Me Sent Eric Ischemia

7/21/2019 Me Sent Eric Ischemia

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Acute Mesenteric IschemiaAcute Mesenteric Ischemia

Scott Q. Nguyen, M.D.Scott Q. Nguyen, M.D.

Celia M. Divino, M.D.Celia M. Divino, M.D.

Mount Sinai School of MedicineMount Sinai School of MedicineDepartment of SurgeryDepartment of Surgery



Mrs. MittyMrs. Mitty

• An ! year"old #oman is $rought to the

%& $y am$ulance from her nursing home#' a ( hour history of severe diffuse

a$dominal pain and distention..



)istory

*hat other points of the history doyou #ant to +no#



)istory, Mrs. Mitty)istory, Mrs. Mitty

• Characteri-ation of

symptoms

• emporal se/uence

• Alleviating '

%0acer$ating factors1

• 2ertinent 2M), &3S,

M%DS.

• Associated signs and

symptoms

• &elevant family h0.

Consider the 4ollo#ing



)istory, Mrs. Mitty

• Characteri-ation of Symptoms1Characteri-ation of Symptoms1 Sudden onset diffuse a$dominal pain and distention (

hours ago. 2ain not locali-ed to any /uadrant.

• Alleviating ' %0acer$ating factors1Alleviating ' %0acer$ating factors1 2ain is e0cruciating, it5s the #orse she5s ever e0perienced Nothing alleviates it

• Associated signs'symptoms1Associated signs'symptoms1 She vomits 67 of feculent emesis on arrival to %&. 7ast 8M 9 hours ago, loose



3ther )istory

• 2M)2M) Atrial 4i$rillation " d05d 6 month ago, anticoagulation

contraindicated #ith history of massive :I $leed C)4, CAD, DM

• 2S)2S) Cholecystectomy, left hemicolectomy for diverticular

disease

• M%DS digo0in, metoprolol, insulin



3ther )istory

• Social )istory 3ccasional #ine,

;< pac+"yr smo+er, /uit 9 yrs ago

• 4amily )istory 2atient una$le to give



*hat is your DifferentialDiagnosis



Differential Diagnosis8ased on )istory and 2resentation

• Small 8o#el 3$struction3$struction

• Acute MesentericAcute MesentericIschemiaIschemia

• 2erforated Diverticulitis2erforated Diverticulitis

• Ischemic ColitisIschemic Colitis

• 2erforated 2eptic =lcer

Disease• Acute 2ancreatitis

• Acute Cholecystitis

• :astroenteritis• Acute Appendicitis



2hysical %0amination

*hat #ould you loo+ for



2hysical %0amination

• >ital Signs1 ? !.;, 2 ? 6<!, 82 ? 6(<';, && ? 9

• Appearance1 thin , in severe distress, legs pulled up to chest,

moaning

• )eart1 irregularly irregular • 7ungs1 mild rales at $ases

• A$domen1 decreased 8S, very distended, mildly tender

diffusely, no guarding're$ound tenderness, no hernias

• &ectal1 loose stool in vault, strea+ed #' fresh $lood

&emaining %0amination findings non"contri$utory



*ould you li+e to revise your

Differential Diagnosis



7a$oratory

*hat #ould you o$tain



• 74s " *N7

• Amylase'7ipase " @'@;" @'@;

• 2'2 " 6!.<'!!.<2'2 " 6!.<'!!.<

• A8: " .!6'!<'B@'6B" .!6'!<'B@'6B

• 7actate .@.@

6!! 6<6

(.@ 6@

6(

(9

(<;!<

6.9

6 9(<

7a$s ordered, Mrs. Mitty

; 2MN5s 99 8ands



7a$ &esults, Discussion

• 7eu+ocytosis "" acute processacute process,, possi$ly infectious possi$ly infectious

• %lectrolytes " elevated 8=N indicating dehydration or" elevated 8=N indicating dehydration or

!rd spacing.!rd spacing.

• Anion gap acidosis " intravascular depletion," intravascular depletion,

Meta$olic acidosis lactic acidosisMeta$olic acidosis lactic acidosis

• Coags Ea$normal coags may reflect sepsis. 2t. not onCoags Ea$normal coags may reflect sepsis. 2t. not on

anticoagulation for Afi$.anticoagulation for Afi$.• Normal 74s' pancreatic en-ymes " no signs of" no signs of

hepatic'pancreatic insulthepatic'pancreatic insult



Interventions at this point



Consider the follo#ing Interventions

• Admit to the hospital'IC=

• Aggressive resuscitation

• Start I> #ith isotonic crystalloid solution NS or 7&

• Insert 4oley catheter

•Monitor response to resuscitation

• Administer $road spectrum anti$iotics

• 7i+ely intra"a$dominal septic process



Studies

*hat further studies #ould you #antat this time



Studies, Mrs. Mitty

• A$dominal F"rays

• 4lat ' =pright4lat ' =pright

• Acute A$dominal Series may include chest at someAcute A$dominal Series may include chest at some

institutionsinstitutions



Studies E &esults

• 2lain a$dominal films

Diffuse dilation of small $o#el #' air fluidlevels on upright vie#. Some air in 7eft

colon and &ectum. N3 free air



*hat is the differential

diagnosis at this point



&evised Differential Diagnosis

6 Acute Mesenteric Ischemia

99 Strangulated small $o#el o$structionStrangulated small $o#el o$struction!! Diverticulitis #' contained perforationDiverticulitis #' contained perforation



*hat ne0t



*hat ne0t

• Mesenteric Angiogram or C

Angiogram



Discussion

• *ith the sudden onset of symptoms, h'o Afi$,and Gpain out of proportion to physical e0am,Hacute mesenteric ischemia should $e high on

the Differential Diagnosis• A mesenteric angiogram #ill allo#

visuali-ation of the visceral vessels celiac,

SMA, IMA



Mesenteric AngiogramMesenteric Angiogram

Note complete lac+ of contrast in mesenteric vessels in A2 vie# left. he

occluded origins of the celiac a0is and superior mesenteric artery are demonstrated

in the 7ateral vie# right.



