaklanmaktadır. Bu özet, MAİ'nin klinik yönetimini bütüncül bir perspektiften sunar.
Mesenteric artery ischemia (MAI) is a vascular pathology with high morbidity and mortality rates resulting from acute or chronic perfusion insufficiency of intestinal tissue. This condition is characterized by the involvement of major mesenteric vessels such as the superior mesenteric artery (SMA), inferior mesenteric artery (IMA), and celiac trunk. Acute mesenteric ischemia (AMI) is an acute emergency that can lead to intestinal necrosis and septic shock; chronic mesenteric ischemia (CMI) progresses slowly and is usually associated with atherosclerotic stenosis. This section comprehensively examines the etiology, pathophysiology, clinical presentation, diagnostic approaches, treatment strategies, and prognostic factors of MAI based on current international guidelines. Etiologically, the main causes of AMI are arterial embolism (40-50%), arterial thrombosis (20-30%), non-occlusive mesenteric ischemia (NOMI) (20-30%), and mesenteric vein thrombosis (5-15%). Arterial embolism is cardiac in origin, such as atrial fibrillation; thrombosis develops on an atherosclerotic background. NOMI is associated with hypoperfusion, venous thrombosis with hypercoagulability. CMI is usually due to atherosclerotic narrowing. In the pathophysiological process, ischemia starts with mucosal damage and progresses to transmural necrosis; in CMI, collateral circulation provides partial protection. Clinical findings are nonspecific: sudden severe pain in AMI, postprandial pain and weight loss in CMI. In diagnostic strategies, computed tomography angiography (CTA) is the gold standard; duplex ultrasound and magnetic resonance angiography are alternatives. Treatment is multidisciplinary: revascularization and surgery in AMI, stenting in CMI. Prognosis depends on early intervention; mortality is 80-90% in untreated AMI. Future studies focus on artificial intelligence-supported imaging and biomarkers. This summary presents the clinical management of MAI from a holistic perspective.
Referanslar
Koelemay M, Björck M, Acosta S, et al. European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Diseases of the Mesenteric Arteries and Veins. Eur J Vasc Endovasc Surg. 2025;70(2):153-218. doi:10.1016/j.ejvs.2025.06.010
Bala M, Catena F, Kashuk J, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 2022;17:54. doi:10.1186/s13017-022-00443-x
Loffroy R, Basile A, Dósa E, et al. CIRSE Standards of Practice for the Interventional Radiology Management of Acute and Chronic Arterial Mesenteric Ischaemia. Cardiovasc Intervent Radiol. 2025;48:1091-1103. doi:10.1007/s00270-025-04080-0
Reintam Blaser A, Mändul M, Björck M, et al. Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study). Crit Care. 2024;28:32. doi:10.1186/s13054-024-04832-6
Audu CO, Schechtman DW, Davis FM. Mesenteric Ischemia. Clin Colon Rectal Surg. 2024;37(6):417-423. doi:10.1055/s-0044-1788788
Tolonen M, Vikatmaa P. Diagnosis and Management of Acute Mesenteric Ischemia: What You Need to Know. J Trauma Acute Care Surg. 2025;99(2):151-161.
Warren AS, Murphy B, Saldana-Ruiz N, et al. Open Revascularization for Acute Mesenteric Ischemia is Associated with Increased Morbidity and Mortality when Compared to Endovascular Intervention. Ann Vasc Surg. 2025;111:386-392. doi:10.1016/j.avsg.2024.10.013
Björck M, Koelemay M, Acosta S, et al. Editor's Choice - Management of Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53(4):460-510. doi:10.1016/j.ejvs.2017.01.010 (Updated 2025)
Klar E, Rahmanian PB, Bücker A, et al. Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int. 2012;109(14):249-256. doi:10.3238/arztebl.2012.0249
Di Serafino M, Severino R, Coppola A, et al. Mesenteric Ischemia: A Comprehensive Review of the Role of Radiology in Diagnosis. Diagnostics. 2025;14(16):1783. doi:10.3390/diagnostics14161783
Tendler DA, Lamont JT. Chronic mesenteric ischemia. UpToDate. Waltham (MA): UpToDate; 2025.
