Mesenteric ischemia: Difference between revisions
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==Background== | ==Background== | ||
=== Pathophysiology === | [[File:Superior mesenteric a.gif|thumb|Frontal view of the superior mesenteric artery and its branches. The large vessel (blue) beside the SMA is the superior mesenteric vein. A considerable number of different branching patterns exist.]] | ||
[[File:Colonic blood supply.png|thumb|Colonic blood supply. Pink - supply from superior mesenteric artery (SMA) and its branches: middle colic, right colic, ileocolic arteries. Blue - supply from inferior mesenteric artery (IMA) and its branches: left colic, sigmoid, superior rectal artery. 7 is for so-called Cannon-Böhm point (the border between the areas of SMA and IMA supplies), which lies at the splenic flexure.]] | |||
*Most commonly superior mesenteric artery (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 | #Mesenteric arterial embolism (ex. Afib) | ||
#Mesenteric arterial thrombosis | #Mesenteric arterial thrombosis (ex. Vasculopath) | ||
#Nonocclusive mesenteric ischemia | #Nonocclusive mesenteric ischemia (ex. Hypovolemia from diuretics) | ||
#Mesenteric venous thrombosis | #[[Mesenteric venous thrombosis]] (ex. hypercoagulable state) | ||
{{Intestinal ischemia types}} | |||
===Risk Factors=== | ===Risk Factors=== | ||
{| class="wikitable sortable" | |||
|+ Risk Factors by Mesenteric Ischemia Type | |||
|- | |||
! scope="col" | '''Type''' | |||
! scope="col" | '''Risk Factor''' | |||
|- | |||
| Arterial Embolism|| | |||
*[[Dysrhythmia]] ([[A. Fib]]) | |||
*[[Cardiomyopathy]] | |||
*Valve Disease | |||
*[[Endocarditis]] | |||
*[[MI]] | |||
|- | |||
| [[Arterial thrombosis|Arterial Thrombosis]]|| | |||
*Atherosclerotic Disease | |||
|- | |||
| [[Venous thrombosis|Venous Thrombosis]]|| | |||
*Prior thrombosis history | |||
*Hypercoagulable state ([[pregnancy]], cancer, clotting disorder) | |||
|- | |||
| Nonocculsive|| | |||
*[[Hypovolemic]] state | |||
*[[Heart failure]] | |||
*[[Myocardial infarction]] with decrease output | |||
*[[Sepsis]] | |||
*[[Diuretic]] use | |||
|} | |||
==Clinical Features== | |||
*[[Abdominal pain|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 | |||
*[[GI bleed|Bloody stools]] | |||
==Diagnosis== | ==Differential Diagnosis== | ||
{{Colitis types}} | |||
{{Abdominal Pain DDX Diffuse}} | |||
== | ==Evaluation== | ||
[[File:Ischemicbowel.png|thumb|CT showing dilated loops of small bowel with thickened walls (black arrow), findings characteristic of ischemic bowel due to thrombosis of the superior mesenteric vein.]] | |||
===Workup=== | |||
*Labs | |||
**CBC | |||
**Chemistry | |||
**[[LFTs]] | |||
**Lipase | |||
**[[Lactate]] | |||
**Consider [[UA]] | |||
*CTA abdomen/pelvis (Bowel wall edema is the most common finding on CT) | |||
*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 | |||
**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> | |||
*[[Analgesia]] (usually [[Opioids]] | |||
*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 (30-60m 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=== | ===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=== | ===Mesenteric venous thrombosis=== | ||
*[[Heparin]]/[[warfarin]] either alone or in combination with surgery | |||
*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> | |||
*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 | |||
==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/> | |||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Vascular]] | |||
[[Category:Surgery]] |
Latest revision as of 04:16, 27 November 2021
Background
- Most commonly superior mesenteric artery (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:
- Mesenteric arterial embolism (ex. Afib)
- Mesenteric arterial thrombosis (ex. Vasculopath)
- Nonocclusive mesenteric ischemia (ex. Hypovolemia from diuretics)
- Mesenteric venous thrombosis (ex. hypercoagulable state)
Intestinal Ischemic Disorder Types
- Ischemic colitis
- Acute mesenteric ischemia
- Mesenteric venous thrombosis
- Chronic mesenteric ischemia ("intestinal angina")
Risk Factors
Type | Risk Factor |
---|---|
Arterial Embolism |
|
Arterial Thrombosis |
|
Venous Thrombosis |
|
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
- Infectious colitis
- Ischemic colitis
- Ulcerative colitis
- CMV colitis
- Crohn's colitis
- Toxic colitis (antineoplastic agents)
- Pseudomembranous colitis
- Fibrosing colonopathy (Cystic fibrosis)
Diffuse Abdominal pain
- Abdominal aortic aneurysm
- Acute gastroenteritis
- Aortoenteric fisulta
- Appendicitis (early)
- Bowel obstruction
- Bowel perforation
- Diabetic ketoacidosis
- Gastroparesis
- Hernia
- Hypercalcemia
- Inflammatory bowel disease
- Mesenteric ischemia
- Pancreatitis
- Peritonitis
- Sickle cell crisis
- Spontaneous bacterial peritonitis
- Volvulus
Evaluation
Workup
- Labs
- CTA abdomen/pelvis (Bowel wall edema is the most common finding on CT)
- 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
- Correct electrolyte imbalances prior to IV contrast or surgical exploration[1]
- Analgesia (usually Opioids
- IV antibiotics - broad spectrum antibiotics to prevent sepsis [2]
- Second-generation cephalosporin plus metronidazole[3], 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,[4] 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[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
- ↑ Wyers MC. Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010 Mar;23(1):9-20.
- ↑ Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341
- ↑ 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.
- ↑ Berland T, Oldenburg WA. Acute mesenteric ischemia. Curr Gastroenterol Rep. 2008 Jun;10(3):341-6.
- ↑ Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology. 2000 May;118(5):954-68.
- ↑ Clair DG, Beach JM. Mesenteric Ischemia. N Engl J Med. 2016 Mar 10;374(10):959-68.