Difference between revisions of "Mesenteric ischemia"

(L sided pain)
(Management)
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==Background==
 
==Background==
=== Pathophysiology ===
+
*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 embolism (ex. Afib)
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*Hypovolemic state
 
*Hypovolemic state
 
*Heart Failure
 
*Heart Failure
*MI w/ dec output
+
*[[Myocardial infarction]] with decrease output
 
*Sepsis
 
*Sepsis
 
*Diuretic use
 
*Diuretic use
 
|}
 
|}
  
=== Epidemiology ===
+
===Epidemiology===
 
*Mean age: 70yo
 
*Mean age: 70yo
 
*2/3 women
 
*2/3 women
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*Hypovolemia / [[hypotension]]
 
*Hypovolemia / [[hypotension]]
 
*Meds
 
*Meds
** Diuretics
+
**Diuretics
** Vasoconstrictive
+
**Vasoconstrictive
** Digoxin
+
**Digoxin
* Dialysis
+
*Dialysis
  
 
==Clinical Features==
 
==Clinical Features==
 
*Pain out of proportion to exam. Abdomen often soft, without guarding.  
 
*Pain out of proportion to exam. Abdomen often soft, without guarding.  
**Pain often L sided around watershed areas of colon (splenic flexure and recto-sigmoid junction)
+
**Pain often left sided around watershed areas of colon (splenic flexure and recto-sigmoid junction)
 
*Severe, generalized, colicky
 
*Severe, generalized, colicky
 
*Bloody stools
 
*Bloody stools
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{{Abdominal Pain DDX Diffuse}}
 
{{Abdominal Pain DDX Diffuse}}
  
==Diagnosis==
+
==Evaluation==
 
*Labs
 
*Labs
 
**[[Lactate]] (higher later)
 
**[[Lactate]] (higher later)
 
**WBC (often >15K)
 
**WBC (often >15K)
 
**Chemistry (metabolic acidosis)
 
**Chemistry (metabolic acidosis)
 +
**Hyperphosphatemia
 +
*Upright or left lateral decub XR with intraabdominal air
 
*CTA
 
*CTA
*Mesentaric angiography considered gold standard
+
*Mesenteric angiography considered gold standard
  
 
==Management==
 
==Management==
* [[IVF]]
+
*[[IVF]]
* IV [[antibiotics]] - broad spectrum abx to prevent sepsis <ref>Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341</ref>
+
*IV [[antibiotics]] - broad spectrum antibiotics to prevent sepsis <ref>Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341</ref>
* Narcotic analgesia
+
*[[Opioid]] analgesia
  
 
===Acute arterial embolus===
 
===Acute arterial embolus===
* Papaverine infusion (30-60 mg/h IV) OR
+
*Papaverine infusion (30-60m g/h IV) '''OR'''
* surgical embolectomy OR
+
*Surgical embolectomy '''OR'''
* intra-arterial thrombolysis
+
*Intra-arterial thrombolysis with IR
  
 
===Nonocclusive mesenteric ischemia===
 
===Nonocclusive mesenteric ischemia===
* Papaverine infusion
+
*Papaverine infusion
  
 
===Mesenteric venous thrombosis===
 
===Mesenteric venous thrombosis===
* [[Heparin]]/[[warfarin]] either alone or in combination with surgery
+
*[[Heparin]]/[[warfarin]] either alone or in combination with surgery
* Immediate heparinization should be started even when surgical intervention is indicated
+
*Immediate heparinization should be started even when surgical intervention is indicated
** Decreases progression of thrombosis and improves survival
+
**Decreases progression of thrombosis and improves survival
  
 
===Chronic mesenteric ischemia===
 
===Chronic mesenteric ischemia===
# Angioplasty with or without stent placement or surgical revascularization
+
*Angioplasty with or without stent placement or surgical revascularization
  
 
==Disposition==
 
==Disposition==
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**Vascular
 
**Vascular
 
**Surgery
 
**Surgery
 +
 +
==See Also==
 +
 +
 +
==External Links==
 +
  
 
==References==
 
==References==

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