Mesenteric ischemia: Difference between revisions
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* Dialysis | * Dialysis | ||
== | ==Clinical Features== | ||
* Pain out of proportion to exam. Abdomen often soft, without guarding. | * Pain out of proportion to exam. Abdomen often soft, without guarding. | ||
* Severe, generalized, colicky | * Severe, generalized, colicky | ||
== | ==Differential Diagnosis== | ||
{{Colitis types}} | |||
{{Abdominal Pain DDX Diffuse}} | |||
==Diagnosis== | |||
*Labs | *Labs | ||
**[[Lactate]] (higher later) | **[[Lactate]] (higher later) | ||
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*Mesentaric angiography considered gold standard | *Mesentaric angiography considered gold standard | ||
== | ==Management== | ||
* [[IVF]] | * [[IVF]] | ||
* IV [[antibiotics]] | * IV [[antibiotics]] | ||
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**Surgery | **Surgery | ||
== | ==References== | ||
[[Category:GI]] | [[Category:GI]] | ||
Revision as of 19:09, 11 May 2015
Background
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.
- Severe, generalized, colicky
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
Diagnosis
- Labs
- Lactate (higher later)
- WBC (often >15K)
- Chemistry (metabolic acidosis)
- CTA
- Mesentaric angiography considered gold standard
Management
- IVF
- IV antibiotics
- Narcotic analgesia
Acute arterial embolus
- Papaverine infusion (30-60 mg/h IV) OR
- surgical embolectomy OR
- intra-arterial thrombolysis
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