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Celiac
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Inferior mesenteric
Marginal
Rectal
Superior mesenteric
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This patient with cardiac risk factors (hypertension, hyperlipidemia, coronary artery disease) who presents with acute onset of severe abdominal pain related to eating that is out of proportion to the physical exam most likely has superior mesenteric ischemia. The superior mesenteric artery supplies the distal ileum that was found to be necrotic. The intestines are supplied by contiguous and anastomotic arteries so that they are able to efficiently absorb nutrients of digestion. The major arteries include the celiac trunk, the superior mesenteric artery, and the inferior mesenteric artery. The celiac trunk provides the blood supply from the stomach to the proximal duodenum and also supplies mesoderm-derived organs such as the liver, gallbladder, pancreas, and spleen. The superior mesenteric artery provides the blood supply from the distal duodenum to the proximal 2/3 of the transverse colon. Finally, the inferior mesenteric artery provides the blood supply from the distal 1/3 of the transverse colon to the upper portion of the rectum at which point the systemic inferior rectal blood supply is found. The most important anastomosis in the supply of the colon is the marginal artery of Drummond that links the superior and inferior mesenteric arteries. The marginal artery is sometimes also supplemented by the arc of Riolin, which is located at the base of the mesentery. Damage to either of these structures can cause necrosis of the splenic flexure watershed zone. Zhang et al. evaluated the characteristics of left-sided colonic perfusion in elderly patients and found that the marginal artery and the arc of Riolin were important in 100% and 2% of patients, respectively. Incorrect Answers: Answer 1: The celiac trunk provides the blood supply from the stomach to the proximal duodenum and also supplies mesoderm-derived organs such as the liver, gallbladder, pancreas, and spleen. Answer 2: The inferior mesenteric artery provides the blood supply from the distal 1/3 of the transverse colon to the upper portion of rectum. Answer 3: The marginal artery of Drummond links the superior and inferior mesenteric arteries and would cause ischemia to the watershed splenic flexure region of the colon if damaged. Answer 4: The inferior rectal artery is derived from the systemic circulation (internal iliac artery) and supplies the distal portion of the rectum. Bullet Summary: The superior mesenteric artery provides the blood supply from the distal duodenum to the proximal 2/3rds of the transverse colon.
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