Difference between revisions of "Mesenteric ischemia"

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== Pathophysiology ==
+
==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:
 
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)
  
#Mesenteric arterial embolism
+
{| class="wikitable sortable"
#Mesenteric arterial thrombosis
+
|+ Risk Factors for Mesenteric Ischemia Types
#Nonocclusive mesenteric ischemia
+
|-
#Mesenteric venous thrombosis
+
! scope="col" | '''Type'''
 
+
! scope="col" | '''Risk Factor'''
 
+
|-
 
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| Arterial Embolism||
== Epidemiology ==
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*Dysrhythmia (A. Fib)
 +
*Valve Disease
 +
*MI
 +
|-
 +
| Arterial Thrombosis||
 +
*Atherosclerotic Disease
 +
|-
 +
| Venous Thrombosis||
 +
*Prior thrombosis history
 +
*Hypercoagulable state (preg, cancer, clotting disorder)
 +
|-
 +
| Nonocculsive||
 +
*Hypovolemic state
 +
*Heart Failure
 +
*[[Myocardial infarction]] with decrease output
 +
*Sepsis
 +
*Diuretic use
 +
|}
  
 +
===Epidemiology===
 
*Mean age: 70yo
 
*Mean age: 70yo
 
*2/3 women
 
*2/3 women
  
== Risk Factors ==
+
===Risk Factors===
 
 
 
*CAD
 
*CAD
*Valvular heart disease
+
*[[Valvular heart disease]]
*Dysrhythmia
+
*[[Dysrhythmia]]
*Hypovolemia / hypotension
+
*Hypovolemia / [[hypotension]]
 
*Meds
 
*Meds
** Diuretics
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**Diuretics
** Vasoconstrictive
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**Vasoconstrictive
** Digoxin
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**Digoxin
* Dialysis
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*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
  
== Signs/Symptoms ==
+
==Differential Diagnosis==
 +
{{Colitis types}}
  
* Pain out of proportion to exam
+
{{Abdominal Pain DDX Diffuse}}
* Severe, poorly localized, colicky
 
  
== W/U ==
+
==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
  
* Lactate (higher later)
+
==Management==
* CTA
+
*[[IVF]]
* Angiography
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*IV [[antibiotics]] - broad spectrum antibiotics to prevent sepsis <ref>Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341</ref>
 +
*[[Opioid]] analgesia
  
== Treatment ==
+
===Acute arterial embolus===
 +
*Papaverine infusion (30-60m g/h IV) '''OR'''
 +
*Surgical embolectomy '''OR'''
 +
*Intra-arterial thrombolysis with IR
  
* IVF
+
===Nonocclusive mesenteric ischemia===
* IV Abx
+
*Papaverine infusion
* Narcotic analgesia
 
  
Acute arterial embolus
+
===Mesenteric venous thrombosis===
* Papaverine infusion (30-60 mg/h IV) OR
+
*[[Heparin]]/[[warfarin]] either alone or in combination with surgery
* surgical embolectomy OR
+
*Immediate heparinization should be started even when surgical intervention is indicated
* intra-arterial thrombolysis
+
**Decreases progression of thrombosis and improves survival
  
Nonocclusive mesenteric ischemia
+
===Chronic mesenteric ischemia===
* Papaverine infusion
+
*Angioplasty with or without stent placement or surgical revascularization
  
Mesenteric venous thrombosis
+
==Disposition==
* Heparin/warfarin either alone or in combination with surgery
+
*Admit with consultation of one or more of the following
* Immediate heparinization should be started even when surgical intervention is indicated
+
**IR
** Decreases progression of thrombosis and improves survival
+
**Vascular
 +
**Surgery
  
Chronic mesenteric ischemia
+
==See Also==
* Angioplasty with or without stent placement or surgical revascularization
 
  
== Consultation ==
 
  
* IR
+
==External Links==
* Vascular
 
* Surgery
 
  
== Source ==
 
  
6/06 MISTRY, Rosen's, Tintinalli
+
==References==
 +
<references/>
  
<br/>[[Category:GI]]<br/><br/>
+
[[Category:GI]]
 +
[[Category:Vascular]]

Revision as of 20:22, 13 October 2018

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:

  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
  • Atherosclerotic Disease
Venous Thrombosis
  • Prior thrombosis history
  • Hypercoagulable state (preg, cancer, clotting disorder)
Nonocculsive

Epidemiology

  • Mean age: 70yo
  • 2/3 women

Risk Factors

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

Diffuse Abdominal pain

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

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

See Also

External Links

References

  1. Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341