Bowel Ischaemia

Question 1

Main types of bowel ischaemia

Answer 1

Acute mesenteric
Chronic mesenteric
Chronic colonic

AF with mesenteric is common

Question 2

What is acute mesenteric ischaemia

Answer 2

Almost always small bowel and SMA thrombosis/embolism

Can also be mesenteric vein thrombosis or non-occlusive disease

Question 3

Acute mesenteric ischaemia presentation

Answer 3

Triad: acute severe abdominal pain, no abdo signs, hypovolaemic shock
Constant pain centrally or RIF, not proportional to degree of illness

Question 4

Acute mesenteric ischaemia investigations

Answer 4

Inc Hb due to plasma loss, inc WCC
Persistent metabolic acidosis due to high lactate
AXR shows gasless abdo early on
CT/MRI shows ischaemia

Question 5

Acute mesenteric ischaemia complications

Answer 5

Septic peritonitis

Progression of Systemic Inflammatory Response Syndrome (SIRS) to multi-organ failure

Question 6

Acute mesenteric ischaemia treatment

Answer 6

Resus with fluid, piperacillin/tazobactam and LMWH
Thrombolytics via catheter if arteriography done
Dead bowel removed surgically with revascularisation if possible

Question 7

Acute mesenteric ischaemia prognosis

Answer 7

<40% survive non-occlusive/arterial thrombosis

Not bad for venous/embolic ischaemia

Question 8

Chronic mesenteric ischaemia presentation

Answer 8

‘Intestinal angina’
Triad: severe, colicky post-prandial pain; weight loss; upper abdominal bruit
±PR bleeding, malabsorption, nausea+vomiting
History may point to atheromas and low flow state in all 3 mesenteric arteries

Question 9

Chronic mesenteric ischaemia tests

Answer 9

CT angiography + Contrast MR angiography

Question 10

Chronic mesenteric ischaemia treatment

Answer 10

Surgery due to acute infarction risk

Percutaneous transluminal angioplasty and stent insertion, has superceded revascularisation

Question 11

What is chronic colonic ischaemia

Answer 11

Ischaemia colitis, follows low IMA flow

Can be from mild ischaemia to gangrenous colitis

Question 12

Chronic colonic ischaemia presentation

Answer 12

Lower left-sided abdo pain ± bloody diarrhoea

Question 13

Chronic colonic ischaemia diagnosis

Answer 13

CT may help but colonoscopy is gold-standard

Question 14

Chronic colonic ischaemia treatment

Answer 14

Usually conservative - fluid replacement + antibiotics

Gangrenous ischaemic colitis needs prompt resus, surgical resection and stoma formation