Acute Me Sent Eric Ischemia

ACUTE MESENTERIC ACUTE MESENTERIC ISCHEMIAISCHEMIA

clinical presentation, therapeutic clinical presentation, therapeutic approachapproach

Cokkinis (1921)Cokkinis (1921)““occlusion of the mesenteric vessels is regarded as one of occlusion of the mesenteric vessels is regarded as one of those conditions of which the diagnosis is impossible, the those conditions of which the diagnosis is impossible, the prognosis hopeless, and the treatment almost uselessprognosis hopeless, and the treatment almost useless .”.”

ACS (2006) “acute mesenteric ischemia is an uncommon life-threatening clinical entity that ultimately leads to death unless it is diagnosed and treated appropriately”

Outcomes After SurgeryOutcomes After Surgery

2001200111

30 day mortality30 day mortality

Embolic Embolic 59%59%

Thrombotic Thrombotic 62%62%

2002200222

30 day mortality 30 day mortality 32%32%

1 year mortality 1 year mortality 57%57%

3 year mortality 3 year mortality 68%68%

2003200333

Peri-op mortality Peri-op mortality 62%62%

2003200344


2005200555


11 Ann Surg 2001;233(6):801-808 Ann Surg 2001;233(6):801-80822 J Vasc Surg 2002;35:445-52 J Vasc Surg 2002;35:445-5233 Ann Vasc Surg 2003;17:72-79 Ann Vasc Surg 2003;17:72-7944 Vasc Endovasc Surg 2003;37:245-252 Vasc Endovasc Surg 2003;37:245-25255 W J Surg 2005;29:645-648 W J Surg 2005;29:645-648

Accordingly, the index of suspicion for this disease should be high whenever a patient presents with acute-onset severe abdominal pain that is out of proportion to the physical findings.

Once the diagnosis is made, prompt intervention is required to minimize morbidity and mortality.

M.E. 57 year-old female patientM.E. 57 year-old female patient

Onset 12 hours earlierOnset 12 hours earlier Mild right upper quadrant pain Mild right upper quadrant pain Nausea and vomitingNausea and vomiting DiarrheaDiarrhea

Past medical historyPast medical history Obesity BMI=32kg/mpObesity BMI=32kg/mp Sinus node diseaseSinus node disease Artificial pacemakerArtificial pacemaker Grade I atrioventricular blockGrade I atrioventricular block AppendectomyAppendectomy Medication Preductal, Bisogamma, PropafenonaMedication Preductal, Bisogamma, Propafenona

Clinical examination revealed Clinical examination revealed tenderness in the right tenderness in the right upper quadrant of the abdomen. upper quadrant of the abdomen.

Temperature was measured to be 37 degrees. Temperature was measured to be 37 degrees.

Blood tests Blood tests Leucocytosis of 16.0 x 109/L Leucocytosis of 16.0 x 109/L Glucose 212 mg/dL (65-110)Glucose 212 mg/dL (65-110) Amylasemia 120 U/L (20-110)Amylasemia 120 U/L (20-110) LDH 726 U/LLDH 726 U/L Bilirubinemia 1.6 U/L (0.2-1.3)Bilirubinemia 1.6 U/L (0.2-1.3)

UrineUrine Amyl-U 1200 U/L (32-641)Amyl-U 1200 U/L (32-641)

Plain abdominal radiographyPlain abdominal radiography normalnormal

UltrasonographyUltrasonography Edema of the pancreasEdema of the pancreas

Supposed diagnosis Mild Supposed diagnosis Mild Acute PancreatitisAcute Pancreatitis

TreatmentTreatment As for acute pancreatitisAs for acute pancreatitis No antibiotherapyNo antibiotherapy

EvolutionEvolution Significant improvementSignificant improvement General statusGeneral status Abdominal painAbdominal pain Soft abdomenSoft abdomen No nausea, no vomitingNo nausea, no vomiting Blood tests after 24 hoursBlood tests after 24 hours

Leucocyte 12.7x109/ Leucocyte 12.7x109/ μμLL TBil 6.9 U/L (0.2-1.3)TBil 6.9 U/L (0.2-1.3) AST 88 U/L AST 88 U/L PLT 82,000 /PLT 82,000 /μμLL

48 hours after admission48 hours after admission

8 a.m. 8 a.m. scleral jaundicescleral jaundice ultrasonography nothing newultrasonography nothing new blood testsblood tests

TBil 9.9 U/L (0.2-1.3)TBil 9.9 U/L (0.2-1.3) AST 67 U/L AST 67 U/L LDH 1142 U/L (313-618)LDH 1142 U/L (313-618) PLT 90,000 /PLT 90,000 /μμLL Leucocyte 10.0x109/ Leucocyte 10.0x109/ μμLL

