Difference between revisions of "Mesenteric ischemia"

(Risk Factors)
Line 32: Line 32:
  
 
=== 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==
 
==Diagnosis==
 
===Signs/Symptoms===
 
===Signs/Symptoms===
# Pain out of proportion to exam
+
* Pain out of proportion to exam
# Severe, poorly localized, colicky
+
* Severe, poorly localized, colicky
  
 
==Work Up==
 
==Work Up==
#Labs
+
*Labs
##[[Lactate]] (higher later)
+
**[[Lactate]] (higher later)
##WBC (often >15K)
+
**WBC (often >15K)
##Chemistry (metabolic acidosis)
+
**Chemistry (metabolic acidosis)
#CTA
+
*CTA
#Mesentaric angiography considered gold standard
+
*Mesentaric angiography considered gold standard
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
Line 64: Line 64:
  
 
== Treatment ==
 
== Treatment ==
# IVF
+
* [[IVF]]
# IV Abx
+
* IV [[antibiotics]]
# Narcotic analgesia
+
* Narcotic analgesia
  
 
===Acute arterial embolus===
 
===Acute arterial embolus===
# Papaverine infusion (30-60 mg/h IV) OR
+
* Papaverine infusion (30-60 mg/h IV) OR
# surgical embolectomy OR
+
* surgical embolectomy OR
# intra-arterial thrombolysis
+
* intra-arterial thrombolysis
  
 
===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===

Revision as of 13:21, 3 February 2015

Background

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
  • Athrosclerotic Disease
Venous Thrombosis
  • Prior thrombosis history
  • Hypercoagulable state (preg, cancer, clotting disorder)
Nonocculsive
  • Hypovolemic state
  • Heart Failure
  • Diuretic use

Epidemiology

  • Mean age: 70yo
  • 2/3 women

Risk Factors

Diagnosis

Signs/Symptoms

  • Pain out of proportion to exam
  • Severe, poorly localized, colicky

Work Up

  • Labs
    • Lactate (higher later)
    • WBC (often >15K)
    • Chemistry (metabolic acidosis)
  • CTA
  • Mesentaric angiography considered gold standard

Differential Diagnosis

Diffuse Abdominal Pain

Diffuse Abdominal pain

Treatment

Acute arterial embolus

  • Papaverine infusion (30-60 mg/h IV) OR
  • surgical embolectomy OR
  • intra-arterial thrombolysis

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

  1. Angioplasty with or without stent placement or surgical revascularization

Disposition

  • Admit with consultation of one or more of the following
    • IR
    • Vascular
    • Surgery

Source

  • Rosen's
  • Tintinalli