Mesenteric ischemia

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Background

Pathophysiology

4 distinct entities:

  1. Mesenteric arterial embolism
  2. Mesenteric arterial thrombosis
  3. Nonocclusive mesenteric ischemia
  4. Mesenteric venous thrombosis

Epidemiology

  1. Mean age: 70yo
  2. 2/3 women

Risk Factors

  1. CAD
  2. [[Valvular heart disease[[
  3. Dysrhythmia
  4. Hypovolemia / hypotension
  5. Meds
    1. Diuretics
    2. Vasoconstrictive
    3. Digoxin
  6. Dialysis

Diagnosis

Signs/Symptoms

  1. Pain out of proportion to exam
  2. Severe, poorly localized, colicky

Work Up

  1. Labs
    1. Lactate (higher later)
    2. WBC (often >15K)
    3. Chemistry (metabolic acidosis)
  2. CTA
  3. Angiography

Differential Diagnosis

Diffuse Abdominal Pain

Diffuse Abdominal pain

Treatment

  1. IVF
  2. IV Abx
  3. Narcotic analgesia

Acute arterial embolus

  1. Papaverine infusion (30-60 mg/h IV) OR
  2. surgical embolectomy OR
  3. intra-arterial thrombolysis

Nonocclusive mesenteric ischemia

  1. Papaverine infusion

Mesenteric venous thrombosis

  1. Heparin/warfarin either alone or in combination with surgery
  2. Immediate heparinization should be started even when surgical intervention is indicated
    1. 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