Mesenteric ischemia: Difference between revisions
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==Management== | ==Management== | ||
*[[IVF]] | *Aggressive [[IVF]] resuscitation, continued after revascularization due to capillary leak | ||
*Correct electrolyte imbalances prior to IV contrast or surgical exploration<ref>Wyers MC. Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010 Mar;23(1):9-20.</ref> | |||
*IV [[antibiotics]] - broad spectrum antibiotics to prevent sepsis <ref>Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341</ref> | *IV [[antibiotics]] - broad spectrum antibiotics to prevent sepsis <ref>Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341</ref> | ||
*[[Opioid]] analgesia | *[[Opioid]] analgesia | ||
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*Immediate heparinization should be started even when surgical intervention is indicated | *Immediate heparinization should be started even when surgical intervention is indicated | ||
**Decreases progression of thrombosis and improves survival | **Decreases progression of thrombosis and improves survival | ||
** | |||
===Chronic mesenteric ischemia=== | ===Chronic mesenteric ischemia=== | ||
Revision as of 19:16, 20 April 2019
Background
- Most commonly SMA, thus typically involves small bowel (especially jejunum) and right colon
- Left colon uncommonly involved due to collateral flow
Pathophysiology
4 distinct entities:
- Mesenteric arterial embolism (ex. Afib)
- Mesenteric arterial thrombosis (ex. Vasculopath)
- Nonocclusive mesenteric ischemia (ex. Hypovolemia from diuretics)
- Mesenteric venous thrombosis (ex. hypercoagulable state)
| Type | Risk Factor |
|---|---|
| Arterial Embolism |
|
| Arterial Thrombosis |
|
| Venous Thrombosis |
|
| Nonocculsive |
|
Epidemiology
- Mean age: 70yo
- 2/3 women
Risk Factors
- CAD
- Valvular heart disease
- Dysrhythmia
- Hypovolemia / hypotension
- Meds
- Diuretics
- Vasoconstrictive
- Digoxin
- Dialysis
Clinical Features
- Pain out of proportion to exam. Abdomen often soft, without guarding.
- Pain often left sided around watershed areas of colon (splenic flexure and recto-sigmoid junction)
- Severe, generalized, colicky
- Bloody stools
Differential Diagnosis
Colitis
- Infectious colitis
- Ischemic colitis
- Ulcerative colitis
- CMV colitis
- Crohn's colitis
- Toxic colitis (antineoplastic agents)
- Pseudomembranous colitis
- Fibrosing colonopathy (Cystic fibrosis)
Diffuse Abdominal pain
- Abdominal aortic aneurysm
- Acute gastroenteritis
- Aortoenteric fisulta
- Appendicitis (early)
- Bowel obstruction
- Bowel perforation
- Diabetic ketoacidosis
- Gastroparesis
- Hernia
- Hypercalcemia
- Inflammatory bowel disease
- Mesenteric ischemia
- Pancreatitis
- Peritonitis
- Sickle cell crisis
- Spontaneous bacterial peritonitis
- Volvulus
Evaluation
- Labs
- Lactate (higher later)
- WBC (often >15K)
- Chemistry (metabolic acidosis)
- Hyperphosphatemia
- Upright or left lateral decub XR with intraabdominal air
- CTA
- Mesenteric angiography considered gold standard
Management
- Aggressive IVF resuscitation, continued after revascularization due to capillary leak
- Correct electrolyte imbalances prior to IV contrast or surgical exploration[1]
- IV antibiotics - broad spectrum antibiotics to prevent sepsis [2]
- Opioid analgesia
Acute arterial embolus
- Papaverine infusion (30-60m g/h IV) OR
- Surgical embolectomy OR
- Intra-arterial thrombolysis with IR
Nonocclusive mesenteric ischemia
- Papaverine infusion
Mesenteric venous thrombosis
- Heparin/warfarin either alone or in combination with surgery
- Immediate heparinization should be started even when surgical intervention is indicated
- Decreases progression of thrombosis and improves survival
Chronic mesenteric ischemia
- Angioplasty with or without stent placement or surgical revascularization
Disposition
- Admit with consultation of one or more of the following
- IR
- Vascular
- Surgery