Ischaemic Bowel Disease

Question 1

What are the three main groups of conditions that ischaemic bowel disease is comprised of? Which is the most common?

Answer 1

Acute mesenteric ischaemia

Chronic mesenteric ischaemia (gut claudication)

Colonic ischaemia

Question 2

In acute mesenteric ischaemia, what is most commonly the cause? Why?

Answer 2

Thromboembolism of the SMA (most vertical branch off the aorta)

Question 3

In acute mesenteric ischaemia caused by hypoperfusion, which arterial territory is most commonly affected? Why?

Answer 3

The coeliac axis territory (foregut to the major duodenal papilla). This, unlike the SMA/IMA region, has few collaterals

Question 4

What are the risk factors for ischaemic bowel disease?

Answer 4

• Old age
• Smoking history
• Hypercoagulable states
• AF
• MI (decreased CO)
• Structural heart defects
• Hx of vasculitis

Question 5

What findings on history and examination would you expect in a patient with acute mesenteric ischaemia?

Answer 5

• Abdominal pain (acute, severe)
• Melaena/haematochezia
• Diarrhoea
• Abdominal tenderness (less tender than would be expected from pain described)
• Abdominal bruit

Question 6

What findings on history would you expect to find in a patient with chronic mesenteric ischaemia?

Answer 6

• Abdominal pain (colicky, post-prandial, “gut claudication”)
• Melaena/haematochezia
• Diarrhoea
• Loss of weight (food hurts)

Question 7

What findings on history might you expect to find in a patient with ischaemic colitis?

Answer 7

• LLQ abdominal pain
• Bloody diarrhoea
• ?Pyrexia

Question 8

What would be investigations to consider in a patient suspected of having ischaemic bowel disease?

Answer 8

• FBE (WCC raised)
• Amylase (elevated)
• UEC
• ECG (cardiac cause)
• XR
  
  • Thickened walls (acute ischaemia)
  • Gas in the portal vein (acute ischaemia)
• Endoscopy
• Mesenteric angiography

Question 9

What are the general management prinicples for a patient with acute mesenteric ischaemia?

Answer 9

• General
  
  • Fluid resuscitation, oxygen, NG tube, NPO, empiric antibiotics, exploratory laparoscopy
• Thromboembolic cause
  
  • Antispasmodic - papaverine
  • Arterial reconstruction, venous thrombectomy
  • Bowel resection

Question 10

What are the general management prinicples for a patient with chronic mesenteric ischaemia?

Answer 10

• Medical optimisation of co-morbidities
• Endovascular optimisation (e.g. stenting), grafting

Question 11

What are the general management principles for patients with ischaemic colitis?

Answer 11

• Most episodes are managed conservatively, but if recurrent or severe:
• If chronic (e.g. symptoms > 2 weeks for recurrent) segmental colectomy may be required