Mesenteric ischemia: Difference between revisions
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=== Epidemiology === | === Epidemiology === | ||
*Mean age: 70yo | |||
*2/3 women | |||
===Risk Factors=== | ===Risk Factors=== | ||
*CAD | |||
*[[Valvular heart disease]] | |||
*[[Dysrhythmia]] | |||
*Hypovolemia / [[hypotension]] | |||
*Meds | |||
** Diuretics | |||
** Vasoconstrictive | |||
** Digoxin | |||
* Dialysis | |||
==Diagnosis== | ==Diagnosis== | ||
===Signs/Symptoms=== | ===Signs/Symptoms=== | ||
* Pain out of proportion to exam | |||
* Severe, poorly localized, colicky | |||
==Work Up== | ==Work Up== | ||
*Labs | |||
**[[Lactate]] (higher later) | |||
**WBC (often >15K) | |||
**Chemistry (metabolic acidosis) | |||
*CTA | |||
*Mesentaric angiography considered gold standard | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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== Treatment == | == Treatment == | ||
* [[IVF]] | |||
* IV [[antibiotics]] | |||
* Narcotic analgesia | |||
===Acute arterial embolus=== | ===Acute arterial embolus=== | ||
* Papaverine infusion (30-60 mg/h IV) OR | |||
* surgical embolectomy OR | |||
* intra-arterial thrombolysis | |||
===Nonocclusive mesenteric ischemia=== | ===Nonocclusive mesenteric ischemia=== | ||
* Papaverine infusion | |||
===Mesenteric venous thrombosis=== | ===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=== | ===Chronic mesenteric ischemia=== |
Revision as of 13:21, 3 February 2015
Background
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)
Type | Risk Factor |
---|---|
Arterial Embolism |
|
Arterial Thrombosis |
|
Venous Thrombosis |
|
Nonocculsive |
|
Epidemiology
- Mean age: 70yo
- 2/3 women
Risk Factors
- CAD
- Valvular heart disease
- Dysrhythmia
- Hypovolemia / hypotension
- Meds
- Diuretics
- Vasoconstrictive
- Digoxin
- Dialysis
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
- 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
Treatment
- IVF
- IV antibiotics
- Narcotic analgesia
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
- 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