6 p.m. 6 p.m. altered general statusaltered general status abdominal examination mild tenderness abdominal examination mild tenderness ultrasonography intestinal gas distension ultrasonography intestinal gas distension supportive measures supportive measures

72 hours after admision72 hours after admision

Progressive deterioration of general Progressive deterioration of general conditioncondition

Abdominal examination - upper quadrants Abdominal examination - upper quadrants tenderness tenderness

Blood tests – Blood tests – normal !!!normal !!! Ultrasonography - immobile intestinal loopsUltrasonography - immobile intestinal loops CT-scan arrangedCT-scan arranged

Operation Operation

Acute mesenteric Acute mesenteric ischemiaischemia

Jejunoileal resection + right Jejunoileal resection + right colectomycolectomy

Ileostomy and colostomyIleostomy and colostomy

Only 45 cm of jejunum was Only 45 cm of jejunum was sparedspared

14 days later jejunocolic anastomosis14 days later jejunocolic anastomosis

p.o. course simplep.o. course simple

Short bowel syndromeShort bowel syndrome

One month 2-4 stools/dayOne month 2-4 stools/day

One year the patient was wellOne year the patient was well

The classic presentation for patients with embolic disease of the mesenteric vessels and thrombotic mesenteric occlusion is sudden-onset midabdominal pain that is described as being out of proportion to the physical findings.

95% of patients presented with abdominal pain, 44% with nausea, 35% with vomiting, and 35% with diarrhea; only 16% presented with blood per rectum.

Park WM, Gloviczki P, Cherry KJ Jr, et al: Contemporary management of acute mesenteric ischemia: factors associated with survival. J Vasc Surg 35:445, 2002

Patients with MVT often present with various nonspecific abdominal complaints; accordingly, this diagnosis may be especially challenging. Common complaints include nausea, vomiting, diarrhea, abdominal cramping, and nonlocalized abdominal pain.

As a rule, these symptoms are not acute. A study of MVT patients found that 84% presented with abdominal

pain. Of those 84%, only 16% presented with peritoneal signs, whereas 68% presented with vague abdominal pain. Other presenting symptoms included diarrhea (42%), nausea and vomiting (32%), malaise (16%), and upper GI bleeding (10%).

Patients with NOMI present somewhat differently. The pain reported is usually not as sudden as that noted with embolic or thrombotic occlusion: it is generally more diffuse and tends to wax and wane (unlike the pain associated with embolic or thrombotic disease, which tends to get progressively worse).

Morasch MD, Ebaugh JL, Chiou AC, et al: Mesenteric venous thrombosis: a changing clinical entity. J Vasc Surg 34:680, 2001

Risk factors provide essential clues for correct identification of these disease processes.

Patients with embolic occlusion of the mesenteric circulation typically have a history of recent cardiac events (e.g.,myocardial infarction, atrial fibrillation, mural thrombus, mitral valve disease, or left ventricular aneurysm) or previous embolic disease.

In Park’s study, 50% of the patients who presented with embolic occlusive disease had atrial fibrillation

Patients with acute mesenteric ischemia secondary to thrombotic occlusive disease typically have other manifestations of diffuse atherosclerotic disease (e.g., CAD, peripheral artery disease, and carotid stenosis).

The risk factors for NOMI are slightly different. This condition usually occurs during severe low-flow states and represents

extreme mesenteric vasoconstriction. It is much more common among severely ill patients in an intensive care unit who require vasopressors and among patients undergoing dialysis with excessive fluid removal.

The risk factors for MVT include a history of previous venous thrombosis or pulmonary embolism, a known or suspected hypercoagulable state, oral contraception, and estrogen supplementation. In a study of 31 patients who presented with MVT at Northwestern University, 13 (42%) were diagnosed with a hypercoagulable state, six (19%) had a history of previous thrombotic episodes, and four (13%) had a history of cancer


Morasch MD, Ebaugh JL, Chiou AC, et al: Mesenteric venous thrombosis: a changing clinical entity. J Vasc Surg 34:680, 2001

Clinical Presentation: Clinical Presentation: LaboratoryLaboratory

Limited clinical utilityLimited clinical utility arterial lactatearterial lactate11

amylaseamylase22

CK, CK-BBCK, CK-BB33

Serum phosphateSerum phosphate44

Other useless markers: LDH, PAF, TNF-Other useless markers: LDH, PAF, TNF-αα, , AP, AST/ALT, AP, AST/ALT, αα-glutathione-glutathione

1 Eur J Surg 1994;160:381-4

2 Br J Surg 1986;73:219-21

3 Dig Dis Sci 1991;36:1589-93

4 Br J Surg 1982;69:S52-3

Investigative Studies

Although there are no basic laboratory or radiographic studies that are diagnostic for acute mesenteric ischemia, such studies can help confirm the diagnosis when it is suspected on the basis of the history and the physical examination.

