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ACUTE MESENTERIC
ISCHAEMIA
MAMIEK DWI PUTRO
DEPARTEMEN – SMF BEDAH
FK UNAIR -RSU Dr SUTOMO – SURABAYA
SURABAYA , 11 – 12 MARET 2017
INTRODUCTION
• Acute mesenteric ischaemia ( AMI ) is defined :
- As sudden acute arterial or venous occlusion or
- Drop in circulating pressure resulting in insufficient blood flow within the
mesenteric circulation
• Isolated colonic ischaemia , focal segmental ischaemia secondary to adhesions,
hernia or other form of extrinsic compression are excluded
• AMI account for about 1 : 1000 acute hospital admissions, in Sutomo hospital
only 2 cases in 1 year
Eur J Trauma Emerg Surg ( 2016 ) 42:253 – 270
Laporan mingguan jaga II Dep /SMF Bedah RSDS
ETIOLOGY
Four different aetiological of AMI :
o Arterial embolism mesenteric ischaemia ( EAMI )
o Arterial thrombosis mesenteric ischaemia ( TAMI )
o Venous thrombosis mesenteric ischaemia ( VAMI ) or
Mesenteric venous thrombosis ( MVT )
o Non – occlusive mesenteric ischaemia ( NOMI )
Eur J Trauma Emerg Surg ( 2016 ) 42:253 – 270World J Gastrointest pathophysiol 2016 February 15; 7 (1 ): 125 -130
….....ETIOLOGY
– 70 – 80 % cases of AMI are caused by an arterial emboli or
thrombosis ( EAMI, TAMI , VAMI ) within the ( superior ) mesenteric
artery
– NOMI for about 20 % , usually occurs in patients critically ill,
artificially ventilated, who have undergone the stress of a surgical
procedure , large doses of vasopressor
– AMI will caused mesenteric infarction , intestinal necrosis ,
perforation an overwhelming inflammatory response and death
World J gastroenterol 2013, March 7; 19 ( 9 ) : 1338- 1341
RISK FACTORS
* Eur J Trauma Emerg Surg ( 2016 ) 42:253 - 270
CLINICAL PRESENTATION
– AMI most typical symptom is abdominal pain that is disproportionate to physical examination
finding.
– The pain initially is visceral , diffused, non – localized and moderate to severe, constant
sometimes colicky and occasionally unresponsive to opioid analgesic.
– Examination finding early in the course of disease are limited and non- specific, including
minimal abdominal tenderness
– If ischaemia is attributed to arterial emboli , the pain is severe and abrupt; but if arterial
thrombosis more gradual progression.
– If the ischaemia has progressed transmurally, sign of peritonitis and septicemia are
encountered
– Bowel necrosis, septic shock and death are common complication
World J Gastrointest pathophysiol 2016 February 15; 7 (1 ): 125 -130
DIAGNOSTIC MODALITIES
▪ CLINICAL PRESENTATION :
AMI is rare condition in early stage, symptom and sign are non- specific
▪ LABORATORY FINDING ( are non specific ) :
- complete blood count (leucocytosis )
- metabolic acidosis is a common but non specific disorder
- an elevated D-Dimer, PPT,APTT when MVT occurs
- should be evaluated protein C and S, antithrombin III , anticardiopilin
antibody
- an elevated serum L- lactate
World J gastroenterol 2013, March 7; 19 ( 9 ) : 1338- 1341
Laboratory finding cannot be used as a marker for AMI because of their insufficient likelihood ratiosL – lactate is associated with late stage mesenteric ishaemiawith extensive transmural infarction,tissue –hypoperfusion,anaerobic metabolism
*World J gastroenterol 2013, March 7; 19 ( 9 ) : 1338- 1341
…....DIAGNOSTIC MODALITIES
▪ IMAGING TECHNIQUES :
- CT Scan , in order to exclude other causes with similar clinical
features,
- CT finding include intra mural ( penumatosis intestinalis), portal vein
gas, focal edematous bowel wall, mesentery edema, abnormal gas
pattern, arterial occlusion may present lack of enhancement of the vessel,
- In MVT ,CT scan demonstrate an enlargement mesenteric or portal vein
with sharp definition of the venous wall and low density within the vessel
World J Gastrointest pathophysiol 2016 February 15; 7 (1 ): 125 -130
…....DIAGNOSTIC MODALITIES
▪ IMAGING TECHNIQUES :….......
