Intestinal Ischaemia Flashcards
What are the 3 types of ischaemic bowel disease?
acute mesenteric ischaemia
chronic mesenteric ischaemia
ischaemic colitis
What are the features of mesenteric ischaemia?
Typically small bowel Due to embolism Sudden onest, severe symptoms Urgent surgery High mortality
What are the features of ischaemic colitis?
Large bowel Transient, less severe Blood diarrhoea Thumbprinting Conservative management
What are RFs for bowel ischaemia?
increasing age
atrial fibrillation (mesenteric ischaemia)
other causes of emboli: endocarditis, malignancy
cardiovascular disease risk factors: smoking, hypertension, diabetes
cocaine (ischaemic colitis)
What are the presenting features of intestinal ischaemia?
abdominal pain rectal bleeding diarrhoea fever bloods - elevated white blood cell count + lactic acidosis
What investigation is done for intestinal ischaemia?
CT
What artery is commonly affected in acute mesenteric ischaemia?
Superior mesenteric
What is the management for acute mesenteric ischaemia?
urgent surgery is usually required
embolus = open embolectomy/arterial bypass +- bowel resection
thrombus = endovascular therapy
What pain is felt in chronic mesenteric ischaemia?
Colickly, intermittent abdominal pain
What causes ischaemic colitis?
acute but transient compromise in the blood flow to the large bowel
leads to inflammation, ulceration and haemorrhage
What is the investigation for ischaemic colitis?
AXR
‘Thumbprinting sign’ caused by mucosal oedema/haemorrhage
What is the management for Ischaemic colitis?
Supportive
Surgery if conservative fails e.g. generalised peritonitis, perforation of haemorrhage
Define large bowel obstruction
A mechanical interruption (either complete or partial) to the flow of intestinal contents, with multiple potential causes
What are the presenting features of large bowel obstruction?
Intermittent abdo pain Distention N+V Change in bowel habit Hard faeces (impaction) Soft stools (partial obstruction) Weight loss Palpable mass Tenesmus
What are some RFs for large bowel obstruction?
Colorectal adenomas/polyps Malignancy IBD Diverticular disease Hernia Gynae conditions Diabetes Previous abdo surgery Radiotherapy Male Obesity Age
What scan for large bowel obstruction?
Urgent CT
May visualise obstruction, perforation, dilatation, ischaemia, malignancy
What other investigations for large bowel obstruction?
FBC - iron deficiency anaemia (colorectal cancer)
High WBC may indicate perforation or necrosis
Low potassium
Raised CRP
Urea/Creatinine ratio: dehydration = AKI risk
What is the management for suspected large bowel obstruction?
Initial supportive care and A-E assessment Manage fluids Analgesia NBM Emergency surgery
What are the 3 main types of surgery for large bowel obstruction?
Right hemicolectomy
Hartmann’s procedure
Sutotal/total colectomy
What is a right hemicolectomy?
Any operation that removes the ileocaecal valve and the caecum.
The colonic resection can be limited to the caecum or extended to the descending colon
What is Hartmann’s procedure?
Removal of the sigmoid colon with formation of a left iliac fossa colostomy
Rectal stump closed
Reversible
What is a subtotal/total colectomy?
For obstructing lesions in the descending or sigmoid colon
Ileosigmoid or ileorectal anastomoses
What are the presenting symptoms of small bowel osbtruction?
Abdo pain
Bloating
Vomiting
Failure to pass flatus or stool
What are RFs for small bowel obstruction?
Prev abdo surgery Crohn's Hernia Appendicitis Malignancy Intussusception Volvulus Foreign body ingestion
What investigations are done in small bowel obstruction?
CT
Water-soluble contrast study if pt fails to improve within 48 hours
ABG
FBC
What is the management for small bowel obstruction when surgery is indicated?
Supportive care
NG decompression
Emergency surgery
Correction of underlying cayse
What is NG decompression?
Prevent aspiration of vomit by gastric decompression
When is surgery indicated in small bowel obstruction?
Peritonitis
Hernia strangulation
Bowel ischaemia
What must be done if surgery is suspeted?
Assess bleeding and venous thromboembolism risk
Group and save
AB prescription
How do you define dilated small bowel?
> 3cm on AXR
What is volvulus?
torsion of the colon around it’s mesenteric axis resulting in compromised blood flow and closed loop obstruction
What is sigmoid volvulus?
Large bowel obstruction caused by the sigmoid colon twisting on the sigmoid mesocolon
80% of cases
What conditions are associated with sigmoid volvulus?
older patients
chronic constipation
Chagas disease
neurological conditions e.g. Parkinson’s disease, Duchenne muscular dystrophy
psychiatric conditions e.g. schizophrenia
What conditions are associated with caecal volvulus?
all ages
adhesions
pregnancy
What are the presenting features of volvulus?
constipation
abdominal bloating
abdominal pain
nausea/vomiting
How is volvulus diagnosed?
AXR
Sigmoid - Large, dilated colon (coffee bean sign)
Caecal - Small bowel obstruction might be seen
How is volvulus managed?
sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
caecal volvulus: management is usually operative. Right hemicolectomy is often needed
How can you identify small bowel on an AXR?
valvulae conniventes, mucosal folds, cross the full width of the bowel