C AngiogramC Angiogram

Note complete occlusion and lac+ of I> contrast filling the superior

mesenteric artery from its origin from the aorta Arro#s.



3ther studies

C angiogram ' M& angiogram

• sensitivity ;, specificity 6<< for em$oli

• additionally can detect thic+ened, distended

$o#el loops

• more sensitive for Mesenteric >enous

hrom$osis



Management

*hat should $e done ne0t



Management

• 2re"operative preparation2re"operative preparation• Assure ade/uate resuscitationAssure ade/uate resuscitation

• MonitoringMonitoring

• 4oley Catheter 4oley Catheter

• =rgent e0ploration=rgent e0ploration

• Surgical em$olectomySurgical em$olectomy

• Assess $o#el via$ilityAssess $o#el via$ility



Management

• 2re"operative preparation• Assure ade/uate resuscitationAssure ade/uate resuscitation

• MonitoringMonitoring• Non"invasive1 %J:, 82, 2ulse 30imetry, foley catheter Non"invasive1 %J:, 82, 2ulse 30imetry, foley catheter

• Consider invasive monitoring1 Central venous catheter, 2AConsider invasive monitoring1 Central venous catheter, 2ACatheter Arterial lineCatheter Arterial line

• 3perative echni/ue' =rgent e0ploration• Midline 7aparotomyMidline 7aparotomy

• &elevant Anatomy&elevant Anatomy• Surgical %m$olectomySurgical %m$olectomy




Surgical %m$olectomySurgical %m$olectomy

• 2ac+ $o#el to &ight, %0pose2ac+ $o#el to &ight, %0pose

SMASMA

• ArteriotomyArteriotomy

• 2ass $alloon em$olectomy2ass $alloon em$olectomy

catheter catheter


• &esect if necessary&esect if necessary

Necrotic $o#el from

mesenteric ischemia.



Discussion

Acute mesenteric ischemia is a vascular emergency #ith overall mortality B<"<. here are four main pathophysiologic processes #hich have the samecommon endpoint, $o#el necrosis, a$dominal sepsis, and death. Mesentericarterial anatomy is nota$le for rich collateral flo# $et#een the celiac trun+,superior mesenteric artery, and inferior mesenteric artery. :radual occlusion of9 of the ! vessels is tolera$le as rich collateral $ranches form $et#een these.

Acute occlusion of any of the vessels or their $ranches causes acute intestinalischemia and necrosis..



Discussion

The four processes:

1) Acute arterial embolus -usually from cardiogenic embolusin pts w/ Afib or valvular disorders. !A is the commonvessel affected as it has a less acute ta"e off from aorta

#) Acute arterial thrombosis - chronic atherosclerotic pla$ueat origin of vessel acutely thromboses

%) &hronic mesenteric ischemia - atherosclerosis of visceralvessels 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 *on-occlusive mesenteric ischemia can also be seen in low-flow states

Di iDi i



DiscussionDiscussion

DiagnosisDiagnosis -- re/uires high degree of suspicion. Classically presents asre/uires high degree of suspicion. Classically presents asGpain out of proportion to physical e0amH or severe pain #'o peritonealGpain out of proportion to physical e0amH or severe pain #'o peritoneal

signs. he history of Cardiac disease, valvular disease, or Afi$ shouldsigns. he history of Cardiac disease, valvular disease, or Afi$ should

alert one to an em$olic disease. :old standard for diagnosis is mesentericalert one to an em$olic disease. :old standard for diagnosis is mesenteric

angiogram, $ut C angiogram is more and more $eing used.angiogram, $ut C angiogram is more and more $eing used.

TreatmentTreatment "" re/uires aggressive resuscitation and hemodynamicre/uires aggressive resuscitation and hemodynamic

monitoring as patients $ecome critically ill very /uic+ly. =rgent surgerymonitoring as patients $ecome critically ill very /uic+ly. =rgent surgery

#' viseral revasculari-ation em$olectomy, throm$ectomy,#' viseral revasculari-ation em$olectomy, throm$ectomy,

endarterectomy, or $ypass is re/uired. After this, evaluation of via$ilityendarterectomy, or $ypass is re/uired. After this, evaluation of via$ility

of $o#el segments should $e performed #ith resection of any necroticof $o#el segments should $e performed #ith resection of any necrotic portions. portions.



Q=%SI3NS



&eferences

• o#nsend CM. Sa$iston e0t$oo+ of Surgery.o#nsend CM. Sa$iston e0t$oo+ of Surgery.6th %dition6th %dition

• Cameron K7. Current Surgical herapy. thCameron K7. Current Surgical herapy. th

%dition%dition

• 3lden$urg et al. Acute Mesenteric Ischemia.3lden$urg et al. Acute Mesenteric Ischemia.

Arch Intern Med 6B(16<;("B9. 9<<(Arch Intern Med 6B(16<;("B9. 9<<(



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