Ischaemic Bowel Disease

Question 1

What should this prompt you to want to exclude?

Atrial fibrillation with abdominal pain.

Answer 1

Mesenteric ischaemia

Question 2

Which part of the gut does acute mesenteric ischaemia affect?

Answer 2

Small bowel

Question 3

What are the causes of acute mesenteric ischaemia?

Answer 3

1. SMA embolism (50%)
2. SMA thrombosis (20%)
3. Non-occlusive disease (20%) e.g. poor cardiac output

Question 4

What is this a presentation of?
Acute severe abdominal pain (constant, central). No/minimal abdominal signs. Rapid hypovolaemia (shock). Degree of illness out of proportion to clinical signs.

Answer 4

Acute mesenteric ischaemia

Question 5

How is a suspected acute mesenteric ischaemia investigated?

Answer 5

1. Increased Hb (plasma loss)
2. High WCC
3. Raised amylase
4. Persistent metabolic acidosis (high lactate)
5. Gasless abdomen on AXR

Question 6

What is the treatment for acute mesenteric ischaemia?

Answer 6

1. Fluid resuscitation, antibiotics (tazocin), LMWH.
2. Revascularisation pre-surgery if possible.
3. Surgery definitely to resect dead bowel.
4. Poor prognosis <40% survival

Question 7

What is chronic mesenteric ischaemia?

Answer 7

‘Intestinal angina’

Combination of a low flow state and diffuse atherosclerotic disease in all three mesenteric arteries.

Question 8

What is this a presentation of?

Severe, colicky, post-prandial abdominal pain. Weight loss, upper abdominal bruit, PR bleeding, nausea, vomiting.

Answer 8

Chronic mesenteric ischaemia

Question 9

How is a suspected chronic mesenteric ischaemia investigated?

Answer 9

1. Rare and difficult to diagnose

2. CT angiography/contrast enhanced MR angiography.

Question 10

What is the treatment for chronic mesenteric ischaemia?

Answer 10

1. Surgery considered due to ongoing risk of acute infarction.
2. Percutaneous angioplasty

Question 11

What is the most common form of bowel ischaemia and which area of the gut is most commonly affected?

Answer 11

1. Ischaemic colitis

2. Splenic flexure

Question 12

What is ischaemic colitis?

Answer 12

Follows loss of flow in the inferior mesenteric artery due to in situ thrombosis and ranges from mild ischaemia to gangrenous colitis.

Question 13

Which ischaemic condition is this a presentation of?

Lower left-sided abdominal pain +/- bloody diarrhoea.

Answer 13

Ischaemic colitis

Question 14

How is a suspected ischaemic colitis investigated?

Answer 14

1. CT helpful but lower GI endoscopy is gold standard.

2. AXR may show thumbprinting.

Question 15

What is the management for ischaemic colitis?

Answer 15

1. Usually conservative with NBM, NG tube, fluid replacement and antibiotics.
2. Gangrenous ischaemic colitis needs urgent resection and stoma formation.