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Mesenteric Ischaemia - Overview of management approach
Joint Hospital Surgical Grand Round Dr Shirley Liu Department of Surgery North District Hospital
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Mesenteric Ischaemia A.J. Cokkinis 1926
“Occlusion of the mesenteric vessels is apt to be regarded as one of those condition of which …the diagnosis is impossible, …the prognosis hopeless, …and the treatment almost useless” A.J. Cokkinis 1926 Cokkinis AJ. Mesenteric vascular occlusion. London, Bailliere, Tindall and Cox. 1926pp1-93
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Commonest outcome…
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Pathophysiology Resting bowel: 20% cardiac output Postprandial bowel:
Bradbury AW, et al. Br J Surg 1995;82:
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Mesenteric arteries SMA IMA Acute SMA occlusion Ischaemic colitis
Affect small and large bowel Affect large bowel alone
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What happens to bowel during absolute ischaemia?
15 mins - Structural changes to intestinal villi 3 hours - Mucosal sloughing - Still reversible Time is crucial ! 6 hours - Transmural necrosis - Gangrene - Perforation 15 mins 3 hours 6 hours Absolute ischaemia Udassin R, et al. J Surg Res 1994;56:221-5
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Mesenteric ischaemia Acute Mesenteric Ischaemia Chronic
Arterial occlusion Venous Non-occlusive Non-occlusive Mesenteric ischaemia (NOMI) 15% Mesenteric Venous thrombosis (MVT) 15% Embolism 20-30% Thrombosis 50% Bradbury AW, et al. Br J Surg 1995;82:
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Management of acute mesenteric ischaemia
Clinical suspicion Ischaemic bowel cannot be excluded Exclude other non-vascular abdominal emergencies Unstable/ Peritonism present Stable & Peritonism absent Diagnosis not certain negative finding CT scan or angiography Positive finding Non-occlusive mesenteric ischaemia Mesenteric Venous thrombosis SMA occlusion Trans-arterial vasodilator infusion Immediate heparinization Surgical treatment No improvement
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Management of acute mesenteric ischaemia
Clinical suspicion Ischaemic bowel cannot be excluded Exclude other non-vascular abdominal emergencies
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Past history of atherosclerotic diseases
Clinical suspicion… Elderly patients Associated comorbidities: Hypertension % IHD % Diabetes % AF % Renal failure % Peripheral vascular disease 18% Past history of atherosclerotic diseases Park WM, et al. J Vasc Surg 2002;35:445-52
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Clinical suspicion… Laboratory tests Symptoms and signs Leukocytosis
Abdominal pain % - Pain out of proportion of signs Nausea % Vomiting % Diarrhea % PR bleeding % Fever % Tachycardia % Abd distension % Laboratory tests Leukocytosis Elevated urea Elevated creatinine Elevated lactate Metabolic acidosis DIC Most symptoms and signs are non-specific Need to exclude other non-vascular emergencies Endean ED, et al. Ann Surg 2001;233: Park WM, et al. J Vasc Surg 2002;35:445-52 Sreedharan S, et al. Singapore Med J 2007;48:319-23
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Clinical suspicion… Normal plain X-ray Signs suggestive of
bowel infarction: - Dilated thickened bowel loops - Ground glass appearance - Thumb printing - Pneumatosis intestinalis - Gas in portal vein
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Clinical triad… Sudden abdominal pain Gut Cardiac source emptying
Klass AA. Ann Surg 1951;134: Sudden abdominal pain Acute Mesenteric ischaemia Gut emptying Cardiac source of embolization
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Management of acute mesenteric ischaemia
Clinical suspicion Ischaemic bowel cannot be excluded Exclude other non-vascular abdominal emergencies Unstable/ Peritonism present Stable & Peritonism absent Diagnosis not certain Surgical treatment CT scan or angiography
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Conventional angiography
CT scan Conventional angiography Diagnostic role Sensitivity SMA occlusion 78% Bowel ischaemia 61% Either one % SMA occlusion % Bowel ischaemia N/A Exclude other sources of acute abdomen Can identify venous thrombosis Can identify NOMI Therapeutic role Allow endovascular interventions Park WM, et al. J Vasc Surg 2002;35:445-52
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Features in CT scan SMA thrombus Bowel wall thickening
Non-enhanced bowel wall Pneumatosis intestinalis Portal venous gas Fluid collection Wiesner W, et al. Radiology 2003;226:635-50
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Kirkpatrick ID, et al. Radiology 2003;229:91-98
CT angiogram Kirkpatrick ID, et al. Radiology 2003;229:91-98
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CT scan vs Angiography CT scan - More preferred choice
- Can exclude other non-vascular emergencies if diagnostic confusion Both are time-consuming - introduce critical delay in management
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Management of acute mesenteric ischaemia
Clinical suspicion Ischaemic bowel cannot be excluded Exclude other non-vascular abdominal emergencies Unstable/ Peritonism present Stable & Peritonism absent Diagnosis not certain negative finding CT scan or angiography SMA occlusion Positive finding Surgical treatment
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Acute SMA Occlusion SMA Embolism SMA Thrombosis Aortic ostium ~15%
Around Middle colic artery ~40% Distal branches ~45% SMA Thrombosis Aortic ostium ~60-80% Distal branches ~5% Around Middle colic artery ~15% Acosta S, et al. Ann Surg 2005;241:516-22
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Immediate resuscitation…
Before operation Bowel rest Fluid resuscitation Close hemodynamic monitoring Nasogastric decompression Indwelling urinary catheterization Parenteral antibiotics Anticoagulation by heparin Schwartz LB, et al. Surg Clin North Am 1997;77:
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Definitive surgical exploration
Midline laparotomy 1. Assessment of bowel viability 2. Determination of underlying cause 3. Mesenteric revascularization 4. Resection of necrotic bowel 5. Second look laparotomy
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Assessment of bowel viability
1. Clinical Judgment - pink serosa - visible peristalsis - positive pulsations - bleeding from cut edges (Ballard JL, et al. Am Surg 1993;59:309-11) 2. Doppler USG - hand-held doppler (Hobson RW, et al. J Surg Res 1976;20:231-5) 3. Fluorescein -Injection of fluorescein and inspection under Wood’s lamp (Bergman RT, et al. Ann Vasc Surg 1992; 6:74-9)
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Assessment of bowel viability
Necrotic bowel Equivocal viability Extensive infarction Limited infarction Revascularization procedures Tender loving care
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Determination of underlying cause: Thrombosis or embolism?
