Updated: 12/20/2019

Mesenteric Ischemia

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Snapshot
  • A 68-year-old woman is brought to the emergency room for severe abdominal pain for the past 2 hours. She reports that she was watching TV when suddenly her stomach began hurting. The pain got progressively worse and is currently described as stabbing, 9/10 pain distributed throughout the abdominal region. Her past medical history is significant for atrial fibrillation.
Introduction
  • Clinical definition
    • medical condition where the small intestine is injured secondary to any process that reduces intestinal blood flow
    • acute mesenteric ischemia
      • characterized by acute onset of severe abdominal pain and is associated with high risk of mortality
    • chronic mesenteric ischemia
      • gradual decrease of blood flow typically associated with atherosclerosis
      • characterized by postprandial abdominal pain with unintentional weight loss, food aversion, and vomiting
  • Epidemiology
    • demographics
      • most commonly affects people > 60 years of age
    • risk factors
      • atrial fibrillation
      • heart failure
      • chronic kidney failure
      • hypercoagulable states
      • previous myocardial infarction
  • Pathogenesis
    • can be due to a variety of processes
      • acute mesenteric ischemia is most commonly caused by an embolism in the main mesenteric artery
      • chronic mesenteric ischemia is most commonly caused by atherosclerosis 
    • arterial occlusion
      • embolism secondary to atrial fibrillation, myocardial infarction, or valvular disease
      • thrombosis secondary to artherosclerosis
    • non-occlusive arterial disease
      • splanchnic vasoconstriction
      • hypoperfusion due to hypotension
    • venous thrombosis
Presentation
  • Acute mesenteric ischemia  
    • symptoms  
      • sudden onset of severe abdominal pain
      • nausea
      • diarrhea
      • vomiting
      • gastrointestinal bleeding
    • physical exam
      • fever
      • tachycardia
      • abdominal pain out of proportion to physical findings
      • peritoneal signs if bowel infarction
  • Chronic mesenteric ischemia
    • symptoms
      • post-prandial abdominal pain that resolves (e.g., "intestinal angina")
      • nausea
      • food aversion
      • vomiting
      • gastrointestinal bleeding
    • physical exam
      • weight loss
      • abdominal bruit
Studies
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is primarily based on clinical presentation and confirmed via angiography
    • imaging
      • mesenteric angiography 
        • gold standard for arterial occlusive disease
        • allows for differentiation of the different etiologies and direct infusion of vasodilators in the setting of nonocclusive ischemia  
      • computed tomography (CT) with angiography  
        • best initial imaging
        • will elucidate other causes of abdominal pain
        • findings may include mesenteric edema, bowel dilatation, bowel wall thickening, intramural gas, and mesenteric stranding
      • abdominal radiograph
        • can rule out other causes of abdominal pain
        • images will often appear normal
    • studies
      • laboratory studies
        • leukocytosis
        • elevated lactic acid 
Differential
  • Ischemic colitis 
    • differentiating factors
      • will demonstrate pathology of the large bowel on imaging
  • Perforated viscus
    • differentiating factors
      • visualization of gas on abdominal radiograph
Treatment
  • Therapy is dependent on the etiology and can be pharmacological or surgical
  • Non-occlusive mesenteric ischemia
    • IV fluid resuscitation
    • nasogastric tube decompression
    • anti-coagulation regimen (as needed)
    • vasodilator (e.g. papaverine)
  • Occlusive mesenteric ischemia
    • surgical revascularization via angioplasty
    • thrombolytic therapy
  • Emergency laparotomy       
    • indicated if evidence of bowel infarction/necrosis or peritonitis
    • may require bowel resection
Complications
  • Sepsis
  • Death
  • Bowel necrosis
  • Perforation  
 

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(M2.GI.15.74) A 68-year-old male smoker with a history of peripheral vascular disease and a below the knee amputation, presents to the emergency room with excruciating abdominal pain and vomiting for the last 6 hours. Vital signs are T 101.0 F HR 136 BP 150/96 RR 18 Sat 93% on room air. Abdominal exam shows a non-distended, exquisitely tender abdomen which the patient refuses to allow you to examine. While assessing peripheral pulses you note that they are irregular. A digital rectal exam is Guiac positive. Laboratory values are notable for a leukocytosis and a lactic acid of 6.8 mmol/L. An ECG is shown in Figure A. What is the next best step in diagnosis? Tested Concept

QID: 106694
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Diagnostic peritoneal lavage

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CT Angiography

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Technetium-99 tagged RBC scintigraphy

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Upper Endoscopy

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Upper GI with follow through

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