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
*Mean age = 70 years old (>70% of cases occur in women)
 
===Pathophysiology===
4 distinct entities:
4 distinct entities:
#Mesenteric arterial embolism (ex. Afib)
#Mesenteric arterial embolism (ex. Afib)
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#Mesenteric venous thrombosis (ex. hypercoagulable state)
#Mesenteric venous thrombosis (ex. hypercoagulable state)


===Risk Factors===
{| class="wikitable sortable"
{| class="wikitable sortable"
|+ Risk Factors for Mesenteric Ischemia Types
|+ Risk Factors by Mesenteric Ischemia Type
|-
|-
! scope="col" | '''Type'''
! scope="col" | '''Type'''
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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 ===
*Mean age: 70yo
*2/3 women
===Risk Factors===
*CAD
*[[Valvular heart disease]]
*[[Dysrhythmia]]
*Hypovolemia / [[hypotension]]
*Meds
** Diuretics
** Vasoconstrictive
** Digoxin
* 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==
===Workup===
*Labs
*Labs
**CBC
**Chemistry
**LFTs
**Lipase
**Lactate
**Consider UA
*CT abdomen/pelvis with IV contrast
*Mesenteric angiography considered gold standard (if available, typically as a secondary study)
===Diagnosis===
*Typically diagnosed on CT
*Labs may show the following (although do not rule need for CT):
**[[Lactate]] (higher later)
**[[Lactate]] (higher later)
**WBC (often >15K)
**WBC (often >15K)
**Chemistry (metabolic acidosis)
**Chemistry (metabolic acidosis)
*CTA
**Hyperphosphatemia
*Mesentaric angiography considered gold standard


==Management==
==Management==
* [[IVF]]
===General===
* IV [[antibiotics]] - broad spectrum abx to prevent sepsis <ref>Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341</ref>
*Aggressive [[IVF]] resuscitation, continued after revascularization due to capillary leak
* Narcotic analgesia
**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>
*[[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 [[Metronidazole]] 15 mg/kg IV LOAD over 1 hour, for severely ill, maintenance 500 mg IV q6 hours,<ref>Berland T, Oldenburg WA. Acute mesenteric ischemia. Curr Gastroenterol Rep. 2008 Jun;10(3):341-6.</ref> '''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==
*Admit with consultation of one or more of the following
*Admit with consultation of one or more of the following:
**IR
**IR
**Vascular
**Vascular
**Surgery
**Surgery
==See Also==
*[[Abdominal pain]]
==External Links==


==References==
==References==

Revision as of 18:50, 8 August 2019

Background

  • Most commonly SMA, thus typically involves small bowel (especially jejunum) and right colon
  • Left colon uncommonly involved due to collateral flow
  • Mean age = 70 years old (>70% of cases occur in women)

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

Risk Factors by Mesenteric Ischemia Type
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

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

Workup

  • Labs
    • CBC
    • Chemistry
    • LFTs
    • Lipase
    • Lactate
    • Consider UA
  • CT abdomen/pelvis with IV contrast
  • Mesenteric angiography considered gold standard (if available, typically as a secondary study)

Diagnosis

  • Typically diagnosed on CT
  • Labs may show the following (although do not rule need for CT):
    • Lactate (higher later)
    • WBC (often >15K)
    • Chemistry (metabolic acidosis)
    • Hyperphosphatemia

Management

General

  • Aggressive IVF resuscitation, continued after revascularization due to capillary leak
  • Opioid analgesia
  • IV antibiotics - broad spectrum antibiotics to prevent sepsis [2]
  • 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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