5 mesenteric ischemia
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Acute Mesenteric Ischemia
Scott Q. Nguyen, M.D.
Celia M. Divino, M.D.
Mount Sinai School of Medicine
Department of Surgery
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Mrs. Mitty
An 83 year-old woman is brought to the
ER by ambulance from her nursing homew/ a 4 hour history of severe diffuse
abdominal pain and distention.
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History
What other points of the history doyou want to know?
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History, Mrs. Mitty
Characterization of
symptoms
Temporal sequence
Alleviating /
Exacerbating factors:
Pertinent PMH, ROS,
MEDS.
Associated signs and
symptoms
Relevant family hx.
Consider the Following
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History, Mrs. Mitty
Characterization of Symptoms: Sudden onset diffuse abdominal pain and distention
4 hours ago.
Pain not localized to any quadrant.
Alleviating / Exacerbating factors: Pain is excruciating, its the worse shes ever experienced
Nothing alleviates it
Associated signs/symptoms: She vomits 1L of feculent emesis on arrival to ER.
Last BM 2 hours ago, loose
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Other History
PMH Atrial Fibrillation - dxd 1 month ago,
anticoagulation contraindicated with history ofmassive GI bleed
CHF, CAD, DM
PSH
Cholecystectomy, left hemicolectomy for
diverticular disease
MEDS
digoxin, metoprolol, insulin
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Other History
Social History
Occasional wine,
50 pack-yr smoker, quit 2 yrs ago
Family History Patient unable to give
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What is your DifferentialDiagnosis?
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Differential DiagnosisBased on History and Presentation
Small Bowel Obstruction
Acute MesentericIschemia
Perforated Diverticulitis
Ischemic Colitis
Perforated Peptic Ulcer
Disease Acute Pancreatitis
Acute Cholecystitis
Gastroenteritis Acute Appendicitis
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Physical Examination
What would you look for?
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Physical Examination
Vital Signs: T = 38.5, P = 103, BP = 140/85, RR = 28
Appearance: thin , in severe distress, legs pulled up to chest,moaning
Heart: irregularly irregular Lungs: mild rales at bases
Abdomen: decreased BS, very distended, mildly tenderdiffusely, no guarding/rebound tenderness, no hernias
Rectal: loose stool in vault, streaked w/ fresh blood
Remaining Examination findings non-contributory
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Would you like to revise your
Differential Diagnosis?
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Laboratory
What would you obtain?
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LFTs - WNL
Amylase/Lipase - 89/95
PT/PTT - 13.0/33.0
ABG - 7.31/30/69/16
Lactate 7.9
133 101
4.9 19
14
42
40530
1.2
240
Labs ordered, Mrs. Mitty
85 PMNs 22 Bands
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Lab Results, Discussion
Leukocytosis - acute process,possibly infectious
Electrolytes - elevated BUN indicating dehydration or
3rd spacing.
Anion gap acidosis - intravascular depletion,Metabolic acidosis (lactic acidosis)
Coagsabnormal coags may reflect sepsis. Pt. not on
anticoagulation for Afib. Normal LFTs/ pancreatic enzymes - no signs of
hepatic/pancreatic insult
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Interventions at this point?
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Consider the following Interventions
Admit to the hospital/ICU
Aggressive resuscitation
Start IV with isotonic crystalloid solution( NS or LR)
Insert Foley catheter
Monitor response to resuscitation
Administer broad spectrum antibiotics
Likely intra-abdominal septic process
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Studies
What further studies would you wantat this time?
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Studies, Mrs. Mitty
Abdominal X-rays
Flat / Upright
Acute Abdominal Series (may include chest at some
institutions)
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StudiesResults
Plain abdominal films
Diffuse dilation of small bowel w/ air fluidlevels on upright view. Some air in Left
colon and Rectum. NO free air
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What is the differential
diagnosis at this point?
