Difference between revisions of "Mesenteric ischemia"

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

Latest 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