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Mesenteric Ischemia

Aka: Mesenteric Ischemia, Mesenteric Infarction, Mesenteric Artery Embolism, Mesenteric Artery Thrombosis, Mesenteric Venous Thrombosis, Colonic Ischemia, Intestinal Ischemia, Colonic Vasculitis
  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): 328-32
    3. Jamieson (1982) Br J Surg 69:S52
    4. Kairaluoma (1977) Am J Surg 133:188
    5. Wolk (1981) Int Surg 65(3):231

Colitis, Ischemic (C0162529)

Definition (MSH) Inflammation of the COLON due to colonic ISCHEMIA resulting from alterations in systemic circulation or local vasculature.
Concepts Disease or Syndrome (T047)
MSH D017091
ICD10 K55.9
SnomedCT 30588004
English Ischemic Colitis, Colitis, Ischemic, ISCHEMIC COLITIS, Ischemic colitis, NOS, Ischaemic colitis, NOS, ischemic colitis (diagnosis), ischemic colitis, Colitis ischaemic, Colitis ischemic, Colitis, Ischemic [Disease/Finding], colities ischemic, colitis ischaemic, colitis ischemic, colonic ischemia, Ischemic colitis as other diagnosis for the colon, Ischemic colitis as reason for lower g.i. examination, Ischemic colitis, Colonic ischaemia, Colonic ischemia, Ischaemic colitis, Ischemic colitis (disorder), colitis; ischemic, ischemic; colitis, Colitis;ischaemic, Colitis;ischemic, ischaemic colitis
German ischaemische Kolitis, Kolitis ischaemisch, Colitis ischaemica, Dickdarmentzündung, ischämische, Ischämische Kolitis, Kolitis, ischämische
Swedish Kolit, ischemisk
Japanese ｷｮｹﾂｾｲﾀﾞｲﾁｮｳｴﾝ, 虚血性大腸炎, 大腸炎-虚血性, 乏血性大腸炎
Czech kolitida ischemická, Ischemická kolitida
Finnish Iskeeminen koliitti
Russian ISHEMICHESKII KOLIT, KOLIT ISHEMICHESKII, ИШЕМИЧЕСКИЙ КОЛИТ, КОЛИТ ИШЕМИЧЕСКИЙ
Polish Zapalenie okrężnicy niedokrwienne
Hungarian Vastagbélgyulladás ischaemiás, Ischaemiás colitis, Ischaemiás vastagbélgyulladás
French Colite ischemique, Colite ischemique comme motif de realisation d'une coloscopie, Colite ischémique
Italian Colite ischemica come motivo di endoscopia del tratto digestivo inferiore, Colite ischemica
Dutch colitis; ischemisch, ischemie; colitis, ischemische colitis, Colitis, ischemische, Ischemische colitis
Spanish colitis isquémica (trastorno), colitis isquémica, isquemia colónica, isquemia cólica, Colitis isquémica, Colitis Isquémica, Colitis Isquemica
Portuguese Colite isquémica, Colite Isquêmica
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Gastrointestinal tract vascular insufficiency (C0156149)

Concepts Disease or Syndrome (T047)
SnomedCT 266521006, 155768005, 312607004
English GIT vascular insuffic. NOS, Gastrointestinal tract vascular insufficiency, GIT vascular insuffic. NOS (disorder), GI tract vasculr insufficiency, GIT vascular insufficiency NOS, Gastrointestinal tract vascular insufficiency NOS (disorder), Gastrointestinal tract vascular insufficiency NOS, intestinal ischaemia, intestinal ischemia, ischemia bowel, ischemia intestinal, insufficiency intestine vascular, bowel ischaemia, ischemic bowel disease, bowel ischemia, Gastrointestinal tract vascular insufficiency (disorder)
Spanish GIT vascular insuffic. NOS, insuficiencia vascular del tracto gastrointestinal (trastorno), insuficiencia vascular del tracto gastrointestinal, SAI (trastorno), insuficiencia vascular del tracto gastrointestinal, SAI, insuficiencia vascular del tracto gastrointestinal
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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