Abdominal Vascular Issues Flashcards
Mesenteric Ischemia Etiology
Occlusive
Emboli from cardiac source
cardiac cath
cholesterol embolism
oral contraceptives
heme d/o
systemic dz
portal HTN
abd surgery/trauma
malignancy
Mesenteric Ischemia Etiology
non-occlusive/low flow states
shock
sepsis
CHF
AS
arrhythmias
dialysis
vasopressors
Mesenteric Ischemia Etiology
Chronic Ischemia
atherosclerosis
Mesenteric Ischemia Risk Factors
adhesions
herniation
volvulus
mesenteric/RP fibrosis
malignancy
trauma
increased age
refer to etiology
Celiac artery supplies what structures with blood flow?
esophagus
stomach
superior 1/2 of duodenum & pancreas
spleen
Superior Mesenteric Artery (SMA) supplies what structures with blood flow?
head & inferior pancreas
distal duodenum
jejunum
ileum
transverse & ascending colon
ileocecal
Inferior Mesenteric Artery (IMA) supplies what structures with blood flow?
descending colon
sigmoid colon
rectum
Mesenteric Ischemia Clinical Manifestations include?
may be acute, subacute, or chronic
pain: sever, persistent, poorly localized & out of proportion to tenderness
fever
mental status changes
abd distention
N/V
bloody diarrhea
hypotension
tachycardia
bowel sounds increased initially then decreased
Mesenteric Ischemia Labs to get include?
CBC (leukocytosis)
CMP
coags
ABG (Acidosis)
amylase/lipase
lactate
Mesenteric Ischemia Abd radio graph to exclude what?
may detect what?
secondary causes of ischemia or other causes of abd pain, N/V, distention (perforation or obstruction)
thumbprinting from submucosal hemorrhage, ileus, or pneumatosis or portal venous (PV) gas indicating necrosis & gangrene
Mesenteric Ischemia CT angiography
may be normal in acute cases or ischemia
or may reveal bowel wall thickening
submucosal hemorrhage
mesenteric stranding
thrombosis
pneumatosis
PV gas
Mesenteric Ischemia Management includes:
Emergency Laparotomy if?
ICU management includes?
peritoneal signs suggest intestinal necrosis, pneumatosis, PV gas on imaging
fluid resuscitation to optimize CO
Respiratory Support
Broad-specturm Abx to cover GNB & anaerobes to prevent bacterial translocation
Mesenteric Ischemia Prognosis:
acute arterial ischemia of SB has ~ what % mortality rate if not treated urgently?
venous thrombosis of SB has better or worse prognosis than arterial?
Colonic ischemia has better or worse prognosis than SB?
70%
better
better
Superior Mesenteric Embolism (occlusive)
accounts for ~ what % of noncolonic mesenteric ischemia?
Most originate from where?
50%
heart
Superior Mesenteric Embolism (occlusive)
Diagnosis is done via?
selective mesenteric angiography
Superior Mesenteric Embolism (occlusive)
Treatment:
If detected early use what?
If detected later do what?
Use systemic what?
thrombolytic therapy (streptokinase, urokinase, TPA) infused directly into area of embolus in select patients
laparotomy +/- bowel resection, +/- embolectomy, +/- 2nd look
Systemic anticoagulation
Superior Mesenteric Artery Thrombosis
accounts for ~ what % of primary, noncolonic ischemia?
15%
Superior Mesenteric Artery Thrombosis Risk Factors includes?
older age
atherosclerosis (HTN, HLD, DM, Smoking)
low-flow states
hypercoagulable states
vasculitis
aortic, mesenteric aneurysms
Superior Mesenteric Artery Thrombosis Diagnosis is done via?
CTA, MRA, doppler U/S
Selective mesenteric angiography
Superior Mesenteric Artery Thrombosis Treatment includes?
surgical thrombectomy +/- bowel resection
Bypass graft (BPG) +/- bowel resection
systemic anticoagulation
broad-spectrum abx
Acute Nonocclusive, Noncolonic Primary Arterial Ischemia
accounts for ~ what % of primary noncolonic mesenteric ischemia?
results from what?
