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Acute Mesenteric Ischemia and Infarction
Dr. Sajad Ali (MBBS., MS.) Gastrointestinal & Laparoscopic surgeon Dr Ahmed Abanamy Hospital
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A First Big Distinction…
Mesenteric Ischemia – ischemia of the small bowel, usually 2/2 an acute cause involving the SMA or SMV. Ischemic colitis – ischemia of the colon, rarely with a known acute precipitating cause.
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Superior Mesenteric Artery (SMA)
Largest caliber vessel + 45-degree angle makes it most commonly occluded Aorta Celiac Trunk SMA IMA
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Superior Mesenteric Artery (SMA)
Emboli occlude past the middle colic, causing small bowel ischemia Middle Colic SMA Jejunal & Ileal Arteries Occlusion Point Right Colic Ileocolic
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Etiologies of Acute Mesenteric Ischemia (AMI)
SMA Occlusion (at least 60% of cases) Embolism: MI, Afib, Endocarditis, Valve d/o Thrombosis: Atherosclerosis – plaque rupture Nonocclusive Mesenteric Ischemia (NOMI) Atherosclerosis + shock + vasopressors Mesenteric Venous Thrombosis (MVT) Primary clotting disorder
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Etiologies of Acute Mesenteric Ischemia (AMI)
Focal small bowel ischemia - rare Partial malrotation, volvulus, mesenteric hematoma, strangulated hernia Unknown ?Mesenteric small vessel disease
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History & 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
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History & Physical SMA Thrombosis:
Prodrome of postprandial pain/nausea and weight loss Presentation with classic symptoms Non-occlusive Mesenteric Ischemia: Unexplained decline in clinical status or failure to follow expected recovery
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History & Physical Mesenteric Venous Thrombosis: Fever
Abdominal distension Hemoccult positive stool
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Laboratory Findings Anion gap metabolic acidosis
Elevated arterial/venous lactate Leukocytosis Hemoconcentration Elevated LDH, amylase, AST, and CPK Elevated K and Phos are late signs
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Radiology Plain films – thumbprinting, thickened bowel (<40% sensitivity) CT – thickened/dilated bowel, intramural hematoma, pneumatosis (64% sensitivity) MRI – promising but untested to date Mesenteric angiography – test of choice; can identify the type of AMI
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Differential Diagnosis
Other serious conditions to consider: Pancreatitis Acute Diverticulitis Acute Cholecystitis Small bowel obstruction Perforation of a viscous Ruptured aneurysm
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Treatment Resuscitation with fluids/blood products Anticoagulation
Infusion of a vasodilator Glucagon systemically OR Papaverine through a catheter
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From Ischemia to Infarction
Marked by peritoneal signs, fever Emergent laporatomy Restoration of interrupted blood flow with arteriotomy or bypass graft Resection of infarcted bowel Second-look in hours Vasodilators and careful pressor use
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A Word on Ischemic Colitis
Presentation: less & more focal pain (usually left-sided), more bloody diarrhea, >90% are over 60 years old. Etiology rarely identified: ?small vessel disease +/- hypoperfusion Episodes usually self limited except when stricture or gangrene develops Colonoscopy is initial evaluation of choice
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