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Mesenteric ischemia (Acute mesenteric (Aetiology (Autoimmune Vasculitis,…
Mesenteric ischemia
Acute
mesenteric
Management
Initial (ABCDE)
Definitive
Conservative
Information, advice, support
NBM in case of surgery
Refer to GI surgeons ASAP
Surgical
Angioplasty
+/- embolectomy
Investigative laparotomy
Indication: sepsis
MOA: removal of necrotic bowel
Medical
IV fluids
E.g. 0.9% NaCl
Analgesia
Per WHO ladder
Abx
Per local guidance
Thrombolysis
If no perforation
Clinical
presentation
(triad)
Pain
Site
Abdomen
Diffuse/poor localisation
Onset
Acute
Radiation
May go to back
Associated symptoms
Shock
Timing
Constant, persistent
Severity
SEVERE
Character
Often colicky
Shock
No abdo signs
Pathophysiology
Usually arterial embolism or thrombosis blocks blood supply
Usually small bowel involved (so pathology in SMA)
Rapid hypovolemia leading to shock
Diagnosis
Examination
Resp - tachypnoeic (compensation for metabolic acidosis)
Abdo - tachycardic (shock)
Abdo - NO SIGNS
PR - nil
Investigations
Bedside
Obs (low BP, tachycardia, tachypnoea)
ECG (may have AF)
Bloods
ABG (metabolic acidosis, high lactate)
FBC (anaemia, raised WCC), CRP (raised),
glucose, LFTs, U+Es, amylase (raised),
clotting, group&save/crossmatch
Imaging
Erect CXR- exclude perf
AXR - see dilated bowel loops, thumb printing
CT/ MR angiography (
diagnostic)
ECHO - heart lesions
History
PC/HPC: sudden onset diffuse pain, may radiate to back,
associated shock
PMH: CVD/PVD disease, vasculitis, prev surgery
DH: Meds, allergies
FH: CVD, ischemic bowel
SH: occupation, smoking, alcohol
Aetiology
Autoimmune
Vasculitis
Iatrogenic
Radiotherapy
Trauma
Direct bowel trauma
Strangulation i.e. hernia, volvulus
Vascular
Arterial thrombosis/embolic (post-MI, AF)
Venous thrombosis in mesentry
Infection
Sepsis (shock)
Drugs
Vasopressors
Cocaine
Complications
MOF
Septic peritonitis
Chronic
mesenteric
Clinical
presentation
N+V
Weight loss
Pain
Character
Colicky
Radiation
May go to back
Onset
Acute
Associated symptoms
N+V, weight loss,
malabsorption, PR bleeds
Site
Abdo, generalised
Timing
Intermittent
Exacerbating/relieving factors
Exacerbating - eating
Relieving - not eating
Severity
SEVERE
PR bleeding
Management
Initial (ABCDE)
Definitive
Surgery
Angioplasty and stenting
Transaortic endartectomy (coeliac trunk/SMA)
Bypass grafting
Medical
Nitrates (if unsuitable for surgery)
Diagnosis
Examination
Cardio: signs of associated CVD
Abdo: may have abdo bruit, signs of malabsorption
PR: may have bloody stool
Investigations
Imaging
Erect CXR: exclude perf
AXR: often nil
CT/MRI angiography (
diagnostic)
Bloods
FBC, U+E, LFT, clotting, amylase,
glucose, troponins, G&S, crossmatch
Bedside
Obs (tachycardia, tachypnoea)
ECG (may show e.g. AF, prev MI)
History
PC/HPC: chronic complaint of acute onset colicky pain, worse after eating, associated weight loss, PR bleeds
PMH: Often other CVD/PVD
DH: meds, allergies
FH: CVD, bowel disease
SH: occupation, alcohol, smoking
Pathophysiology
Vascular disease (angina) of the bowel
Eating increases oxygen requirements
to bowel which cannot be met
Essentially mesenteric angina
Ischemic
colitis
Pathophysiology
Reduced flow in IMA, usally local atheroma
Mucosa and submucosa of large bowel (usually splenic flex)
Ischemia and necrosis
Clinical
presentation
Pain
Character
Colicky
Radiation
Nil
Onset
Acute
Associated symptoms
Nausea
Vomiting
Diarrhoea
PR bleeding
Site
LIF
Timing
Intermittent
Exacerbating/relieving factors
Severity
Blood diarrhoea
Nausea
Vomiting
Diagnosis
Examination
Cardio - tachycardic
Resp - tachypnoeic
Abdo - tender LIF
PR - bloody diarrhoea
Investigations
Bloods
FBC (anaemia), CRP, LFTs, U+Es,
group&save/crossmatch
Bedside
Obs (pyrexia, tachycardia, tachypnoea)
ECG (tachycardia)
Imaging
Erect CXR (perf)
AXR (thumbprinting - colonic oedema)
CT (ischemic colitis)
Colonoscopy (blue swollen mucosa, contact bleeding)
History
PC/HPC: acute onset colicky pain in LIF,
associated bloody diarrhoea, nausea, vomiting
PMH: CVD, known medical conditions
DH: meds, allergies
FH: CVD, bowel disease
SH: occupation, smoking, alcohol
Management
Initial (ABCDE)
Definitive
Medical
IV fluids
E.g. NaCl 0.9%
Analgesia
E.g. paracetamol, NSAIDs
Surgical
Resection
Indication: gangrenous colon
Conservative
Referral ASAP to GI surgeons
NBM (rest bowel, may need surgery)
Definition
Interrupted blood supply to part of the bowel,
leading to ischemia and possibly infarction