20%
low-flow states
Acute Nonocclusive, Noncolonic Primary Arterial Ischemia Risk Factors include?
older age
hypotension from arrhythmias, heart failure, shock sepsis, MI, hemorrhage, HD
Vasospasm
athersclerosis
Acute Nonocclusive, Noncolonic Primary Arterial Ischemia Clinical Manifestations include?
may be less acute
vague symptoms (distention, nausea, MS changes, fever, mild hypotension)
Acute Nonocclusive, Noncolonic Primary Arterial Ischemia Diagnosis is done via?
selective mesenteric angio
Acute Nonocclusive, Noncolonic Primary Arterial Ischemia Treatment includes?
Prolonged infusion of vasodilator (papaverine) if vasospasm
Optimization of CO, BP
Broad-spectrum abx
Mesenteric Venous Thrombosis
Usually where?
Symptoms may be what?
Accounts for ~ what % of primary noncolonic mesenteric ischemia?
superior mesenteric vein (SMV)
acute (hrs-days) or sub acute (wks-months)
10%
Mesenteric Venous Thrombosis Risk Factors include?
hypercoagulable/hyperviscosity states?
Intra-abdominal infections/inflammation?
protein C/S deficiency
ATIII deficiency
Factor V Leiden mutation
antiphospholipid syndrome
sickle cell
portal HTN
trauma
vasculitis
Mesenteric Venous Thrombosis Clinical Manifestations include?
may be vague c/o over wks - mo
if acute, similar to that of arterial occlusion
bacteremia may be present (bacteroides)
GIB possible
Mesenteric Venous Thrombosis Diagnosis is done via?
CT scan: thrombosis of SMV
Mesenteric Venous Thrombosis Management includes?
laparotomy if acute +/- bowel resection
fluid resuscitation
broad-spectrum abx
systemic anticoagulation if no GIB
Colonic Ischemia
most common cause of what? ~ what % of all cases?
many are what? in thosee > what age, no apparent inciting event occurs?
likely secondary to waht?
mesenteric ischemia; 50%
acute; 60
transient, non-occlusion of colon
Colonic Ischemia
Medical Conditions and Surgical Hx independently associated with colon ischemia include? (red check marks)
CHF or Ischemic heart dz
Peripheral Vascular dz
Shock
Abdominal Surgery
Colonic Ischemia Clinical Manifestations Include?
Acute abd pain (LLQ)
bloody diarrhea
urgent desire to defecate
abd distention
fever
tachycardia
Colonic Ischemia lab work up includes?
albumin
amylase
CBC
CMP
CK
lactate
LDH
Stool: Cdiff, cx, O&P
Colonic Ischemia Imaging includes?
CT w/ IV/PO contrast
CTA if suspect CI of R colon
Colonoscopy w/n 48hrs
Colonic Ischemia Diagnosis
Lab testing may be what?
what may CBC reveal? (2)
CT scan may see what?
Colonoscopy may show?
nonspecific
leukocytosis; hemoconcentration
may see colonic thickening, edema, “thumbprinting”, pneumatosis & portomesenteric venous gas may be c/w transmural colonic infarction
patchy ulceration, edema, erhythema:
stop at distal most area
bx if no gangrene
avoid if acute peritonitis
Colonic Ischemia Management
Most resolve how?
give what?
Optimization of what?
spontaneously
fluid resuscitation
CO
Colonic Ischemia Management
Broad-specturm ABx:
indication & timing is what?
there is no evidence of what?
Believed to prevent what? by decreasing what?
What type of abx?
untested
no clinical evidence of benefit
poor outcomes by decreasing bacterial translocation
anti-anaerobe + fluroquinolone or aminoglycoside or 3rd gen cephalosporin (ceftriaxone)
Colonic Ischemia Management
Surgery acute indications are?
peritoneal signs
massive bleeding
universal fulminant colitis w/ w/o toxic megacolon
PV gas &/or pneumatosis
deteriorating clinical condition
