Gen Surg: Bowel ischaemia Flashcards
What are the 3 main types of bowel ischaemia?
- Acute mesenteric ischaemia
- Chronic mesenteric ischaemia
- Ischaemic colitis/Chronic colonic ischaemia
What is acute mesenteric ischaemia?
ACute interruption in the blood supply to the mesentery. It can result from occlusion of arterial inflow, occlusion of venous outflow or failure of perfusion
What are causes of acute mesenteric ischaemia?
- SMA thrombosis/embolism
- Mesenteric vein Thrombosis
- Low flow states - heart failure
- Trauma
- VAsculitis
- Radiotherapy
- Strangulation
How do those with acute mesenteric ischaemia tend to present?
Triad of
- Acute severe abdominal pain - constant, central or concentrated to RIF
- Features of hypovolaemic shock
- Distended, tender abdomen, with absent bowel sounds
Can also have
- Haematochezia/malaena
- Diarrhoea
Degree of illness is far out of proportion with signs
If you suspected acute mesenteric ischaemia, what investigations would you consider doing?
- Bloods - FBC, U+E’s, ABG
- ECR
- Erect CXR
- AXR
- CT/MR angiography/Formal arteriography
What might you see on FBC in someone with acute mesenteric ischaemia?
- Increased Hb - due to increased plasma loss
- Increased WCC
What might you see on U+E’s in someone with acute mesenteric ischaemia?
- Uraemia
- Elevated creatinine
What might you see on ABG in someone with acute mesenteric ischaemia?
- Acidosis
- Elevated lactate
What might you find on ECG in someone with acute mesenteric ischaemia?
Indication of cause
- AF
- Arrhythmia
- ACute MI
What might you find on AXR in someone with suspected acute mesenteric ischaemia?
May inidicate aetiology
- Air fluid levels
- Bowel dilation
- Bowel wall thickening
- Pneumatosis
How would you manage someone with acute mesenteric ischaemia?
ABCDE
- Fluid resiscitation
- Antibiotics
- LMWH
- Consider Local thrombolytics
-
Surgical
- Revascularisation
- Resection
What are life-threatening complications of acute mesenteric ischaemia?
- Septic peritonitis
- SIRS
- Multi-organ failure
What are features of chronic mesenteric ischaemia?
Triad of:
- Severe colicky, post-prandial abdominal pain - ‘gut cluadication’
- Weight loss - eating hurts
- Upper abdominal bruit
May also have
- PR bleeding
- Malabsorption
- Nausea + Vomiting
What tests would you do if you suspected chronic mesenteric ischaemia?
CT angiography/Contrast enhanced MR angiography
How would you manage someone with chronic mesenteric ischaemia?
- Percutaneous transluminal angioplasty + stent insertion
- Consider open revascularisation - not really used anymore
What is chronic mesenteric ischaemia also known as?
Intestinal angina
What are symptoms of ischaemic colitis?
- Sudden onset lower left-sided abdominal pain
- Bloody diarrhoea
What arteries are often implicated in ischaemic colitis?
- SMA
- IMA
What are signs of ischaemic colitis?
Distended and tender abdomen
What investigations would you consider doing in someone with suspected ischaemic colitis?
- AXR
- Consider Colonoscopy
What is the following?
Thumb print sign - a radiographic sign of large bowel wall thickening, usually caused by oedema, related to an infective or inflammatory process (colitis). It can be seen in ischaemic colitis
How would you manage someone with ischaemic colitis?
Conservative
- Fluid replacement
- Antibiotics
-
If gangrenous ischaemic colitis
- Resuscitation
- Embolisation +/- Surgical resection + Stoma formation
What complication can commonly develop after an attack of ischaemic colitis?
Ischaemic strictures
Where is the most common site for mesenteric ischaemia to occur?
Splenic flexure - watershed between SMA and IMA
