The Diagnosis of Acute Mesenteric Ischemia: A Systematic Review and Meta-analysis
Open accessAbstract
OBJECTIVES: Acute mesenteric ischemia is an infrequent cause of abdominal pain in emergency department (ED) patients; however, mortality for this condition is high. Rapid diagnosis and surgery are key to survival, but presenting signs are often vague or variable, and there is no pathognomonic laboratory screening test. A systematic review and meta-analysis of the available literature was performed to determine diagnostic test characteristics of patient symptoms, objective signs, laboratory studies, and diagnostic modalities to help rule in or out the diagnosis of acute mesenteric ischemia in the ED. METHODS: In concordance with published guidelines for systematic reviews, the medical literature was searched for relevant articles. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was used to evaluate the overall quality of the trials included. Summary estimates of diagnostic accuracy were computed by using a random-effects model to combine studies. Those studies without data to fully complete a two-by-two table were not included in the meta-analysis portion of the project. RESULTS: The literature search identified 1,149 potentially relevant studies, of which 23 were included in the final analysis. The quality of the diagnostic studies was highly variable. A total of 1,970 patients were included in the combined population of all included studies. The prevalence of acute mesenteric ischemia ranged from 8% to 60%. There was a pooled sensitivity for l-lactate of 86% (95% confidence interval [CI] = 73% to 94%) and a pooled specificity of 44% (95% CI = 32% to 55%). There was a pooled sensitivity for D-dimer of 96% (95% CI = 89% to 99%) and a pooled specificity of 40% (95% CI = 33% to 47%). For computed tomography (CT), we found a pooled sensitivity of 94% (95% CI = 90% to 97%) and specificity of 95% (95% CI = 93% to 97%). The positive likelihood ratio (+LR) for a positive CT was 17.5 (95% CI = 5.99 to 51.29), and the negative likelihood ratio (-LR) was 0.09 (95% CI = 0.05 to 0.17). The pooled operative mortality rate for mesenteric ischemia was 47% (95% CI = 40% to 54%). Given these findings, the test threshold of 2.1% (below this pretest probability, do not test further) and a treatment threshold of 74% (above this pretest probability, proceed to surgical management) were calculated. CONCLUSIONS: The quality of the overall literature base for mesenteric ischemia is varied. Signs, symptoms, and laboratory testing are insufficiently diagnostic for the condition. Only CT angiography had adequate accuracy to establish the diagnosis of acute mesenteric ischemia in lieu of laparotomy.
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Based on the literature, contrast-enhanced CT-scan has a good accuracy in diagnosing arterial and venous occlusive AMI.
“Based on the literature, contrast-enhanced CT-scan has a good accuracy in diagnosing arterial and venous occlusive AMI [21, 22]”
From Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study) (2024) · cites this paper as [21]
The Radiographic Tests section reports high pooled CT sensitivity (94%) and specificity (95%) for acute mesenteric ischemia, supporting the general accuracy claim. But the Limitations section says the results were not stratified by etiology, so the paper does not establish that accuracy specifically for arterial and venous occlusive cases. (LLM, conf=0.88)
Experimental — accuracy not yet measuredPrevious observations have shown that clinical characteristics and laboratory tests are unable to clearly distinguish between patients with and without AMI.
“Previous observations have shown that clinical characteristics and laboratory tests are unable to clearly distinguish between patients with and without AMI [19, 21].”
From Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study) (2024) · cites this paper as [21]
Common clinical symptoms of AMI include acute abdominal pain (60-100%), diffuse abdominal tenderness (54-90%), abdominal distension (18-54%), peritoneal signs (13-65%), nausea and/or vomiting (39-93%), and diarrhoea and/or rectal bleeding (12-48%).
“The common clinical symptoms of AMI include acute abdominal pain (60 e 100%), diffuse abdominal tenderness (54 e 90%), abdominal distension (18 e 54%), peritoneal signs (13 e 65%), nausea and or vomiting (39 e 93%), and diarrhoea and or rectal bleeding (12 e 48%). 122”
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- Authors
- Cudnik, M. T., Darbha, S., Jones, J., Macedo, J., Stockton, S. W., & Hiestand, B. C.
- Affiliations
- The Ohio State University (US)
- Wake Forest University Health Sciences (US)
- Corresponding author
- Hiestand, Brian C.
- Venue
- Academic Emergency Medicine
- Publisher
- Wiley
- Published
- 2013-11
- Volume
- 20
- Issue
- 11
- Pages
- 1087-1100
- ISSN
- 1069-6563 (ISSN-L)
- OpenAlex
- W2056853802
- Cited by
- 275
- References
- 87
- Citations by year
- 2026: 19 · 2025: 23 · 2024: 23 · 2023: 29 · 2022: 17 · 2021: 25 · 2020: 51 · 2019: 26 · 2018: 17 · 2017: 13 · 2016: 18 · 2015: 7 · 2014: 6 · 2013: 1
- FWCI
- 1.89
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Academic Emergency Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Abdominal vascular conditions and treatments
- Health Sciences › Medicine › Emergency Medicine › Appendicitis Diagnosis and Management
- Health Sciences › Medicine › Rheumatology › Omental and Epiploic Conditions
- Keywords
- acute mesenteric ischemia, diagnostic accuracy, emergency department diagnosis, lactate, D-dimer, computed tomography, abdominal pain, diagnostic test characteristics, sensitivity and specificity, likelihood ratios, postoperative mortality
- MeSH terms
- Acute Disease, Fibrin Fibrinogen Degradation Products, Humans, Ischemia, Lactates, Physical Examination, Sensitivity and Specificity, Tomography, X-Ray Computed, Vascular Diseases, Biomarkers, Mesenteric Ischemia
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