Updated: 9/10/2019

Mesenteric Ischemia

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  • 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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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GI.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? Review Topic

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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