Mesenteric ischemia: Difference between revisions
No edit summary
Line 19: Line 19:
|-
|-
| Arterial Embolism||
| Arterial Embolism||
*Dysrhythmia (A. Fib)
*[[Dysrhythmia]] ([[A. Fib]])
*Valve Disease
*Valve Disease
*MI
*[[MI]]
|-
|-
| Arterial Thrombosis||
| [[Arterial thrombosis|Arterial Thrombosis]]||
*Atherosclerotic Disease
*Atherosclerotic Disease
|-
|-
| Venous Thrombosis||
| [[Venous thrombosis|Venous Thrombosis]]||
*Prior thrombosis history
*Prior thrombosis history
*Hypercoagulable state (preg, cancer, clotting disorder)
*Hypercoagulable state ([[pregnancy]], cancer, clotting disorder)
|-
|-
| Nonocculsive||
| Nonocculsive||
*Hypovolemic state
*[[Hypovolemic]] state
*Heart Failure
*[[Heart failure]]
*[[Myocardial infarction]] with decrease output
*[[Myocardial infarction]] with decrease output
*Sepsis
*[[Sepsis]]
*Diuretic use
*[[Diuretic]] use
|}
|}


==Clinical Features==
==Clinical Features==
*Pain out of proportion to exam. Abdomen often soft, without guarding.  
*[[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)
**Pain often left sided around watershed areas of colon (splenic flexure and recto-sigmoid junction)
*Severe, generalized, colicky
**Severe, generalized, colicky
*Bloody stools
*[[GI bleed|Bloody stools]]


==Differential Diagnosis==
==Differential Diagnosis==
Line 54: Line 55:
**CBC
**CBC
**Chemistry
**Chemistry
**LFTs
**[[LFTs]]
**Lipase
**Lipase
**Lactate
**[[Lactate]]
**Consider UA
**Consider [[UA]]
*CT abdomen/pelvis with IV contrast
*CT abdomen/pelvis with IV contrast
*Mesenteric angiography considered gold standard (if available, typically as a secondary study)
*Mesenteric angiography considered gold standard (if available, typically as a secondary study)
Line 67: Line 68:
**WBC (often >15K)
**WBC (often >15K)
**Chemistry (metabolic acidosis)
**Chemistry (metabolic acidosis)
**Hyperphosphatemia
**[[Hyperphosphatemia]]


==Management==
==Management==
Line 78: Line 79:
**[[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'''
**[[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
**[[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
*[[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>
**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>


Revision as of 18:00, 22 September 2019

Background

  • Most commonly 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:

  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

Risk Factors by Mesenteric Ischemia Type
Type Risk Factor
Arterial Embolism
Arterial Thrombosis
  • Atherosclerotic Disease
Venous Thrombosis
  • Prior thrombosis history
  • Hypercoagulable state (pregnancy, cancer, clotting disorder)
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

Diffuse Abdominal pain

Evaluation

Workup

  • Labs
  • CT abdomen/pelvis with IV contrast
  • 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):

Management

General

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

  1. ↑ Wyers MC. Acute mesenteric ischemia: diagnostic approach and surgical treatment. Semin Vasc Surg. 2010 Mar;23(1):9-20.
  2. ↑ Acute mesenteric ischemia. Curr Gastroenterol Rep 2008;10:341
  3. ↑ 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.
  4. ↑ Berland T, Oldenburg WA. Acute mesenteric ischemia. Curr Gastroenterol Rep. 2008 Jun;10(3):341-6.
  5. ↑ Brandt LJ, Boley SJ. AGA technical review on intestinal ischemia. American Gastrointestinal Association. Gastroenterology. 2000 May;118(5):954-68.
  6. ↑ Clair DG, Beach JM. Mesenteric Ischemia. N Engl J Med. 2016 Mar 10;374(10):959-68.
Retrieved from "https://www.wikem.org/w/index.php?title=Mesenteric_ischemia&oldid=229335"