MESENTERIC ISCHEMIA.pdf as a surgical point

ISCHEMIA.pdf as a surgical point

1. MESENTERIC ISCHEMIA
Mohammed S. (GSR4)

2. Outline
•Case
•Introduction
•Anatomy
•Classification
•Diagnosis
•Management
•Summary
•References
2

3. Case
•A 35 yr old known cardiac patient ( CRVHD( Severe
MS)) on monthly B.Penicilline on her 2nd post op
year after Lt MRM and completed 6 cycle of
chemotherapy 11 month back .
•Was presented with crampy abdominal pain of 5
day duration ass. with abdominal distension,
vomiting of ingested matter which later become
bilious and failure to pass feces & flatus of 3 days
duration.
•Has low grade intermittent fever
•No previous abdominal surgery

4. P/E
✔ASL
✔PR= 105 regular BP= 70/40 RR=24. Spo2= 97 % atm
✔Pink conj
✔Dry tongue & buccal mucosa
✔Decreased air entery over lower ⅓ bilaterally
✔CVS- Holosystolic murmur over LLSB.
✔Abdomen- distended and moves with respiration
✔Hypoactive bowel sound
✔tenderness all over the abdomen
✔Hyper tympanic to percussion
✔DRE-Empty rectum, no palpable mass, no blood on examining finger
✔GUS- Catheter insitu UOP 30 ml/12 hr( 0.045ml/kg/hr
✔Mss- no Edema, cold extremities

5. Investigations
CBC- WBC= 12.59K N= 88%
Hgb= 10.9 Plt=141k
RFT- Cr= 6.3 BUN =87
• Baseline Cr=1.3 ( 2 weeks back)
Serum e- = Na=131 K=4.91
Cl=99.3

6. •Ass’t = Generalised peritonitis 2° SBO 2° ? + AKI 2° Pre renal
azetomia/ ATN + CRVHD( severe MS) + Septic shock of GI
focus
Rx
•-NGT inserted - upon insertion there was around 300 ml
foul smelling output
•- adrenaline 0.05 mic/kg/min started (10 drop/min)
•- vancomycine ( renal adjusted dose )
•- meropenium ( renal adjusted dose)
•- X- match sent

7. Procedure
•After written and informed consent obtained
•IOF- around 250 ml foul smelling thin pus over general
peritoneum
–Whole small bowel ( from ligament of teritz to ileocecal
valve), transverse colon, cecum & mesentery is gangrenous

•Done - pus sucked out , after count declared correct
abdomen closed in layer

8. Post operatively
Transferred to CICU intubated
Double pressors??????
Fentanyl 50 mic gm IV Q4hr
Ketamine 50 mg /hr ( 1 mg/kg/hr)

9. 1
st
POD
P1-1st POD after exp lap for mesenteric ischemia
P2-Septic shock of GI focus with MOF (cardiac, resiriratory,
renal)
P3-known CRVHD (sever MS, mild TR, mild PHTN)

on-MF
-double pressor
-fentanyl and ketamine
- omeprazole 40 mg iv BID

10. A- protected by ETT
B-on MV AC-VCV TV-360 ml PEEP-5 Fio2 100% RR 48
SaO2=70-75%
-decreased air entry over bilateral lower chest
C- BP-70-90/40-60 PR -110-130
- holosystolic murmur over LLSB
abd -slightly distended
GCS- 2T
Input =3000ml output =50ml balance =2950ml

Arrested at 10pm

11. Introduction
•A syndrome caused by inadequate blood flow via
mesenteric vessels?????? ischemia and gangrene

•Rare but potentially life threatening; MR-50-80%

•Injury severity is inversely proportional to the
mesenteric blood flow

•SMA more frequently involved

12. Anatomy and pathophysiology
•Comprises of 3 major aortic branches with
collaterals
–Celiac artery
– Superior mesenteric artery
– Inferior mesenteric artery
12

13. Collaterals

14. Pathophysiology
•Damage may range from reversible ischemia to transmural
infarction

•Mucosal sloughing within 3 hours of onset and full-thickness
intestinal infarction by 6 hours.

