Presentation on theme: "Acute Mesenteric Ischemia"— Presentation transcript:
1 Acute Mesenteric Ischemia Scott Q. Nguyen, M.D.Celia M. Divino, M.D.Mount Sinai School of MedicineDepartment of Surgery
2 Mrs. MittyAn 83 year-old woman is brought to the ER by ambulance from her nursing home w/ a 4 hour history of severe diffuse abdominal pain and distention.
3 What other points of the history do you want to know?
4 Consider the Following History, Mrs. MittyConsider the FollowingCharacterization of symptomsTemporal sequenceAlleviating / Exacerbating factors:Pertinent PMH, ROS, MEDS.Associated signs and symptomsRelevant family hx.
5 History, Mrs. Mitty Characterization of Symptoms: Sudden onset diffuse abdominal pain and distention hours ago.Pain not localized to any quadrant.Alleviating / Exacerbating factors:Pain is excruciating, it’s the worse she’s ever experiencedNothing alleviates itAssociated signs/symptoms:She vomits 1L of feculent emesis on arrival to ER.Last BM 2 hours ago, loose
6 Other HistoryPMHAtrial Fibrillation - dx’d 1 month ago, anticoagulation contraindicated with history of massive GI bleedCHF, CAD, DMPSHCholecystectomy, left hemicolectomy for diverticular diseaseMEDSdigoxin, metoprolol, insulin
7 Other History Family History Social History Occasional wine, 50 pack-yr smoker, quit 2 yrs agoFamily HistoryPatient unable to give
9 Differential Diagnosis Based on History and Presentation Small Bowel ObstructionAcute Mesenteric IschemiaPerforated DiverticulitisIschemic ColitisPerforated Peptic Ulcer DiseaseAcute PancreatitisAcute CholecystitisGastroenteritisAcute Appendicitis
11 Physical ExaminationVital Signs: T = 38.5, P = 103, BP = 140/85, RR = 28Appearance: thin , in severe distress, legs pulled up to chest, moaningHeart: irregularly irregularLungs: mild rales at basesAbdomen: decreased BS, very distended, mildly tender diffusely, no guarding/rebound tenderness, no herniasRectal: loose stool in vault, streaked w/ fresh bloodRemaining Examination findings non-contributory
12 Would you like to revise your Differential Diagnosis? Strangulated small bowel obstructionAcute Mesenteric IschemiaIschemic Colitis
15 Lab Results, Discussion Leukocytosis - acute process, possibly infectiousElectrolytes - elevated BUN indicating dehydration or 3rd spacing.Anion gap acidosis - intravascular depletion, Metabolic acidosis (lactic acidosis)Coags –abnormal coags may reflect sepsis. Pt. not on anticoagulation for Afib.Normal LFTs/ pancreatic enzymes - no signs of hepatic/pancreatic insult
17 Consider the following Interventions Admit to the hospital/ICUAggressive resuscitationStart IV with isotonic crystalloid solution ( NS or LR)Insert Foley catheterMonitor response to resuscitationAdminister broad spectrum antibioticsLikely intra-abdominal septic process
18 What further studies would you want at this time?
19 Studies, Mrs. Mitty Abdominal X-rays Flat / Upright Acute Abdominal Series (may include chest at some institutions)
26 DiscussionWith 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 DiagnosisA mesenteric angiogram will allow visualization of the visceral vessels (celiac, SMA, IMA)Mesenteric angioram may allow access to vasodilators if non-occlusive disease is present
27 Mesenteric AngiogramNote 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).
28 CT AngiogramNote complete occlusion and lack of IV contrast filling the superior mesenteric artery from its origin from the aorta (Arrows).
29 CT angiogram / MR angiogram Other studiesCT angiogram / MR angiogramsensitivity 75%, specificity 100% for emboliadditionally can detect thickened, distended bowel loopsmore sensitive for Mesenteric Venous Thrombosis
30 What should be done next? ManagementWhat should be done next?
33 Necrotic bowel from mesenteric ischemia. Surgical EmbolectomyPack bowel to Right, Expose SMAArteriotomyPass balloon embolectomy catheterAssess bowel viabilityResect if necessaryNecrotic bowel from mesenteric ischemia.
34 DiscussionAcute mesenteric ischemia is a vascular emergency with overall mortality 60-80%. There are four main pathophysiologic processes which have the same common endpoint, bowel necrosis, abdominal sepsis, and death. Mesenteric arterial anatomy is notable for rich collateral flow between the celiac trunk, superior mesenteric artery, and inferior mesenteric artery. Gradual occlusion of 2 of the 3 vessels is tolerable as rich collateral branches form between these. Acute occlusion of any of the vessels or their branches causes acute intestinal ischemia and necrosis.
35 Discussion The four processes: 1) Acute arterial embolus -usually from cardiogenic embolus in pts w/ Afib or valvular disorders. SMA is the common vessel affected as it has a less acute take off from aorta2) Acute arterial thrombosis - chronic atherosclerotic plaque at origin of vessel acutely thromboses3) Chronic mesenteric ischemia - atherosclerosis of visceral vessels results in abdominal pain (intestinal angina) during times of increased blood demand (digestion)Acute venous occlusion - venous thrombosis causes cessation of venous outflow from intestines*Non-occlusive mesenteric ischemia can also be seen in low-flow states
36 DiscussionDiagnosis - requires high degree of suspicion. Classically presents as “pain 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 hemodynamic monitoring 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.
38 References Townsend CM. Sabiston Textbook of Surgery. 17th Edition Cameron JL. Current Surgical Therapy. 8th EditionOldenburg et al. Acute Mesenteric Ischemia. Arch Intern Med 164:
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