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Acute mesenteric ischemia
1. Acute MesentericAcute Mesenteric
Ischemia and InfarctionIschemia and Infarction
Dr. Sajad Ali (MBBS., MS.)Dr. Sajad Ali (MBBS., MS.)
Gastrointestinal & LaparoscopicGastrointestinal & Laparoscopic
surgeonsurgeon
Dr Ahmed Abanamy HospitalDr Ahmed Abanamy Hospital
2. A First Big Distinction…A First Big Distinction…
Mesenteric IschemiaMesenteric Ischemia – ischemia of the– ischemia of the
small bowelsmall bowel, usually 2/2 an acute cause, usually 2/2 an acute cause
involving the SMA or SMV.involving the SMA or SMV.
Ischemic colitisIschemic colitis – ischemia of the– ischemia of the coloncolon,,
rarely with a known acute precipitatingrarely with a known acute precipitating
cause.cause.
3. Superior Mesenteric Artery (SMA)Superior Mesenteric Artery (SMA)
Largest caliber vessel + 45-degree angleLargest caliber vessel + 45-degree angle
makes it most commonly occludedmakes it most commonly occluded
Celiac Trunk
IMA
SMA
Aorta
4. Superior Mesenteric Artery (SMA)Superior Mesenteric Artery (SMA)
Emboli occlude past the middle colic,Emboli occlude past the middle colic,
causing small bowel ischemiacausing small bowel ischemia
SMA
Middle Colic
Right Colic
Ileocolic
Jejunal & Ileal
Arteries
Occlusion
Point
6. Etiologies of Acute MesentericEtiologies of Acute Mesenteric
Ischemia (AMI)Ischemia (AMI)
Focal small bowel ischemia - rareFocal small bowel ischemia - rare
Partial malrotation, volvulus, mesentericPartial malrotation, volvulus, mesenteric
hematoma, strangulated herniahematoma, strangulated hernia
UnknownUnknown
?Mesenteric small vessel disease?Mesenteric small vessel disease
7. History & PhysicalHistory & Physical
Classic Presentation:
Rapid onset of severe, unrelenting
periumbilical pain
Pain out of proportion to findings on
physical examination.
Nausea and vomiting
Forceful/urgent bowel evacuation
Risk factors for acute mesenteric ischemia
8. History & PhysicalHistory & Physical
SMA Thrombosis:SMA Thrombosis:
Prodrome of postprandial pain/nauseaProdrome of postprandial pain/nausea
and weight lossand weight loss
Presentation with classic symptomsPresentation with classic symptoms
Non-occlusive Mesenteric Ischemia:Non-occlusive Mesenteric Ischemia:
Unexplained decline in clinical status orUnexplained decline in clinical status or
failure to follow expected recoveryfailure to follow expected recovery
10. Laboratory FindingsLaboratory Findings
Anion gap metabolic acidosisAnion gap metabolic acidosis
Elevated arterial/venous lactateElevated arterial/venous lactate
LeukocytosisLeukocytosis
HemoconcentrationHemoconcentration
Elevated LDH, amylase, AST, and CPKElevated LDH, amylase, AST, and CPK
Elevated K and Phos are late signsElevated K and Phos are late signs
11. RadiologyRadiology
Plain films – thumbprinting, thickenedPlain films – thumbprinting, thickened
bowel (<40% sensitivity)bowel (<40% sensitivity)
CT – thickened/dilated bowel, intramuralCT – thickened/dilated bowel, intramural
hematoma, pneumatosis (64% sensitivity)hematoma, pneumatosis (64% sensitivity)
MRI – promising but untested to dateMRI – promising but untested to date
Mesenteric angiography – test of choice;Mesenteric angiography – test of choice;
can identify the type of AMIcan identify the type of AMI
12. Differential DiagnosisDifferential Diagnosis
Other serious conditions to consider:Other serious conditions to consider:
PancreatitisPancreatitis
Acute DiverticulitisAcute Diverticulitis
Acute CholecystitisAcute Cholecystitis
Small bowel obstructionSmall bowel obstruction
Perforation of a viscousPerforation of a viscous
Ruptured aneurysmRuptured aneurysm
13. TreatmentTreatment
Resuscitation with fluids/blood productsResuscitation with fluids/blood products
AnticoagulationAnticoagulation
Infusion of a vasodilatorInfusion of a vasodilator
Glucagon systemically ORGlucagon systemically OR
Papaverine through a catheterPapaverine through a catheter
14. From Ischemia to InfarctionFrom Ischemia to Infarction
Marked by peritoneal signs, feverMarked by peritoneal signs, fever
Emergent laporatomyEmergent laporatomy
Restoration of interrupted blood flow withRestoration of interrupted blood flow with
arteriotomy or bypass graftarteriotomy or bypass graft
Resection of infarcted bowelResection of infarcted bowel
Second-look in 24-48 hoursSecond-look in 24-48 hours
Vasodilators and careful pressor useVasodilators and careful pressor use
15. A Word on Ischemic ColitisA Word on Ischemic Colitis
Presentation: less & more focal painPresentation: less & more focal pain
(usually left-sided), more bloody diarrhea,(usually left-sided), more bloody diarrhea,
>90% are over 60 years old.>90% are over 60 years old.
Etiology rarely identified: ?small vesselEtiology rarely identified: ?small vessel
disease +/- hypoperfusiondisease +/- hypoperfusion
Episodes usually self limited except whenEpisodes usually self limited except when
stricture or gangrene developsstricture or gangrene develops
Colonoscopy is initial evaluation of choiceColonoscopy is initial evaluation of choice