ACUTE MESENTERIC

ISCHEMIA
Gabriel . A. Owoupele
Ml 511
October 2012
DEFINATION
Acute mesenteric ischemia (AMI) is a syndrome
in which inadequate blood flow through the
mesenteric circulation causes ischemia and eventual
gangrene of the bowel wall. Broadly, AMI may be
classified either as arterial or venous disease
CLASSIFICATION



Acute mesenteric ischemia
nonocclusive mesenteric
ischemia(NOMI)
occlusive mesenteric
ischemia(OMI)
Further subdivision of OMI





Venous disease takes the form of mesenteric venous
thrombosis (MVT)
occlusive mesenteric ischemia
acute mesenteric arterial
embolus(AMAE)
acute mesenteric arterial
thrombosis(AMAT)
PATHOPHYSIOLOGY
Insufficient perfusion of the small bowel and colon
may result from arterial occlusion by embolus or
thrombosis (AMAE or AMAT), thrombosis of the
venous system (MVT), or nonocclusive processes
such as vasospasm.
ETIOLOGY
Embolic AMI (AMAE) include the following:
Cardiac emboli - Mural thrombus after MI, auricular thrombus
associated with mitral stenosis and atrial fibrillation, septic emboli
from valvular endocarditis.
Emboli from fragments of proximal aortic thrombus due to a
ruptured atheromatous plaque.
Atheromatous plaque dislodged by arterial catheterization.
Thrombotic AMI (AMAT) include the following:
Atherosclerotic vascular disease (most common)
Aortic aneurysm
Aortic dissection
Arteritis
Decreased cardiac output from MI or CHF
Dehydration from other causes
Causes of NOMI include the following:
Hypotension from CHF, MI, sepsis, aortic
insufficiency, severe liver or renal disease.
Vasopressive drugs
Ergotamine
Cocaine
Digitalis
Causes of MVT in most cases results from a predisposing condition
ranging from
Tumor
abdominal Infections ,
Venous congestion from cirrhosis (portal hypertension)
Venous trauma from accidents or surgery, especially portocaval surgery
Increased intra-abdominal pressure from pneumoperitoneum during
laparoscopic surgery[8]
Pancreatitis
Decompression sickness
To cases of Hypercoagulability from protein C
and S deficiency, antithrombin III deficiency,
dysfibrinogenemia, abnormal plasminogen,
polycythemia vera (most common), thrombocytosis,
sickle cell disease, factor V Leiden mutation,
pregnancy, and oral contraceptive use.
CLINICAL PRESENTATION
General for all classifications
Pain, which could be moderate to severe, diffuse,
nonlocalized or constant.
Nausea and vomiting are found in 75% of affected
patients.
Anorexia and diarrhea progressing to obstipation.
Abdominal distention and gastrointestinal (GI)
bleeding are the primary symptoms in as many as
25% of patients.

AMAE
most abrupt and painful presentation of all types,
as a consequence of the rapid onset of occlusion
and the inability to form additional collateral
circulation. It has been described as abdominal
apoplexy and can be labeled as a bowel attack."
vomiting and diarrhea (gut emptying) are
observed
atrial fibrillation or a recent myocardial infarction
because the emboli are cardiac origin.
Basically caused by a thrombus, typically happens when a previously
partially blocked artery by atherosclerosis becomes completely
occluded.
precipitating event include : sudden drop in C.O from MI or CHF
or a ruptured plaque. Dehydration from vomiting or diarrhea other
illnesses not related.
AMAT
NOMI
Seen mostly in elder patients, often, these elderly patients are
already in the ICU with acute respiratory failure or severe hypotension
from cardiogenic or septic shock, or they are taking vasopressive
drugs. Most of them are taking digitalis.
Clinics include malaise, vague abdominal discomfort which may
intensify upon vomiting and also bloody stool.

MVT
Observed in younger patients
Abdominal pain, which could be acute or sub acute.
Typical symptoms of MVT may have been experienced for a
prolonged period with gradual worsening. The chronic form may
manifest as esophageal variceal bleeding.
INVESTIGATIONS
Most common laboratory abnormalities are
Haemoconcentration
Leucocytosis
Metabolic acidosis
Lactic acidosis( in more advanced cases)
Raised serum makers; amylase, ALP
DIAGNOSIC IMAGING
Angiography: gold standard to aid in diagnosis and preoperative
planning, sensitivity is about 98% for AMI.
Duplex ultrasonography: is highly specific (92-100%) but is not as
sensitive (70-89%) as angiography.
CT scanning & MRI helps exclude other causes of abdominal
pain. It may show pneumatosis intestinalis, portal vein gas, bowel wall
or mesenteric edema, abnormal gas patterns, thumbprinting, streaking
of mesentery, and solid organ infarction.
SMA EMBOLISM
F I GURE S HOWS AB RUP T OCCLUS I ON OF T HE
S UP ERI OR MES ENT ERI C T RUNK
PRI NCI PLES OF MANAGEMENT
Early recognition and intervention
Fluid resusitation and correction of electrolytes disturbance
Nastrogastric tube ; for decompression of the bowel
Broad spectrum antibiotics ; to cover bacterial translocation
Hemodynamic status monitoring
Definative treatment depends on exact etiology
SURGI CAL MANAGEMENT
The use of preoperative angiography( is still controversial )
With peritoneal signs exploratory laparotomy mandated
Revascularization procedure; SMA embolism
- embolectomy
- +/- SMA patch angioplasty


SMA thrombosis; mesenteric bypass
-retrograde ( from iliac artery or infrerenal aorta to SMA)
-antegrade ( from supraceliac aorta to SMA)
Laser doppler, doppler US and fluorescein dyes are useful adjuct
to assess viability
Routine second look laparoscopy is recommeded.

Summary; a practical approach



vascular cause

Non vascular cause 2
nd
look after.
Clinical, radiographic, laboratory data sugesstive of AMI
STABLE UNSTABLE
Angiography Laparotomy
ENDOVASCULAR TECHNI QUES I N
AMAI
Aspiration embolectomy
SMA thrombolysis
Stenting of visceral arteries in acute mesenteric ischemia
MANAGEMENT OF MESENTERI C
VENOUS THROMBOSI S
Anticoagulation is mainstay of treatment.
Workup for hypercoagulability.
Laparotomy if peritoneal signs develops.
- resection of necrotic bowel
- thrombectomy
MANAGEMENT OF NON- OCCLUSI VE
MESENTERI C I SCHEMI A
Correct underlying condition
Optimize fluid status, improve C.O and eliminate vasopressors
Consider catheter-directed intraarterial infussion of vasodilator(
papaverine )
Laparotomy if peritoneal signs develop.