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Scott Q. Nguyen, M.D. Celia M. Divino, M.D. Mount Sinai School of Medicine Department of Surgery
Mrs. Mitty
An 83 year-old woman is brought to the ER by ambulance from her nursing home w/ a 4 hour history of severe diffuse abdominal pain and distention.
History
What other points of the history do you want to know?
Pertinent PMH, ROS, MEDS. Associated signs and symptoms Relevant family hx.
Associated signs/symptoms:
She vomits 1L of feculent emesis on arrival to ER. Last BM 2 hours ago, loose
Other History
PMH Atrial Fibrillation - dxd 1 month ago, anticoagulation contraindicated with history of massive GI bleed CHF, CAD, DM PSH Cholecystectomy, left hemicolectomy for diverticular disease MEDS digoxin, metoprolol, insulin
Other History
Social History
Occasional wine, 50 pack-yr smoker, quit 2 yrs ago
Family History
Patient unable to give
Differential Diagnosis
Based on History and Presentation
Small Bowel Obstruction Acute Mesenteric Ischemia Perforated Diverticulitis Ischemic Colitis
Perforated Peptic Ulcer Disease Acute Pancreatitis Acute Cholecystitis Gastroenteritis Acute Appendicitis
Physical Examination
Vital Signs: T = 38.5, P = 103, BP = 140/85, RR = 28 Appearance: thin , in severe distress, legs pulled up to chest,
moaning
Heart: irregularly irregular Lungs: mild rales at bases Abdomen: decreased BS, very distended, mildly tender
diffusely, no guarding/rebound tenderness, no hernias
Laboratory
What would you obtain?
133
4.9
101
19
30
1.2
240
LFTs - WNL Amylase/Lipase - 89/95 PT/PTT - 13.0/33.0 ABG - 7.31/30/69/16 Lactate 7.9
Studies
Studies Results
Plain abdominal films
Diffuse dilation of small bowel w/ air fluid levels on upright view. Some air in Left colon and Rectum. NO free air
1) Acute Mesenteric Ischemia 2) Strangulated small bowel obstruction 3) Diverticulitis w/ contained perforation?
What next?
What next?
Mesenteric Angiogram or CT Angiogram
Discussion
With the sudden onset of symptoms, h/o Afib, and pain out of proportion to physical exam, acute mesenteric ischemia should be high on the Differential Diagnosis A mesenteric angiogram will allow visualization of the visceral vessels (celiac, SMA, IMA)
Mesenteric Angiogram
Note complete lack of contrast in mesenteric vessels in AP view (left). The occluded origins of the celiac axis and superior mesenteric artery are demonstrated in the Lateral view (right).
CT Angiogram
Note complete occlusion and lack of IV contrast filling the superior mesenteric artery from its origin from the aorta (Arrows).
Other studies
CT angiogram / MR angiogram
sensitivity 75%, specificity 100% for emboli additionally can detect thickened, distended
Management
Management
Pre-operative preparation Assure adequate resuscitation Monitoring Foley Catheter Urgent exploration Surgical embolectomy Assess bowel viability
Management
Pre-operative preparation
Surgical Embolectomy
Pack bowel to Right, Expose SMA Arteriotomy Pass balloon embolectomy catheter
Discussion
Acute mesenteric ischemia is a vascular emergency with overall mortality 60-80%. There are four main pathophysiologic processes which have the same common endpoint, bowel necrosis, abdominal sepsis, and death. Mesenteric arterial anatomy is notable for rich collateral flow between the celiac trunk, superior mesenteric artery, and inferior mesenteric artery. Gradual occlusion of 2 of the 3 vessels is tolerable as rich collateral branches form between these. Acute occlusion of any of the vessels or their branches causes acute intestinal ischemia and necrosis.
Discussion
The four processes: 1) Acute arterial embolus -usually from cardiogenic embolus in pts w/ Afib or valvular disorders. SMA is the common vessel affected as it has a less acute take off from aorta 2) Acute arterial thrombosis - chronic atherosclerotic plaque at origin of vessel acutely thromboses 3) Chronic mesenteric ischemia - atherosclerosis of visceral vessels results in abdominal pain (intestinal angina) during times of increased blood demand (digestion) 4) Acute venous occlusion - venous thrombosis causes cessation of venous outflow from intestines
*Non-occlusive mesenteric ischemia can also be seen in low-flow states
Discussion
Diagnosis - requires high degree of suspicion. Classically presents as
pain out of proportion to physical exam or severe pain w/o peritoneal signs. The history of Cardiac disease, valvular disease, or Afib should alert one to an embolic disease. Gold standard for diagnosis is mesenteric angiogram, but CT angiogram is more and more being used.
QUESTIONS ??????
References
Townsend CM. Sabiston Textbook of Surgery. 17th Edition Cameron JL. Current Surgical Therapy. 8th Edition Oldenburg et al. Acute Mesenteric Ischemia. Arch Intern Med 164:1054-62. 2004
Acknowledgment
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