Abdominal Vascular Issues Flashcards by Andrew Kreutzer

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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

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Mesenteric Ischemia Etiology
non-occlusive/low flow states

shock
sepsis
CHF
AS
arrhythmias
dialysis
vasopressors

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Mesenteric Ischemia Etiology
Chronic Ischemia

atherosclerosis

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Mesenteric Ischemia Risk Factors

adhesions
herniation
volvulus
mesenteric/RP fibrosis
malignancy
trauma
increased age
refer to etiology

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Celiac artery supplies what structures with blood flow?

esophagus
stomach
superior 1/2 of duodenum & pancreas
spleen

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Superior Mesenteric Artery (SMA) supplies what structures with blood flow?

head & inferior pancreas
distal duodenum
jejunum
ileum
transverse & ascending colon
ileocecal

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Inferior Mesenteric Artery (IMA) supplies what structures with blood flow?

descending colon
sigmoid colon
rectum

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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

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Mesenteric Ischemia Labs to get include?

CBC (leukocytosis)
CMP
coags
ABG (Acidosis)
amylase/lipase
lactate

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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

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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

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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

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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

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Superior Mesenteric Embolism (occlusive)
accounts for ~ what % of noncolonic mesenteric ischemia?
Most originate from where?

50%
heart

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Superior Mesenteric Embolism (occlusive)
Diagnosis is done via?

selective mesenteric angiography

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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