Palpate Main trunk of SMA Absent pulse Thrombosis Pulse present proximally but not distally Embolism
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Mesenteric Revascularization
Thrombosis Thrombectomy Bypass grafting Reimplantation of SMA Embolism Balloon catheter embolectomy Vein patch angioplasty
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Revascularization procedures…(1)
Bypass grafting Direction Antegrade bypass from supraceliac aorta Retrograde bypass from infrarenal aorta Both are equally good Conduit Autologous graft Propensity to kink Synthetic graft Contamination during bowel resection may cause synthetic graft infection Foley MI, et al. J Vasc Surg 2000;32:37-47 Bradbury AW, et al. Br J Surg 1995;82:
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Revascularization procedures…(2)
Reimplantation of SMA Aortomesenteric bypass is time-consuming Direct reimplantation of SMA is quicker Recommended as procedure of choice Testart J, et al. Int Angiol 1992;11:181-5
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Resection of necrotic bowel
Anastomosis should not be attempted Equivocal viability at cut ends Exteriorize as stomas
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Second look laparotomy
Who should undergo second look laparotomy? Routine after hours - allow reassessment of bowel viability - claim to have reduced mortality Levy PJ, et al. Surg Gynecol Obstet 1990;170:287-91 Selective approach - increased operative risks for second operation - suggest only when clinical deterioration - but means further infarction with worse outcome Hagmuller GW, et al. Langenbecks Arch Chir 1990:311-15
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Alternative to surgery… Endovascular therapy
Acute SMA thrombosis NOMI Percutaneous balloon angioplasty ± stenting Transarterial thrombolysis infusion of vasodilator Limited use in acute situations Cannot assess bowel viability Only indicated in early cases without bowel infarction
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Management of acute mesenteric ischaemia
Clinical suspicion Ischaemic bowel cannot be excluded Exclude other non-vascular abdominal emergencies Unstable/ Peritonism present Stable & Peritonism absent Diagnosis not certain negative finding CT scan or angiography Non-occlusive mesenteric ischaemia Mesenteric Venous thrombosis SMA occlusion Trans-arterial vasodilator infusion Immediate heparinization Surgical treatment No improvement
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Non-occlusive mesenteric ischaemia (NOMI)
Etiology: no occlusion Low cardiac output Mesenteric vasospasm Treatment is non-surgical Treat underlying cause Transarterial infusion of vasodilator (papeverine) Bradbury AW, et al. Br J Surg 1995;82:
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Mesenteric venous thrombosis (MVT)
Primary MVT (40%) - any hypercoagulable states Secondary MVT (60%) - Portal hypertension - Intraabdominal sepsis - Intraabdominal neoplasia - Pancreatitis - Trauma Treatment is non-surgical Heparinization Thrombophilia screening Bradbury AW, et al. Br J Surg 1995;82:
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Prognosis of acute mesenteric ischaemia
Overall average mortality 60-80% Ischaemic reperfusion injury Multiorgan failure Park WM, et al. J Vasc Surg 2002;35:445-52
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Conclusion Acute mesenteric ischaemia High index of suspicion
Morbid condition High mortality rate High index of suspicion Pain out of proportion of signs Early recognition is crucial
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Management of acute mesenteric ischaemia
Clinical suspicion Ischaemic bowel cannot be excluded Exclude other non-vascular abdominal emergencies Unstable/ Peritonism present Stable & Peritonism absent Diagnosis not certain negative finding CT scan or angiography Positive finding Non-occlusive mesenteric ischaemia Mesenteric Venous thrombosis SMA occlusion Trans-arterial vasodilator infusion Immediate heparinization Surgical treatment No improvement
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Thank you Welcome to NDH
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