MESENTERIC MESENTERIC ISCHEMIA ISCHEMIA THE FORGOTTEN DIAGNOSIS THE FORGOTTEN DIAGNOSIS Richard M. Gore, MD Richard M. Gore, MD North Shore University Health System North Shore University Health System University of Chicago University of Chicago Evanston, Illinois Evanston, Illinois SCBT/MR 2010 SCBT/MR 2010 San Diego, California San Diego, California March 8, 2010 March 8, 2010 16:00 16:00 - - 16:10 16:10
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MESENTERIC ISCHEMIA - Scbtmr...acute mesenteric ischemia sma embolism (50%) nomi (20-30%) sma thrombosis (15-25%) smv thrombosis (5%) pathologic damage mdct findings vasodilation mural
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MESENTERICMESENTERICISCHEMIAISCHEMIA
THE FORGOTTEN DIAGNOSISTHE FORGOTTEN DIAGNOSIS
Richard M. Gore, MDRichard M. Gore, MDNorth Shore University Health SystemNorth Shore University Health System
University of ChicagoUniversity of ChicagoEvanston, IllinoisEvanston, Illinois
SCBT/MR 2010SCBT/MR 2010San Diego, CaliforniaSan Diego, California
March 8, 2010March 8, 201016:0016:00--16:1016:10
TYPE 1: WHITETYPE 1: WHITE
•• VASODILATION VASODILATION WITH HYPEREMIA WITH HYPEREMIA ACUTE IBDACUTE IBD
•• INJURY TO INTRAINJURY TO INTRA--MURAL VESSELS MURAL VESSELS CONTRAST LEAK: CONTRAST LEAK: SHOCK BOWEL, RESHOCK BOWEL, RE--PERFUSION AFTER PERFUSION AFTER ISCHEMIAISCHEMIA
•• HEMORRHAGEHEMORRHAGE
TYPE 1: WHITETYPE 1: WHITE
•• VASODILATION VASODILATION WITH HYPEREMIA WITH HYPEREMIA ACUTE IBDACUTE IBD
•• INJURY TO INTRAINJURY TO INTRA--MURAL VESSELS MURAL VESSELS CONTRAST LEAK: CONTRAST LEAK: SHOCK BOWEL, RESHOCK BOWEL, RE--PERFUSION AFTER PERFUSION AFTER ISCHEMIAISCHEMIA
•• HEMORRHAGEHEMORRHAGE
TYPE 1: WHITETYPE 1: WHITE
•• VASODILATION VASODILATION WITH HYPEREMIA WITH HYPEREMIA ACUTE IBDACUTE IBD
•• INJURY TO INTRAINJURY TO INTRA--MURAL VESSELS MURAL VESSELS CONTRAST LEAK: CONTRAST LEAK: SHOCK BOWEL, RESHOCK BOWEL, RE--PERFUSION AFTER PERFUSION AFTER ISCHEMIAISCHEMIA
•• HEMORRHAGEHEMORRHAGE
TYPE 1: WHITETYPE 1: WHITE
•• VASODILATION VASODILATION WITH HYPEREMIA WITH HYPEREMIA ACUTE IBDACUTE IBD
•• INJURY TO INTRAINJURY TO INTRA--MURAL VESSELS MURAL VESSELS CONTRAST LEAK: CONTRAST LEAK: SHOCK BOWEL, RESHOCK BOWEL, RE--PERFUSION AFTER PERFUSION AFTER ISCHEMIAISCHEMIA
•• Mesenteric ischemia is a complex, Mesenteric ischemia is a complex, multifaceted conditionmultifaceted condition
•• State of the systemic circulationState of the systemic circulation•• Degree of functional or anatomic vascular Degree of functional or anatomic vascular
compromisecompromise•• Number and caliber of vessels affectedNumber and caliber of vessels affected
MESENTERIC ISCHEMIAMESENTERIC ISCHEMIA
•• Response of the vascular bed to diminished Response of the vascular bed to diminished perfusionperfusion
•• Nature and capacity of the collateral Nature and capacity of the collateral circulationcirculation
•• Duration of the ischemic insultDuration of the ischemic insult•• Metabolic requirements of the involved Metabolic requirements of the involved
•• The wide caliber and The wide caliber and narrow take off angle of narrow take off angle of the SMA off the aorta the SMA off the aorta make it particularly make it particularly vulnerable to embolic vulnerable to embolic events.events.
•• The offending emboli The offending emboli usually originate from a left usually originate from a left atrial or ventricular mural atrial or ventricular mural thrombus or vegetations thrombus or vegetations on a heart valveon a heart valve
SMAESMAE
•• Nearly one half of Nearly one half of patients with SMAE patients with SMAE will have synchronous will have synchronous extramesenteric extramesenteric emboli including emboli including peripheral artery peripheral artery emboli and 20% have emboli and 20% have synchronous emboli synchronous emboli to the spleen, kidneys to the spleen, kidneys or other organsor other organs
SMAESMAE
•• Nearly one half of Nearly one half of patients with SMAE patients with SMAE will have synchronous will have synchronous extramesenteric extramesenteric emboli including emboli including peripheral artery peripheral artery emboli and 20% have emboli and 20% have synchronous emboli synchronous emboli to the spleen, kidneys to the spleen, kidneys or other organsor other organs
SAME: CLINICAL FEATURESSAME: CLINICAL FEATURES
•• Sudden onset of severe periumbilical or right Sudden onset of severe periumbilical or right umbilical fossa abdominal pain.umbilical fossa abdominal pain.
•• Severe pain is usually out of proportion to an often Severe pain is usually out of proportion to an often innocent physical examination which may reveal a innocent physical examination which may reveal a soft abdomen with some tenderness on palpation.soft abdomen with some tenderness on palpation.
•• Nausea, vomiting, or diarrhea may occur.Nausea, vomiting, or diarrhea may occur.•• Query patient about cardiac disease such as Query patient about cardiac disease such as
previous myocardial infarction, arrythmias, cardiac previous myocardial infarction, arrythmias, cardiac valve disease, and previous arterial and venous valve disease, and previous arterial and venous embolism. embolism.
•• PAIN OUT OF PROPORTION TO PHYSICAL PAIN OUT OF PROPORTION TO PHYSICAL EXAM, BLOODY DIARRHEA, NAUSEA, EXAM, BLOODY DIARRHEA, NAUSEA, VOMITINGVOMITING
•• ELDERLY: LEFT SIDED INVOLVEMENT DUE TO ELDERLY: LEFT SIDED INVOLVEMENT DUE TO HYPOVOLEMIAHYPOVOLEMIA
•• YOUNG: RIGHT SIDED INVOLVEMENT DUE TO YOUNG: RIGHT SIDED INVOLVEMENT DUE TO HEMORRHAGIC SHOCK OR TRAUMA HEMORRHAGIC SHOCK OR TRAUMA (POOR COLLATERAL BLOOD FLOW, INCON(POOR COLLATERAL BLOOD FLOW, INCON--SISTENT MARGINAL ARTERY OF RT COLON) SISTENT MARGINAL ARTERY OF RT COLON)