Mesenteric Ischemia: quick review

22 Sep

What is it?

A reduction in intestinal blood flow, due to

arterial occlusion, usually SMA (85-95%)

nonocclusive ischemia/hypoperfusion, usually related to low cardiac output (20-30%)

-venous occlusion, usually SMV (5%)

 

 

What are the risk factors?

Advanced age, atherosclerosis, low cardiac output states, cardiac arrhythmias, cardiac valvular disease, recent MI, and intra-abdominal malignancy

 

In younger patients, mesenteric venous thrombosis is the major cause of ischemia

 

 

How does it present?

Rapid onset of severe periumbilical abdominal pain out of proportion to physical exam findings, +/- associated nausea and vomiting

 

Be cautious of a more insidious presentation for venous thrombosis; pain may be present for several days to weeks

 

 

How is it diagnosed?

Mostly clinical suspicion

 

A personal history of previous embolism is present in 1/3 of patients with acute embolic mesenteric ischemia; a personal or family history of DVT or PE is present in ½ of patients with acute mesenteric venous thrombosis

 

Lactate is 100% sensitive, 42% specific for intestinal ischemia/infarction

 

CT angiography (CTA) should be done without oral contrast (to avoid obscuring mesenteric vessels) shows findings of acute ischemia:

-bowel wall thickening

-intestinal pneumatosis with portal venous gas

-bowel dilation

-mesenteric stranding

-portomesenteric thrombosis

-solid organ infarction

 

What is the treatment?

Systemic anticoagulation +/- surgery (embolectomy, thrombectomy, bowel resection)

 

Anticoagulation alone may be reasonable in patients with good collateral blood flow

 

Consider hypercoaguable workup for venous thrombosis.

 

 

Submitted by K Estes.

 

Source: uptodate.com; picture

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