- Mesenteric angiography is the gold standard, accurate and increase
survival , however catheter angiography is invasive and time
consuming
- CT angiography (CTA ) less invasive and less time consuming, to day
CTA may be replaced angiography as the gold standard with
sensitivity specificity of 96 % and 94 % respectively
World J gastroenterol 2013, March 7; 19 ( 9 ) : 1338- 1341
CT SCAN AND CT ANGIOGRAPHY
a. Partially occluding thrombus in the Superior mesenteric vein
b. Normal Mesenteric vein
BA
…...DIAGNOSTIC MODALITY
▪ NEW DIAGNOSTIC STRATEGIES :
❖ RADIOLOGICAL EXAMINATION
- Contrast – enhanced magnetic resonance angiography (CE-MRA), it
is non – invasive and avoids the nephrotoxicity
- A sensitivity and specificity 95 % and 100 % respectively I clinical
trial designed to diagnose severe stenosis or occlusion of the origin
of the celiac axes and superior mesenteric artery
- Non- contrast – enhanced 7 tesla magnetic resonace imaging
( 7T – MRI )allow for the identification of pathological finding of
ischemic colitis and histopathological correlation
- Further research is needed
World J gastroenterol 2013, March 7; 19 ( 9 ) : 1338- 1341
NEW DIAGNOSTIC STRATEGIES…..
❖ BIOCHEMICAL MARKER :
- In AMI, ischaemia starts at the mucosa and extends toward the
serosa. An ideal biomarker for AMI should originate at the mucosa to
detect ischaemia at the earliest stage
- The biochemical marker are :
• I-FABP : intestinal fatty acid binding protein
• Alpha - GST : alpha – glutathione S transferase
• D- Lactate
World J gastroenterol 2013, March 7; 19 ( 9 ) : 1338- 1341
INTESTINAL FATTY ACID BINDING PROTEIN
( I-FABP )
– It is small cytosolic protein found in tissue involved in uptake and consumption
of fatty acid
– It is highly expressed in cell on the luminal side of small intestinal villi
– I-FABP released in to circulation and renally cleared upon enterocyte membrane
integrity loss and has been reported as specific ( 90% ) and sensitive marker (
89 % ) for intestinal necrosis
– These findings suggest that further research is needed to confirm the
diagnostic value of I-FABP in case of mesenteric ischemia
World J gastroenterol 2013, March 7; 19 ( 9 ) : 1338- 1341
ALPHA GLUTATHIONE S TRANSFERASE
( ALPHA – GST )
– A family of cytosolic enzyme in detoxification and release from variety of cell
following cell membrane damage
– It is known to be highly active both in liver and the small intestine mucosa
– It has pooled sensitivity and specificity for diagnosing AMI of 68% and 85 %,
respectively
– A Limitation of alpha – GST is hypotensive patients with multiple organ failure
and hepatic ischaemia may also elevated alpha - GST
World J gastroenterol 2013, March 7; 19 ( 9 ) : 1338- 1341
D- LACTATE
– Which originated from bacteria such as Escherichia coli in the intestinal lumen
– Hypothesized that D- Lactate level increase during mesenteric ischaemia due to
bacterial translocation and over growth following mucosal injury
– A recent review showed sensitivity and sensitivity for D-Lactate only 0.82 and
0.48 , respectively
– D- Lactate cannot be used a marker for AMI
World J Gastrointest pathophysiol 2016 February 15; 7 (1 ): 125 -130
THERAPEUTIC APPROACH
– AMI high mortality rate indicate the importance of urgent medical treatment
– Intra venous fluid administration ,maintenance of hemodynamic stability and adequate oxygen saturation as well as correction of any electrolyte imbalance and acid / base abnormality
– Vasopressor should be avoided
– Blood product can be provided
– Administration of broad spectrum antibiotic start early
– Nasogastric tube decompression and bladder catheterization
– Pain control is mainly accomplished with opioids
World J Gastrointest pathophysiol 2016 February 15; 7 (1 ): 125 -130
…...THERAPEUTIC APPROACH
NOMI ( non- occlusive acute mesenteric ischaemia ) :
– infusion papaverine through angiography catheter
– Subsequent continuous administration of 30 – 60 mg / h after angiography with
appropriate dose adjustment in accordance with clinical response for at least 24 h
– Caution should be taken , hypotension may occur
– VEGF has been recently thoroughly proposed as a future potential therapeutic
approach
World J Gastrointest pathophysiol 2016 February 15; 7 (1 ): 125 -130
…....THERAPEUTIC APPROACH
EMBOLI – THROMBI
• Infusion of thrombolytic agents ( alteplase, tenecteplase, reteplase) within 8 h
of symptoms onset is recommended for selected patients
• Absolut contraindication for intense thrombolysis are the presence of
peritonitis sign or bowel necrosis
• More over , iv administration of anticoagulants to prevent further extension of
thrombus
• Conversion to oral warfarin with suitable dose adjustment is always indicated
for at least 6 mo
World J Gastrointest pathophysiol 2016 February 15; 7 (1 ): 125 -130
….....THERAPEUTIC APPROACH
MULTIDISCIPLINARY SURGICAL MANAGEMENT
• Surgical treatment of AMI with sign of peritonitis is exploratory laparotomy with
meticulous assessment of bowel viability
• Resection of infarcted intestine is strongly indicated, but for anastomosis
remain controversial
• In addition , intra operative doppler US, iv infusion of fluorescein and bowel
under lamp illumination can differentiate poorly perfused bowel
• A second look operation is strongly suggested
World J Gastrointest pathophysiol 2016 February 15; 7 (1 ): 125 -130
…...THERAPEUTIC APPROACH
• More specific :
o In case of embolic AMI an attempt of reperfusion remains of vital
importance . Embolectomy by tranverse arteriotomy proximal to
occlusion, and then by using Fogarty catheter to extract the clot
o In case of thrombotic occlusion with absence of gangrenous
bowel, revascularization is attempted by aorto - mesenteric
bypass or trans aortic - endarterectomy
World J Gastrointest pathophysiol 2016 February 15; 7 (1 ): 125 -130
ILUSTRASI KASUS
– Wanita 46 th dengan keluhan 1 minggu tidak dapat b.a.b , perut
terasa sebah, dan badan panas
– Riwayat penyakit dulu sirosis hepatis, hipertensi portal dan
splenomegali
– Pemeriksaan fisik abdomen distensi, nyeri tekan kwuadran kanan –
kiri bawah tidak teraba tumor , bising usus tidak terdengar.
