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Mesenteric IschemiaAka: Mesenteric Infarction, Mesenteric Artery Embolism, Mesenteric Artery Thrombosis, Mesenteric Venous Thrombosis, Colonic Ischemia, Intestinal Ischemia, Colonic Vasculitis

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  1. Pathophysiology
    1. Watershed blood supply areas most often affected
      1. Splenic flexure
      2. Rectosigmoid
  2. Epidemiology
    1. Uncommon condition (but requires high index suspicion)
      1. Accounts for 1% of Acute Abdominal Pain admits
    2. More common in elderly
    3. Males more commonly affected
  3. Causes: Primary Mesenteric Ischemia (intravascular)
    1. Superior Mesenteric artery embolism (30%)
      1. Cardiac thrombus source is most common
      2. Asoociated with other emboli (20%)
      3. Associated with underlying cardiovascular disease
        1. Cardiac Arrhythmia
        2. Myocardial Infarction
        3. Valvular Disease
    2. Superior Mesenteric artery thrombosis (10%)
      1. Associated conditions
        1. Malignancy
        2. Coagulation disorder
    3. Nonocclusive mesenteric ischemia (50%)
      1. More common in hospitalized patients
      2. Congestive Heart Failure
      3. Hypotension
      4. Hemorrhagic blood loss
      5. Sepsis
      6. Medications
        1. Pressor use
        2. Digitalis
    4. Mesenteric venous thrombosis (10%)
      1. May still eat despite pain
  4. Causes: Secondary mesenteric ischemia (compression)
    1. Adhesions
    2. Herniation
    3. Volvulus
    4. Intussusception
    5. Tumor
    6. Trauma
    7. Retroperitoneal fibrosis
  5. Symptoms
    1. Abdominal Pain
      1. Severe and out of proportion to exam
      2. Pain is poorly localized
      3. Left Lower Quadrant abdominal cramping may occur
    2. Gastroenteritis-type symptoms (one third of cases)
      1. Diarrhea
        1. Superior Mesenteric Artery Embolism
        2. Superior Mesenteric Artery Thrombosis
      2. Nausea and Vomiting
        1. Superior Mesenteric Artery Embolism
        2. Mesenteric Venous Thrombosis
  6. Signs
    1. General
      1. Abdominal tenderness to palpation
      2. Fever
      3. Fecal Occult Blood positive in 25% of cases
    2. Timing
      1. Sudden onset Abdominal Pain
        1. Superior Mesenteric Artery Embolism
        2. Mesenteric Venous Thrombosis
      2. Gradual onset Abdominal Pain
        1. Superior Mesenteric Artery Thrombosis
        2. Nonocclusive Mesenteric Ischemia (NOMI)
  7. Labs: Diagnosis
    1. Complete Blood Count (CBC)
      1. Leukocytosis >15,000 with Left Shift is common
    2. Serum Phosphate Level
      1. Increases within 4 hours (75%)
    3. Labs abnormal if bowel perforation occurs
      1. Arterial Blood Gas (ABG) with Metabolic Acidosis
      2. Serum Amylase increased
      3. Serum lactate increased
  8. Labs: Other
    1. Electrolytes (Chem7)
    2. Renal Function tests
      1. Blood Urea Nitrogen (BUN)
      2. Creatinine
    3. Liver Function Tests (LFT)
      1. AST increased
      2. Lactate Dehydrogenase (LDH)
      3. Creatine Phosphokinase (CK-MM) Increased
    4. ProTime
    5. Partial Thromboplastin Time (PTT)
    6. Fibrin Split Products (FSP)
    7. Fibrinogen
    8. Blood Culture
    9. Urinalysis
    10. Type and Cross
  9. Differential Diagnosis
    1. See Acute Abdominal Pain
    2. See Acute Abdominal Pain Causes
    3. See Abdominal Pain in Older Adults
  10. Radiology
    1. Abdominal XRay (KUB)
      1. Findings suggestive of Mesenteric Ischemia (20-60%)
        1. Adynamic Ileus
        2. Thumb printing of bowel wall
        3. Bowel wall thickening
        4. Air in bowel wall or portal vein
      2. Other conditions identified
        1. Small Bowel Obstruction
          1. Air-fluid levels
          2. Fixed dilated loops of bowel
        2. Volvulus
        3. Viscus perforation
    2. CT Abdomen
      1. Bowel wall thickening (edema, hemorrhage)
      2. Bowel wall gas
    3. Angiography (gold standard)
      1. Order with low threshold
      2. Rapid diagnosis is critical to survival
  11. Management
    1. Immediate Surgical Consultation
    2. Aggressive intravenous fluid hydration
    3. Adnminister Supplemental Oxygen
    4. Nasogastric suction (NG tube)
    5. Discontinue vasoconstricting medications
      1. Discontinue Pressors
      2. Discontinue Digitalis
      3. Discontinue Beta Blockers
    6. Stabilize concurrent cardiovascular disease
      1. Congestive Heart Failure
      2. Cardiac arrhythmia
    7. Antibiotics to cover gram-negative bacteria
  12. Prognosis
    1. Mortality: up to 85%
  13. References
    1. Birnbaumer (2001) CMEA Medicine Lecture, San Diego
    2. Harward (1989) J Vasc Surg 9(2):328
    3. Jamieson (1982) Br J Surg 69:S52
    4. Kairaluoma (1977) Am J Surg 133:188
    5. Wolk (1981) Int Surg 65(3):231

Gastrointestinal tract vascular insufficiency (C0156149)

ConceptsDisease or Syndrome (T047)
ICD9557, 557.9
EnglishBOWEL ISCHEMIA, Gastrointestinal tract vascular insufficiency, INTESTINAL ISCHAEMIA, Intestinal ischemia, Ischaemic bowel disease, Ischaemic disease of gut, ISCHEMIA BOWEL, ISCHEMIA INTEST, Ischemic Bowel Disease, Ischemic disease of gut, Unspecified vascular insufficiency of intestine, Vascular insuff.- intestine, Vascular insufficiency of intestine, Vascular insufficiency of the intestine
Spanishenfermedad isquemica del intestino, insuficiencia vascular del tracto gastrointestinal, insuficiencia vascular intestinal
Parent ConceptsGastrointestinal tract vascular insufficiency (C0156149), [X]Non-infective enteritis and colitis (C0178283), Non-Neoplastic Vascular Disorder (C1335053), Non-Neoplastic Intestinal Disorder (C1882107), Gastrointestinal Diseases (C0017178), Vascular disorder of intestine (C0400883), Duplicate concept (C1274013)
SourcesCST, ICD9CM, MTH, NCI, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Colitis, Ischemic (C0162529)

Definition (MSH)Inflammation of the COLON due to colonic ISCHEMIA resulting from alterations in systemic circulation or local vasculature.
ConceptsDisease or Syndrome (T047)
MSHD017091
EnglishColonic ischaemia, Colonic ischemia, Ischaemic colitis, Ischemic Colitis, Ischemic colitis as other diagnosis for the colon, Ischemic colitis as reason for lower g.i. examination
FrenchColite ischemique, Colite ischemique comme motif de realisation d'une coloscopie
ItalianColite ischemica, Colite ischemica come motivo di endoscopia del tratto digestivo inferiore
Spanishcolitis isquemica, isquemia colica, isquemia colonica
Parent ConceptsColitis (C0009319), Vascular Diseases (C0042373), Ischemia (C0022116), Gastrointestinal tract vascular insufficiency (C0156149)
SourcesCOSTAR, DXP, MSH, MTHMST, MTHMSTFRE, MTHMSTITA, NDFRT, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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