Bowel Ischaemia Flashcards
Acute bowel ischaemia
Acute occlusion of superior mesenteric artery
Causes of acute bowel ischaemia (ARTERIAL)
Embolism (commonly L.hearted side thrombus or iatrogenic rupture-interventional radiological procedure)
Thrombosis from SMA
Vasculitis ( Rheumatoid arthritis, polyarteritis nodosa, SLE)
External compression (commonly a mass)
Main types of bowel ischaemia
Acute mesenteric ischaemia
Chronic mesenteric ischaemia
Ischaemic colitis (colonic ischaemia)
Causes of acute bowel ischaemia (VENOUS)
Thrombosis (Superior Mesenteric Vein)
Hypo-perfusion due to:
HF, dialysis, Recent surgery, infection, drug related
Common type of patients to present with acute bowel ischaemia
Older patients with long-standing congestive heart failure, cardiac arrhythmias, recent MI, hypotension, or peripheral vascular disease.
Younger patients with history of collagen vascular disease, vasculitis, hyper-coagulable state, vasoactive medicine or cocaine use.
Patients with arterial embolus who describe sudden, severe abdominal pain with rapid, forceful bowel evacuation, possibly containing blood.
Presentation of acute bowel ischaemia
Sudden onset of diffuse abdo pain colicky or constant Persists for more than 2-3 hours Commonly peri-umbilical Appear severely ill Palpation to tenderness is a late sign
Presentation of chronic bowel ischaemia
Usually elderly
More common in female (3:1)
Often Hx of heavy smoker or other atherosclerotic factors
Insidious onset with repeated, mild, transient, episodes over many months, becoming progressively more severe
Pain occurs after meals, pain poorly localised
May be sitophobic (fear of eating)
Colonic ischaemia
Most common form of intestinal ischaemia
80% resolves without surgical intervention either spontaneous or conservative
Presentation of colonic ischaemia
Mild-mod pain felt laterally, over time becomes more continuous and intense.
Pain radiates to back
May be frequent bloody loose stools
Tenderness to palpation is an early sign
Abdomen becomes distended, loss of bowel sounds
Investigation for acute, chronic and colonic ischemia
Acute: AXR shows Thumbrinting, subdiaphragmatic air if perforated. Contrast CT to diagnose mesenteric venous thrombosis
Chronic: Angiography shows severe occlusion in at least 2 of the 3 splanchnic vessels (coeliac, IMA or SMA)
Colonic: Colonoscopy shows cobble stone appearance, thumbprinting and strictures. Barium enema can be used if no colonoscopy available.
Management of acute ischaemia
Fluid Resuscitation and adequate oxygen supply
Emprical Ab: Ceftriaxone or levofloxacin AND metranidazole
IF PERITONITIS OR PERFORATION: Exploratory laparotomy or laparoscopy
Papaverine infusion, embelectomy or bypass, bowel resection