Mesenteric ischemia

Background

Pathophysiology

4 distinct entities:

1. Mesenteric arterial embolism (ex. Afib)
2. Mesenteric arterial thrombosis (ex. Vasculopath)
3. Nonocclusive mesenteric ischemia (ex. Hypovolemia from diuretics)
4. Mesenteric venous thrombosis (ex. hypercoagulable state)

Risk Factors for Mesenteric Ischemia Types

Type	Risk Factor
Arterial Embolism	Dysrhythmia (A. Fib) Valve Disease MI
Arterial Thrombosis	Athrosclerotic Disease
Venous Thrombosis	Prior thrombosis history Hypercoagulable state (preg, cancer, clotting disorder)
Nonocculsive	Hypovolemic state Heart Failure Diuretic use

Epidemiology

1. Mean age: 70yo
2. 2/3 women

Risk Factors

1. CAD
2. Valvular heart disease
3. Dysrhythmia
4. Hypovolemia / hypotension
5. Meds
   1. Diuretics
   2. Vasoconstrictive
   3. Digoxin
6. Dialysis

Diagnosis

Signs/Symptoms

1. Pain out of proportion to exam
2. Severe, poorly localized, colicky

Work Up

1. Labs
   1. Lactate (higher later)
   2. WBC (often >15K)
   3. Chemistry (metabolic acidosis)
2. CTA
3. Mesentaric angiography considered gold standard

Differential Diagnosis

Diffuse Abdominal pain

• Abdominal aortic aneurysm
  • Aortocaval fistula
• Acute gastroenteritis
• Aortoenteric fisulta
• Appendicitis (early)
• Bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Small bowel obstruction
  • Malignant bowel obstruction
• Bowel perforation
• Diabetic ketoacidosis
• Gastroparesis
• Hernia
• Hypercalcemia
• Inflammatory bowel disease
• Mesenteric ischemia
  • Mesenteric vein thrombosis
• Pancreatitis
• Peritonitis
• Sickle cell crisis
• Spontaneous bacterial peritonitis
• Volvulus

Treatment

1. IVF
2. IV Abx
3. Narcotic analgesia

Acute arterial embolus

1. Papaverine infusion (30-60 mg/h IV) OR
2. surgical embolectomy OR
3. intra-arterial thrombolysis

Nonocclusive mesenteric ischemia

1. Papaverine infusion

Mesenteric venous thrombosis

1. Heparin/warfarin either alone or in combination with surgery
2. Immediate heparinization should be started even when surgical intervention is indicated
   1. Decreases progression of thrombosis and improves survival

Chronic mesenteric ischemia

1. Angioplasty with or without stent placement or surgical revascularization

Disposition

• Admit with consultation of one or more of the following
  • IR
  • Vascular
  • Surgery

Source

• Rosen's
• Tintinalli