Mesenteric ischemia

Revision as of 20:59, 27 October 2015 by Rossdonaldson1 (talk | contribs) (Chronic mesenteric ischemia)

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
  • Atherosclerotic Disease
Venous Thrombosis
  • Prior thrombosis history
  • Hypercoagulable state (preg, cancer, clotting disorder)
Nonocculsive
  • Hypovolemic state
  • Heart Failure
  • MI w/ dec output
  • Sepsis
  • Diuretic use

Epidemiology

  • Mean age: 70yo
  • 2/3 women

Risk Factors

Clinical Features

  • 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)
  • Severe, generalized, colicky
  • Bloody stools

Differential Diagnosis

Colitis

Diffuse Abdominal pain

Diagnosis

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

Management

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

References

  1. Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341