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Revised Differential Diagnosis
1) Acute Mesenteric Ischemia
2) Strangulated small bowel obstruction3) Diverticulitis w/ contained perforation?
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What next?
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What next?
Mesenteric Angiogram or CT
Angiogram
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Discussion
With the sudden onset of symptoms, h/o Afib,and pain out of proportion to physical exam,acute mesenteric ischemia should be high on
the Differential Diagnosis A mesenteric angiogram will allow
visualization of the visceral vessels (celiac,
SMA, IMA)
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Mesenteric Angiogram
Note complete lack of contrast in mesenteric vessels in AP view (left). The
occluded origins of the celiac axis and superior mesenteric artery are
demonstrated in the Lateral view (right).
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CT Angiogram
Note complete occlusion and lack of IV contrast filling the superior
mesenteric artery from its origin from the aorta (Arrows).
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Other studies
CT angiogram / MR angiogram
sensitivity 75%, specificity 100% for emboli
additionally can detect thickened, distended
bowel loops
more sensitive for Mesenteric Venous
Thrombosis
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Management
What should be done next?
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Management
Pre-operative preparation Assure adequate resuscitation
Monitoring
Foley Catheter
Urgent exploration
Surgical embolectomy
Assess bowel viability
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Management
Pre-operative preparation Assure adequate resuscitation
Monitoring
Non-invasive: EKG, BP, Pulse Oximetry, foley catheter
Consider invasive monitoring: Central venous catheter,PA Catheter ? Arterial line?
Operative Technique/ Urgent exploration
Midline Laparotomy
Relevant Anatomy Surgical Embolectomy
Assess bowel viability
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Surgical Embolectomy
Pack bowel to Right,
Expose SMA
Arteriotomy Pass balloon embolectomy
catheter
Assess bowel viability
Resect if necessary
Necrotic bowel from
mesenteric ischemia.
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Discussion
Acute mesenteric ischemia is a vascular emergencywith overall mortality 60-80%. There are four main
pathophysiologic processes which have the samecommon endpoint, bowel necrosis, abdominal sepsis,
and death. Mesenteric arterial anatomy is notable forrich collateral flow between the celiac trunk, superiormesenteric artery, and inferior mesenteric artery.Gradual occlusion of 2 of the 3 vessels is tolerable as
rich collateral branches form between these. Acuteocclusion of any of the vessels or their branches causesacute intestinal ischemia and necrosis.
i i
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Discussion
The four processes:
1) Acute arterial embolus -usually from cardiogenic embolusin pts w/ Afib or valvular disorders. SMA is the commonvessel affected as it has a less acute take off from aorta
2) Acute arterial thrombosis - chronic atherosclerotic plaqueat origin of vessel acutely thromboses
3) Chronic mesenteric ischemia - atherosclerosis of visceralvessels results in abdominal pain (intestinal angina)during times of increased blood demand (digestion)
4) Acute venous occlusion - venous thrombosis causescessation of venous outflow from intestines
*Non-occlusive mesenteric ischemia can also be seen in low-flow states
Di i
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Discussion
Diagnosis- requires high degree of suspicion. Classically presents aspain out of proportion to physical exam or severe pain w/o
peritoneal signs. The history of Cardiac disease, valvular disease, or
Afib should alert one to an embolic disease. Gold standard for
diagnosis is mesenteric angiogram, but CT angiogram is more and
more being used.
Treatment - requires aggressive resuscitation and hemodynamicmonitoring as patients become critically ill very quickly. Urgent
surgery w/ viseral revascularization (embolectomy, thrombectomy,
endarterectomy, or bypass) is required. After this, evaluation of
viability of bowel segments should be performed with resection of any
necrotic portions.
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QUESTIONS ??????
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References
Townsend CM. Sabiston Textbook of Surgery.17th Edition
Cameron JL. Current Surgical Therapy. 8th
Edition
Oldenburg et al. Acute Mesenteric Ischemia.
Arch Intern Med 164:1054-62. 2004
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