– Colok dubur mukosa licin, tidak teraba tumor , tidak nyeri, tidak
terdapat feses , cairan coklat gelap ( pada sarung tangan )
…..ilustrasi kasus
– Periksaan laboratorium :
- Leukosit 24.680
- Hb 7,9 g%
- PLT 303.000
- SGOT 32 u/l dan SGPT 14,3 u/l
- S.Creat 1,08 mg / dl dan BUN 11,0 mg/dl
- Albumin 4g/dl , Glob 2,6 g/dl
- Faal hemostasis dalam batas normal
…..Ilustrasi kasus
USG abdomen
– Hepar normal
– Spleen S III
– Distensi usus kecil
– Ascites
With courtesy prof Soetamto
…...ilustrasi kasus
Foto polos abdomen
– Distensi usus
– Tak tampak gambaran colon
Colon in loop
– Gambaran colon normal
With courtesy prof Soetamto With courtesy prof Soetamto
• Dilakukan punksi ascites : cairan ascites hemorrhagis , analisa sitologis cairan
ascites tidak tampak sel ganas
• Hari ke 5 perawatan perut tambah tegang , tekanan intra abdominal 28 cm H2O
• Diputuskan untuk Explorasi – Laparotomi, didapatkan
- nekrosis ileum sepanjang 15 cm, terletak 100 cm dari ICJ
- thrombosis vena mesenterica superior, cairan ascites >>
- tidak ada perlekatan, jeratan, volvulus, maupun hernia interna
- hepar fibrosis, lien S IV
- dilakukan reseksi usus , reanastomose – stapler
• Direncanakan re-laparotomi on demand
With courtesy prof Soetamto
Ileum nekrosis sepanjang 15 cmThrombosis v. mesenterica
With courtesy prof Soetamto
With courtesy prof SoetamtoReseksi ileum 20 cmRe- anastomose dengan linier staplerRe- laparotomy on demand
With courtesy prof Soetamto
…...ilustrasi kasus
– 4 hari paska laparotomi , perawatan dalam ICU , cairan dari NGT
ke-merahan, abdomen distensi, tekanan intra abdominal 35 cm
H2O
– Diputuskan untuk Re- open ( Re – Laparotomy )
– Didapatkan :
-nekrosis ileum meluas sampai 150 cm distal lig.Trietz
-thrombosis v.mesenterica dan ascites >> kemerahan
• Dilakukan : -Re – reseksi ileum lebih kurang 100 cm
-Ileostomi
-Bogota – bag ( planned re- laparotomy )
…...ilustrasi kasus
– Hari ke tujuh paska operasi kedua , fungsi ileostomi baik,
penderita minum tabl warfarin ( simarc )
– Dilakukan pengangkatan Bogota – bag , tutup primer luka
laparotomi
– Hasil pemeriksaan histo –PA : nekrosis usus , throbomsis
pembuluh darah vena
– Hari ke sebelas paska tutup luka laparotomi , defekasi melalui
ilestomi lancar, konsistensi faeses mulai padat
– Penderita pulang
With courtesy prof Soetamto With courtesy prof Soetamto
Re – open : - ileum nekrosis lebih kurang 100 cm- re - reseksi ileum yang nekrosis- ileostomi
Hari kesebelas paska tutup laparotomiLuka operasi tidak tampak infeksidanileostomi berfungsi baik, penderita pulang
CONCLUSION
➢ AMI is rare condition with non- specific clinical presentation
➢ AMI is often diagnosed late or even missed due to low clinical
suspicion , therefore a high mortality rate results
➢ By a marker to identify patients with AMI early would be of great
importance in selecting can candidat for CT angiography
➢ Biochemical marker such as I- FABP and GST still in research
➢ Multidisciplinary team are needed for therapeutic approach
TERIMA KASIH
ATAS
PERHATIANNYA
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