Mayo Clinic study 98% of patients who presented with acute mesenteric ischemia were

found to have an elevation of the leukocyte count, and 50% were found to have counts higher than 20,000/mmc.

lactate is another nonspecific indicator of mesenteric bowel ischemia - 91% of patients had elevated lactate levels, with 61% having levels higher than 3 mmol/L

71% of patients presented with an elevated AST


Abdominal X-rays

can neither establish nor exclude the diagnosis of acute mesenteric ischemia

may reveal signs that are consistent with bowel ischemia. If obtained early, abdominal plain films should show no abnormalities.

if obtained late in the presentation, however, they may reveal edematous bowel with thumbprinting. In severe cases, abdominal plain films may reveal gas in the bowel wall and the portal vein. More commonly, however, they reveal a pattern consistent with ileus or are completely unremarkable.

Duplex Ultrasonography

limited role in the management of acute mesenteric ischemia, given the acute nature of the presentation, the accompanying ileus with excessive bowel gas and bowel edema (which hinders visualization of the mesenteric vessels)

capable of imaging stenotic and occlusive lesions at the origin of a mesenteric vessel

is of no value in detecting emboli beyond the proximal portion of the vessel.

similarly, it has no role in the diagnosis of NOMI.

Sensitivity: 100%Sensitivity: 100%

Specificity: 91%Specificity: 91%

Computed TomographyComputed Tomography

CriteriaCriteria pneumatosispneumatosis venous gasvenous gas SMA/celiac/IMA occlusion SMA/celiac/IMA occlusion

w/distal diseasew/distal disease arterial embolismarterial embolism

OROR bowel wall thickening + bowel wall thickening +

one of following:one of following: lack of bowel wall lack of bowel wall

enhancementenhancement solid organ infarctionsolid organ infarction venous thrombosisvenous thrombosis

11 Radiol 2003;229:91-98 Radiol 2003;229:91-98

AngiographyAngiography Gold StandardGold Standard

Anatomic delineation of Anatomic delineation of occlusion and collateralsocclusion and collaterals

Plan operative Plan operative revascularizationrevascularization

Allow infusion of Allow infusion of therapeutic agents therapeutic agents (lytics, vasodilators)(lytics, vasodilators)

11 Ann Surg 2001;233(6):801-808 Ann Surg 2001;233(6):801-808

If diffuse bowel necrosis exists and the bowel is not salvageable, it is best to close the abdomen without attempting further therapy.

Approximately 50 cm of viable bowel is required to sustain life if the ileocecal valve is present, and 100 cm is preferable.

Thompson JS, Langnas AN, Pinch LW, et al: Surgical approach to short-bowel syndrome. Experience in a population of 160 patients. Ann Surg 222:600, 1995

Primary anastomosis or primary stomas ?Primary anastomosis or primary stomas ?

Primary anastomoses, especially in the small intestine, can be performed if brisk bleeding from the edges of the bowel wall is observed and the patient is stable.

Alternatively, long segments of marginal bowel left in situ may be stapled or oversewn, with continuity established during a second-look procedure.

After resection of the colon, creation of a stoma is generally indicated. An important consideration is the patient’s hemodynamic status.

If cardiac output is compromised or there is an ongoing requirement for vasopressors and inotropic support, delay in intestinal reconstruction may be safer, avoiding the risk for an anastomotic leak or dehiscence

perioperative mortalities ranging from 32% to 69% and 5-year survival rates ranging from 18% to 50%


Edwards MS, Cherr GS, Craven TE, et al: Acute occlusive mesenteric ischemia: surgical management and outcomes. Ann Vasc Surg 17:72, 2003

Klempnauer J, Grothues F, Bektas H, et al: Longterm results after surgery for acute mesenteric ischemia. Surgery 121:239, 1997

ConclusionsConclusions

Atipical presentationAtipical presentation

Early diagnosis and high index of suspicionEarly diagnosis and high index of suspicion

Large resection is suitable when proximal Large resection is suitable when proximal jejunal vascularisation is presentjejunal vascularisation is present

Primary stomas are to be preferred Primary stomas are to be preferred

Early reestablishment of bowel continuity is Early reestablishment of bowel continuity is desirable desirable

Acute Me Sent Eric Ischemia

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