Erişim adresi: https://www.uptodate.com/contents/chronic-mesenteric-ischemia
Oldenburg WA, Lau LL, Rodenberg TJ, et al. Acute mesenteric ischemia: a clinical review. Arch Intern Med. 2004;164(10):1054-1062. doi:10.1001/archinte.164.10.1054
Acosta S. Mesenteric ischemia. Curr Opin Crit Care. 2015;21(2):171-178. doi:10.1097/MCC.0000000000000189
Clair DG, Beach JM. Mesenteric Ischemia. N Engl J Med. 2016;374(10):959-968. doi:10.1056/NEJMra1503884
Acosta S, Björck M. Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010;23(1):9-15. doi:10.1053/j.semvascsurg.2009.12.003
Referanslar
Koelemay M, Björck M, Acosta S, et al. European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Diseases of the Mesenteric Arteries and Veins. Eur J Vasc Endovasc Surg. 2025;70(2):153-218. doi:10.1016/j.ejvs.2025.06.010
Bala M, Catena F, Kashuk J, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 2022;17:54. doi:10.1186/s13017-022-00443-x
Loffroy R, Basile A, Dósa E, et al. CIRSE Standards of Practice for the Interventional Radiology Management of Acute and Chronic Arterial Mesenteric Ischaemia. Cardiovasc Intervent Radiol. 2025;48:1091-1103. doi:10.1007/s00270-025-04080-0
Reintam Blaser A, Mändul M, Björck M, et al. Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study). Crit Care. 2024;28:32. doi:10.1186/s13054-024-04832-6
Audu CO, Schechtman DW, Davis FM. Mesenteric Ischemia. Clin Colon Rectal Surg. 2024;37(6):417-423. doi:10.1055/s-0044-1788788
Tolonen M, Vikatmaa P. Diagnosis and Management of Acute Mesenteric Ischemia: What You Need to Know. J Trauma Acute Care Surg. 2025;99(2):151-161.
Warren AS, Murphy B, Saldana-Ruiz N, et al. Open Revascularization for Acute Mesenteric Ischemia is Associated with Increased Morbidity and Mortality when Compared to Endovascular Intervention. Ann Vasc Surg. 2025;111:386-392. doi:10.1016/j.avsg.2024.10.013
Björck M, Koelemay M, Acosta S, et al. Editor's Choice - Management of Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53(4):460-510. doi:10.1016/j.ejvs.2017.01.010 (Updated 2025)
Klar E, Rahmanian PB, Bücker A, et al. Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int. 2012;109(14):249-256. doi:10.3238/arztebl.2012.0249
Di Serafino M, Severino R, Coppola A, et al. Mesenteric Ischemia: A Comprehensive Review of the Role of Radiology in Diagnosis. Diagnostics. 2025;14(16):1783. doi:10.3390/diagnostics14161783
Tendler DA, Lamont JT. Chronic mesenteric ischemia. UpToDate. Waltham (MA): UpToDate; 2025.
Erişim adresi: https://www.uptodate.com/contents/chronic-mesenteric-ischemia
Oldenburg WA, Lau LL, Rodenberg TJ, et al. Acute mesenteric ischemia: a clinical review. Arch Intern Med. 2004;164(10):1054-1062. doi:10.1001/archinte.164.10.1054
Acosta S. Mesenteric ischemia. Curr Opin Crit Care. 2015;21(2):171-178. doi:10.1097/MCC.0000000000000189
Clair DG, Beach JM. Mesenteric Ischemia. N Engl J Med. 2016;374(10):959-968. doi:10.1056/NEJMra1503884
Acosta S, Björck M. Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010;23(1):9-15. doi:10.1053/j.semvascsurg.2009.12.003
