Chapter 131 - Mesenteric arterial disease introduction

Question 1

First case of acute mesenteric ischemia

Answer 1

1895 Elliott - intestinal resection

Question 2

Chronic mesenteric ischemia first described

Answer 2

Intestinal angina

1918 Goodman
1936 Dunphy characterized it

Question 3

Mesenteric venous thrombosis first described

Answer 3

Warren & Eberhard

1935

Question 4

First SMA embolectomy

Answer 4

Klass 1950

Question 5

First SMA thromboendarterectomy

Answer 5

1958 Shaw & Maynard

Massachusetts General

Question 6

First SMA retrograde bypass

Answer 6

1962 Morris

Question 7

First SMA antegrade bypass

Answer 7

1966 Stoney & Wylie

Question 8

First endo dilation of SMA

Answer 8

1980 Furrer & Novelline

Question 9

First stent celiac artery with Palmaz

Answer 9

Finch 1992

Question 10

Embryologic origin of visceral vessels

Answer 10

Segmental branches from primitive ventral aorta

1) 10th - Celiac
2) 13th - SMA
3) 21st - IMA

Question 11

Anatomic location of the celiac artery

Answer 11

1) L1
2) bordered by median arcuate ligament
3) aortic hiatus superioly
4) superior border of pancreas inferiorly

Question 12

3 branches of the celiac artery

Answer 12

1) left gastric
2) splenic
3) common hepartic

Question 13

Most frequent variation of the celiac trifurcation

Answer 13

Common hepatic comes from SMA or from aorta

Question 14

SMA anatomic location

Answer 14

1) origin crossed by neck of pancreas and splenic vein
2) lies superior to uncinate process of pancreas and third portion of duodenum
3) SMV runs parallel along right border

Question 15

SMA branches

Answer 15

1) inferior pancreaticoduodenal artery
2) middle colic artery
3) right colic
4) ileocolic
5) 3rd order mesenteric branches

Question 16

IMA anatomic location

Answer 16

3-4 cm cephalad to aortic bifurcation to left of midline

L3

Question 17

Major collateral arcade between SMA and IMA

Answer 17

Marginal artery of Drummond

Question 18

Meadering mesenteric artery

Answer 18

of Moskowitz

Arc of Riolan

Question 19

Variation of splanchnic blood flow in different states

Answer 19

1) shock/hypovolemia - 10%
2) fasting 20-25%
3) post-prandial large carb meal 35%

Question 20

Distribution of mesenteric blood flow to layer of intestinal wall

Answer 20

70-80% to mucosal/submucosal layers

Question 21

SMA and celiac flow pattern key points

Answer 21

1) SMA low resistance in post-prandial state
2) SMA flow reversal in fasting state and high resistance
3) Celiac always low resistance due to hepatic bed

Question 22

Extrinsic Factors that control mesenteric arteriolar tone

Answer 22

1) sympathetic efferents in prevertebral celiac and mesenteric ganglia
2) RAAS angiotensin II action in hypovolemic states
3) low volume state hyperosmolarity –> vasopressin
4) shear stress –> NO synthase –> NO release and vasodilation

Question 23

Intrinsic regulation of mesenteric arteriolar tone

Answer 23

1) metabolic pathway: mucosal ischemia –> metabolic byproduct –> vasodilation
2) myogenic pathway: decrease perfusion pressure –> arteriolar baroreceptors –> decrease wall tension

Question 24

Prevalence of mesenteric stenosis in elderly

Answer 24

17.5%

Question 25

Epidemiology of mesenteric ischemia gender ratio

Answer 25

female:male 3:1

Question 26

Non-occlusive mesenteric ischemia diagnostic criteria

Answer 26

1) ileus/abdominal pain
2) catecholamine requirement
3) episode of hypotension
4) gradual rise in serum transaminase level

if 3/4 met then high dose PGE1 treatment

Question 27

Moneta criteria for mesenteric ischemia

Answer 27

SMA PSV 275 cm/s
sen 92% with 96% accuracy

Celiac PSV 200 cm/s
sen 87% with 82% accuracy

for 70% stenosis

Question 28

AbuRahma criteria for mesenteric ischemia

Answer 28

SMA PSV 295 = 50% stenosis
400 = 70% stenosis
sen 87%; spe 89%

Celiac PSV 240 = 50% stenosis
320 = 70% stenosis

Question 29

Post-stenting SMA stenosis DUS criteria

Answer 29

> 275 cm/s PSV as significant in stent restenosis

Question 30

Soult et al criteria for in-stent SMA and celiac stenosis > 70%

Answer 30

SMA 445 cm/s

Celiac 289 cm/s

Question 31

CT to detect acute mesenteric ischemia sen and spe

Answer 31

sen 93%

spe 96%

Question 32

Gastric tonometry what is it

Answer 32

Measurement of pCO2 in gastric, jejunal or colonic mucosa via NG tube to diagnose mesenteric ischemia

Question 33

Medical treatment of mesenteric ischemia

Answer 33

1) statin
2) anticoagulation
3) fluid
4) TPN
5) antibiotics

Question 34

Techniques to assess bowel viability

Answer 34

1) pulse oximetry
2) oxygen tension measurement
3) spectrophotometry
4) doppler ultrasound
5) fluorescein dye and Wood’s lamp
6) laser doppler flometry
7) infrared imaging

Question 35

Clinical assessment of bowel viability

Answer 35

1) serosal color
2) bowel peristalsis
3) vessel palpation

Question 36

Diagnosis of NOMI

Answer 36

Selective mesenteric angiography with papaverine or PGE1 vasodilator

Question 37

Recurrence of mesenteric venous thrombosis without anticoagulation

Answer 37

36%