Mesenteric ischemia: Difference between revisions
m (Rossdonaldson1 moved page Mesenteric Ischemia to Mesenteric ischemia) |
|||
(36 intermediate revisions by 8 users not shown) | |||
Line 1: | Line 1: | ||
== 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 | #Mesenteric arterial embolism (ex. Afib) | ||
#Mesenteric arterial thrombosis | #Mesenteric arterial thrombosis (ex. Vasculopath) | ||
#Nonocclusive mesenteric ischemia | #Nonocclusive mesenteric ischemia (ex. Hypovolemia from diuretics) | ||
#Mesenteric venous thrombosis | #Mesenteric venous thrombosis (ex. hypercoagulable state) | ||
== | {| class="wikitable sortable" | ||
|+ Risk Factors for Mesenteric Ischemia Types | |||
|- | |||
! scope="col" | '''Type''' | |||
! scope="col" | '''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|| | |||
*Hypovolemic state | |||
*Heart Failure | |||
*[[Myocardial infarction]] with decrease output | |||
*Sepsis | |||
*Diuretic use | |||
|} | |||
== | ===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 types}} | |||
{{Abdominal Pain DDX Diffuse}} | |||
==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== | |||
*[[IVF]] | |||
*IV [[antibiotics]] - broad spectrum antibiotics to prevent sepsis <ref>Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341</ref> | |||
*[[Opioid]] analgesia | |||
===Acute arterial embolus=== | ===Acute arterial embolus=== | ||
*Papaverine infusion (30-60m g/h IV) '''OR''' | |||
*Surgical embolectomy '''OR''' | |||
*Intra-arterial thrombolysis with IR | |||
===Nonocclusive mesenteric ischemia=== | ===Nonocclusive mesenteric ischemia=== | ||
*Papaverine infusion | |||
===Mesenteric venous thrombosis=== | ===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=== | ===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== | ||
<references/> | |||
[[Category:GI]] | [[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:
- 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
- IVF
- IV antibiotics - broad spectrum antibiotics to prevent sepsis [1]
- 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
See Also
External Links
References
- ↑ Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341