•Arterial insufficiency causes tissue hypoxia, leading to initial
bowel wall spasm…Gut emptying by vomiting/diarrhea

•Mucosal sloughing may cause GI bleeding

•Mucosal barrier becomes disrupted, and bacteria, toxins and
vasoactive substances are released into the systemic circulation

15. Classification
•Acute vs chronic

16. Causes of AMI
Non-occlusiveOcclusive
VenousArterial
AMATAMAE
MVT
NOMI
NB: A secondary clinical entity of AMI occurs as a consequence of mechanical
obstruction

17. AMAE
•Most common cause

•The embolic source is
usually in the heart

•Embolism to the SMA
accounts for 50% of cases;

AMAT
•Tend to occur in the
proximal mesenteric
arteries, near their origins.

•Preexisting atherosclerotic
lesions at these sites.

18. NOMI
•Vasospasm

•Usually diagnosed in
critically ill patients

MVT
•Mesenteric venous
thrombosis accounts for 5%
to 15% of cases

•Involves the SMV in 95% of
cases.

•Primary vs secondary

19. Chronic mesenteric ischemia
•Develops insidiously, allowing for development of collateral circulation,
and, therefore, rarely leads to intestinal infarction.

•Chronic mesenteric arterial ischemia results from atherosclerotic lesions
in the main splanchnic arteries (celiac, superior mesenteric, and inferior
mesenteric arteries).

•In most patients with symptoms attributable to chronic mesenteric
ischemia, at least two of these arteries are either occluded or severely
stenosed.

•A chronic form of mesenteric venous thrombosis can involve the portal or
splenic veins and may lead to portal hypertension, with resulting
esophagogastric varices, splenomegaly, and hypersplenism.

•Postprandial abdominal pain is the most prevalent symptom, producing a
characteristic aversion to food (“food fear”) and weight loss.

20. •Most patients with chronic mesenteric venous
thrombosis are asymptomatic because of the
presence of extensive collateral venous
drainage routes; this condition is usually
discovered as an incidental finding on imaging
studies.
•However, some patients with chronic
mesenteric venous thrombosis present with
bleeding from esophagogastric varices

21. S/Sx
•Non specific initially before evidence of
peritonitis?????? Dx and Rx delayed

22. •Severe abdominal pain, out of proportion to the
degree of tenderness on examination is the hallmark
of acute mesenteric ischemia
•The pain is typically perceived to be colicky and most
severe in the midabdomen.
•Associated symptoms
•Physical findings are characteristically absent early in
the course of ischemia. With the onset of bowel
infarction, abdominal distension, peritonitis, and
passage of bloody stools occur.

23. Diagnosis
•Doppler U/S
•MDCT… gold standard
•MRI
•X-ray
•Laparoscopy?

24. Is there a role for vasopressor drugs?

25. Management
•Medical vs surgical
•Resuscitation
•Supplementary oxygen
•Broadspectrum antibiotic cover should be given
•Statins
•Anticoagulation
•Various thrombolytic medications
•Vasodilators
•Surgical approaches?????? embolectomy
(endovascular/open) endarterectomy, ballon
dilatation, stenting and bypass

26. Summary
•B/c of the high mortality and difficulty of Dx,
mesenteric ischemia poses a substantial legal
risk--- high degree of clinical suspicion, early
and aggressive diagnostic imaging and early
surgical consultation with clear
documentation of timing
•Early Dx and Rx?????? improve outcome

27. References
•Schwartz's surgery 11th edition
•AMI: guidelines of the world society of emergency
surgery
•The European Society for Trauma and Emergency
Surgery (ESTES) Study Group 2013 guidelines for the
management of AMI.
•Mesenteric ischemia: Pathogenesis and challenging
diagnostic and therapeutic modalities
•Medscape

28. Thank U