5 Mesenteric Ischemia

7/30/2019 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



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Surgical Embolectomy

Pack bowel to Right,

Expose SMA

Arteriotomy Pass balloon embolectomy

catheter


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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AcknowledgmentThe preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATION

In order to improve our educational materials wewelcome your comments/ suggestions at:

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