Updated: 4/20/2022

Mesenteric Ischemia

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  • Snapshot
  • 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
  • ETIOLOGY
    • 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
  • 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
    • Diagnostic testing
      • diagnostic approach
        • diagnosis is primarily based on clinical presentation and confirmed via angiography
      • 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?

QID: 106694
FIGURES:

Diagnostic peritoneal lavage

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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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