Acute Mesenteric Acute Mesenteric Ischemia: Ischemia: Diagnostic approach and management Diagnostic approach and management Dr. Law Siu King Dr. Law Siu King Department of Department of surgery surgery United Christian United Christian Hospital Hospital www.surgical- tutor.org.uk
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Acute Mesenteric Ischemia: Diagnostic approach and management Dr. Law Siu King Department of surgery United Christian Hospital .
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It is a syndrome It is a syndrome in which inadequate blood flow through in which inadequate blood flow through
the mesenteric circulation causes the mesenteric circulation causes ischemia and eventual gangrene of the ischemia and eventual gangrene of the bowel wall. bowel wall.
It can be classified It can be classified according to its according to its etiologyetiology SMA embolismSMA embolism SMA thrombosisSMA thrombosis Non-occlusive Non-occlusive
Oldenburg et al Arch Intern Med 2004;164:1054-1062
PresentationPresentation
Classical description of early Classical description of early symptomsymptom Abdominal pain that is out of proportion Abdominal pain that is out of proportion
to physical findingsto physical findings However, classic presentation may absence However, classic presentation may absence
in 20-25% of cases.in 20-25% of cases.
Kazmers et al Ann Vas surg 12:187-197,1998
PresentationPresentation
EarlyEarly Prominent Prominent
symptoms of GI symptoms of GI emptying ( nausea, emptying ( nausea, vomiting , vomiting , diarrhea )diarrhea )
Patient presents with severe abdominal pain consistent with ischemic bowel
Obtain history and perform physical examination.Pain is out of proportion to physical findings is a significant clue.
Look for risk factors for acute mesenteric ischemia.
InvestigationInvestigation
Blood test:Blood test: Most common Most common
laboratory laboratory abnormalities are:abnormalities are: haemoconcentrationhaemoconcentration LeucocytosisLeucocytosis Metabolic acidosisMetabolic acidosis Lactic acidosis (in more Lactic acidosis (in more
advanced case)advanced case) Other serum markersOther serum markers
Raised Raised amylaseamylase ALPALP
Imaging:Imaging: AXR:AXR: Features suggestive Features suggestive
High sensitivity and High sensitivity and specificityspecificity
Therapeutic role for Therapeutic role for infusion therapyinfusion therapy
Disadvantage:Disadvantage: InvasiveInvasive Less easily availableLess easily available second-line study in second-line study in
patients with a strong patients with a strong suspicion of MVT suspicion of MVT
Increase use of CTA in diagnosis of acute mesenteric ischemia
Bradbury et al The British Journal of surgery 82(11): 1446-1459,1995
Patient presents with severe abdominal pain consistent with ischemic bowel
Obtain history and perform physical examination.Pain is out of proportion to physical findings is a significant clue.Look for risk factors for acute mesenteric ischemia.Order investigative studies:Laboratory tests: WBC count, lactate, ASTImaging: abdominal X-ray, duplex ultrasonography, CTA, MRA
Acute mesenteric ischemiaPeritoneal sign is present Peritoneal sign is absence
Principles of Principles of managementmanagement
Early recognition and interventionEarly recognition and intervention Fluid resuscitation and correction of Fluid resuscitation and correction of
for decompression of bowelfor decompression of bowel Broad spectrum antibiotics Broad spectrum antibiotics
to cover bacterial translocationto cover bacterial translocation Hemodynamic status monitoring( Foley Hemodynamic status monitoring( Foley
catheter, CVP, A line )catheter, CVP, A line ) Definitive Tx depends on its etiologyDefinitive Tx depends on its etiology
Surgical explorationSurgical exploration
Surgical exploration if evidence of Surgical exploration if evidence of intestinal infarction/ with intestinal infarction/ with peritonitisperitonitis.. Allow assessment of Allow assessment of bowel viabilitybowel viability Identify underlying Identify underlying causes of diseasecauses of disease Resection necrotic bowelResection necrotic bowel Perform Perform revascularizationrevascularization if appropriate if appropriate
SMA thrombosisSMA thrombosis Mesenteric bypass Mesenteric bypass 11
retrograde (from retrograde (from iliac artery or iliac artery or infrarenal aorta to infrarenal aorta to SMA) SMA)
antegrade ( from antegrade ( from supraceliac aorta to supraceliac aorta to SMA) SMA)
Reimplantation of Reimplantation of SMA to aortaSMA to aorta22
1.Kazmers et al Ann Vasc Surg 1998;12:187-1972.Kieny R et al Ann Vasc Surg 1990;8(4):495-500
How can we assess bowel How can we assess bowel viability ?viability ?
Direct inspectionDirect inspection Visible & palpable pulsations in mesenteric arcade, Normal colour and appearances of the bowel serosa, Peristalsis Bleeding from cut surfaces Sensitivity of 82%, specificity of 91%
IV fluorescein Administer IV sodium fluorescein (1g) and inspect bowel
under ultraviolet (Wood’s) lamp. Viable bowel has smooth, uniform fluorescence
Doppler Assessment of antimesenteric intestinal arterial flow
Kazmers et al Ann Vas Surg 12:187-197,1998
IV fluorescein Administer IV sodium fluorescein (1g) and
inspect bowel under ultraviolet (Wood’s) lamp. Viable bowel has smooth, uniform
fluorescence Doppler
Assessment of antimesenteric intestinal arterial flow
Who should have second Who should have second look laparotomy? look laparotomy?
Some surgeons Some surgeons advocate advocate routine routine second-look second-look laparotomylaparotomy at 24- at 24-48hr48hr Claimed reduced Claimed reduced
mortality ratemortality rate
Other adopt a Other adopt a selective approachselective approach and perform a and perform a second laparotomy second laparotomy when patient when patient deterioates deterioates clinically.clinically. Can avoid Can avoid
unnecessary second unnecessary second operation if patient operation if patient remains wellremains well
Bradbury et al The British Journal of Surgery Vol 82(11), November 1995
Endovascular Techniques in Endovascular Techniques in Acute arterial mesenteric Acute arterial mesenteric
StentingStenting of visceral of visceral arteries in acute arteries in acute mesenteric ischemiamesenteric ischemia33
Hybrid approach to SMAHybrid approach to SMA stenting for SMA stenting for SMA thrombosisthrombosis44
Combination of open Combination of open exploration +endovascular exploration +endovascular approach with retrograde approach with retrograde open mesenteric stentopen mesenteric stent
1.Acosta et al, Cardiovasc Intervent Radiol 32:895-905,20092.Schoots et al, J Vasc Interv Radiol 16:317-329,20053.Gartenschlaeger. Cardiovasc Intervent Radiol 31:398-400,20084.Wyers et al, J Vasc Surg 45:269-275,2007
Case series have been shown that endovascular approaches were feasible
Management of Mesenteric Management of Mesenteric venous thrombosisvenous thrombosis
Anticoagulation Anticoagulation is mainstay of is mainstay of treatmenttreatment
Workup for hypercoagulability .Workup for hypercoagulability . Laparotomy if peritoneal signs Laparotomy if peritoneal signs
develop. develop. Resection of necrotic bowelResection of necrotic bowel Thrombectomy ( few case reports only ) Thrombectomy ( few case reports only )
1.Bradbury et al The British Journal of Surgery Vol 82(11), November 1995
Management of non-Management of non-occlusive mesenteric occlusive mesenteric