Mesenteric ischemia: Difference between revisions
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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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|-
|-
| Arterial Thrombosis||
| Arterial Thrombosis||
*Athrosclerotic Disease
*Atherosclerotic Disease
|-
|-
| Venous Thrombosis||
| Venous Thrombosis||
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*Hypovolemic state
*Hypovolemic state
*Heart Failure
*Heart Failure
*[[Myocardial infarction]] with decrease output
*Sepsis
*Diuretic use
*Diuretic use
|}
|}


=== Epidemiology ===
===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
**Diuretics
## Vasoconstrictive
**Vasoconstrictive
## Digoxin
**Digoxin
# Dialysis
*Dialysis


==Diagnosis==
==Clinical Features==
===Signs/Symptoms===
*Pain out of proportion to exam. Abdomen often soft, without guarding.
# Pain out of proportion to exam
**Pain often left sided around watershed areas of colon (splenic flexure and recto-sigmoid junction)
# Severe, poorly localized, colicky
*Severe, generalized, colicky
*Bloody stools


==Work Up==
==Differential Diagnosis==
#Labs
{{Colitis types}}
##[[Lactate]] (higher later)
 
##WBC (often >15K)
{{Abdominal Pain DDX Diffuse}}
##Chemistry (metabolic acidosis)
#CTA
#Mesentaric angiography considered gold standard


==Differential Diagnosis==
==Evaluation==
===Diffuse [[Abdominal Pain]]===
*Labs
{{Template:Abdominal Pain DDX Diffuse}}
**[[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


== Treatment ==
==Management==
# IVF
*Aggressive [[IVF]] resuscitation, continued after revascularization due to capillary leak
# IV Abx
*Correct electrolyte imbalances prior to IV contrast or surgical exploration<ref>Wyers MC. Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010 Mar;23(1):9-20.</ref>
# Narcotic analgesia
*[[Opioid]] analgesia
*IV [[antibiotics]] - broad spectrum antibiotics to prevent sepsis <ref>Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341</ref>
**Second-generation cephalosporin plus metronidazole<ref>Klar E, Rahmanian PB, Bücker A, Hauenstein K, Jauch KW, Luther B. Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int. 2012 Apr;109(14):249-56 full-text, commentary can be found in Dtsch Arztebl Int 2012 Oct;109(42):709 full-text, Dtsch Arztebl Int 2012 Oct;109(42):710.</ref>
'''OR'''
**[[Levofloxacin]] 500 mg IV q24 hours PLUS<ref>Berland T, Oldenburg WA. Acute mesenteric ischemia. Curr Gastroenterol Rep. 2008 Jun;10(3):341-6.</ref>
**[[Metronidazole]] 15 mg/kg IV LOAD over 1 hour, for severely ill, maintenance 500 mg IV q6 hours OR
***[[Piperacillin/tazobactam]] 3.375 mg IV q6 hours
*Anticoagulation with [[heparin]] is usually appropriate in all patients with mesenteric ischemia, with exception of those with typical contraindications
**Some experts will recommend delaying heparin for 48 hours due to risk for intraluminal bleeding in bowels<ref>Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology. 2000 May;118(5):954-68.</ref>


===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
*Mesenteric artery bypass surgery '''OR'''
*Retrograde open mesenteric stenting '''OR'''
*tPA intra-arterial thrombolysis with IR
*PLUS/MINUS surgical resection of necrotic bowel after any of above interventions
*PLUS/MINUS 24-48 hour second-look surgery


===Nonocclusive mesenteric ischemia===
===Nonocclusive mesenteric ischemia===
# Papaverine infusion
*Transcatheter vasodilation via:
**PGE1, alprostadil
**PGI2, epoprostenol
**Papaverine, most commonly used, though use in caution with angina, recent stroke, MI, glaucoma


===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
*Up to 5% of patients require intervention beyond anticoagulation alone<ref>Clair DG, Beach JM. Mesenteric Ischemia. N Engl J Med. 2016 Mar 10;374(10):959-68.</ref>
## Decreases progression of thrombosis and improves survival
*Immediate heparinization should be started even when surgical intervention is indicated
**Decreases progression of thrombosis and improves survival
*PLUS/MINUS tPA intra-arterial thrombolysis with IR
*PLUS/MINUS laparotomy for evidence of bowel necrosis, peritonitis, stricture, severe GI bleeding


===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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**Surgery
**Surgery


== Source ==
==See Also==
*Rosen's
 
*Tintinalli
 
==External Links==
 
 
==References==
<references/>


[[Category:GI]]
[[Category:GI]]
[[Category:Vascular]]

Revision as of 19:32, 20 April 2019

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

  • Aggressive IVF resuscitation, continued after revascularization due to capillary leak
  • Correct electrolyte imbalances prior to IV contrast or surgical exploration[1]
  • Opioid analgesia
  • IV antibiotics - broad spectrum antibiotics to prevent sepsis [2]
    • Second-generation cephalosporin plus metronidazole[3]

OR

  • Anticoagulation with heparin is usually appropriate in all patients with mesenteric ischemia, with exception of those with typical contraindications
    • Some experts will recommend delaying heparin for 48 hours due to risk for intraluminal bleeding in bowels[5]

Acute arterial embolus

  • Papaverine infusion (30-60m g/h IV) OR
  • Surgical embolectomy OR
  • Mesenteric artery bypass surgery OR
  • Retrograde open mesenteric stenting OR
  • tPA intra-arterial thrombolysis with IR
  • PLUS/MINUS surgical resection of necrotic bowel after any of above interventions
  • PLUS/MINUS 24-48 hour second-look surgery

Nonocclusive mesenteric ischemia

  • Transcatheter vasodilation via:
    • PGE1, alprostadil
    • PGI2, epoprostenol
    • Papaverine, most commonly used, though use in caution with angina, recent stroke, MI, glaucoma

Mesenteric venous thrombosis

  • Heparin/warfarin either alone or in combination with surgery
  • Up to 5% of patients require intervention beyond anticoagulation alone[6]
  • Immediate heparinization should be started even when surgical intervention is indicated
    • Decreases progression of thrombosis and improves survival
  • PLUS/MINUS tPA intra-arterial thrombolysis with IR
  • PLUS/MINUS laparotomy for evidence of bowel necrosis, peritonitis, stricture, severe GI bleeding

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. ↑ Wyers MC. Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010 Mar;23(1):9-20.
  2. ↑ Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341
  3. ↑ Klar E, Rahmanian PB, Bücker A, Hauenstein K, Jauch KW, Luther B. Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int. 2012 Apr;109(14):249-56 full-text, commentary can be found in Dtsch Arztebl Int 2012 Oct;109(42):709 full-text, Dtsch Arztebl Int 2012 Oct;109(42):710.
  4. ↑ Berland T, Oldenburg WA. Acute mesenteric ischemia. Curr Gastroenterol Rep. 2008 Jun;10(3):341-6.
  5. ↑ Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology. 2000 May;118(5):954-68.
  6. ↑ Clair DG, Beach JM. Mesenteric Ischemia. N Engl J Med. 2016 Mar 10;374(10):959-68.
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