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MD1 GI - EXAM 1 > Ischémie intestinale > Flashcards

Ischémie intestinale Flashcards

1
Q

What is the anatomy of splanchnic circulation? (3 “axes”)

A
  1. Axe coeliaque (at D12)
  2. Axe mésentérique supérieur (at L1)
  3. Axe mésentérique inférieur (at L3)
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2
Q

What does the axe coeliaque split into?

A

A. gastrique g., a. hépatique commune, a. splénique

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3
Q

Where does the axe coeliaque supply blood?

A

Stomach, duodenum, pancreas, liver

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4
Q

What does the axe mésentérique supérieur split into? (5)

A

a. pancréatico-duodénale antérieure, a. pancréatico-duodénale postéro-inf., a. colique d., a. colique moyenne, a. iléocoliques

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5
Q

Where does the axe mésentérique supérieur supply blood?

A

pancreas, duodenum, small inststin, colon d. and transverse proximal

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6
Q

What does the axe mésentérique inférieur split into? (3)

A

a. colique g., branges sigmoïdiennes, a. rectale supérieure

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7
Q

Where does the axe mésentérique inférieur supply blood?

A

colon transverse distal, colon gm sigmoïde, rectum proximal

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8
Q

Overview of splanchnic circulation:

A
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9
Q

How is the duodenum vascularized? (weird case)

A

Proximal:

  • a. gastroduodénale (a. hépatique commune —> tronc coeliaque)
  • branches pancréaticoduodénales

Distal:

  • Branches pancréaticudiodénales —> AMS

Branches pancréaticoduodénales venant du t. coeliaque et AMS s’anastomosent —> suppléance en cas de thrombose

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10
Q

Veinous return of small instestine:

A

Veinules circulent dans mésentère —> v. mésentérique supérieure (VMS)

VMS + v. splénique = v. porte (VP)

Après avoir traversé le foie, sang retourne à circulation via:

  • v. sus-hépatiques —> v. cave inférieur —> OD
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11
Q

What are the four kinds of intestinal ischemia?

A
  1. Ischémie mésentérique aiguë
  2. Ischémie mésentérique chronique
  3. Ischémie colique
  4. Colite ischémique

Can originate from arteries or veins and can be acute or chronic

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12
Q

What are the main causes of ischémique mésentérique aiguë? (3 kinds)

A

Arterial (most common in AMS)

  • AMS embolism (50%)
  • AMS thrombosis (10%)

Veinous (VMS or VP)

  • Thrombosis (10%) —> vasculitis, FA, pro-coagulation

Non-occlusive ischemia (25%):

  • Severe hypotension, hypovolemia, heart failure
  • Arrhythmia, cocaine, vasoactive Rx
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13
Q

What are the main causes of thrombose veineuse mésentérique? (6)

A
  • Thrombophilies (pro-coag)
  • Inflammation affecting organ that touches vessel (ex: appendicitis, diverticulitis, pancreatis, MII (maladies inflammatoires intestinales))
  • Portal hypertension/cirrhosis
  • Post-abdominal trauma
  • Pregnancy
  • Cancer
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14
Q

What are some clinical manifestations of ischémique mésentérique aiguë?

A

Sudden and severe abdominal pain (diffuse)

Nausea/vomiting

Rapid evolution towards —> peritoneal irritation, perforation (défense localisé —> diffuse —> ventre de bois)

Sepsis and fever

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15
Q

What are some investigations used to dx ischémique mésentérique aiguë?

A

Leucocytose —> neutrophiles

Metabolic acidosis with increased lactates (delayed indication of a severe condition)

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16
Q

What forms of imagery can be used to dx ischémique mésentérique aiguë?

A

Abdominal X-Ray (non-dx)

  • Iléus grêle “thumbprinting”
  • Intestinal pneumatosis
  • Air libre —> perforation du viscère

TDM/angio-TDM: better one

  • exclude other causes of acute abdominal pain
  • angioTDM: pathologies vasculaires/l’état de l’intestin
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17
Q

What is thumbprinting?

A

radiographic sign of large bowel wall thickening, usually caused by edema, related to an infective or inflammatory process (colitis)

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18
Q

Ddx for intestinal ischemia (8)

A
  1. Acute pancreatitis
  2. Rupture d’un viscère creux
  3. Dissection/rupture d’un AAA (aneurysm of aorta)
  4. Cholangitis (bile duct system inflammation)
  5. Cholecystitis (inflammation of the gallbladder)
  6. Renal colic
  7. Sub-occlusion
  8. Appendicitis
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19
Q

What forms of treatment ischémique mésentérique aiguë?

A

Medical: usually works if done early in evolution —> avoid necrosis

  • Ressuscitation volémique, broad spectrum antibiotics (edema can lead to translocation of bacteria to the blood)
  • Reperméabilisation des vaisseaux: héârine ou thrombectomie

Surgical: if intestinal necrosis

  • Emergency laparotomy to resect necrotic sections
  • Most common in AMS “territory”: intestin moyen + distal et colon proximal
20
Q

What is the mortality rate of ischémie mésentérique aiguë?

A

70-90% if dx made after necrosis has started —> dx early to act fast

21
Q

What is ischémie mésentérique chronique?

A

Also known as “angine mésentérique”

22
Q

What is the blood flow to the intestines?

A

20% du débit cardiaque en période basale et 35% post prandiale

23
Q

What causes ischémie mésentérique chronique?

A

Most often: mesenteric atherosclerosis

  • arterial supply to viscera is insufficient
  • O2 is brought to viscera by 3 principal vessels (tronc coeliaque, AMS and AMI)… if atherosclerosis in 2/3 —> angine mésentérique
24
Q

What are some clinical manifestations of ischémie mésentérique chronique?

A

Pain: peri-umbilical/epigastric, post-prandial/proportional to size of meal… will lead to weight loss due to pt restricting intake to dim. sx

  • Sx similar to cardiac angina —> inc. if theres effort… in this case, effort = digestion
25
Signs during physical examination of ischémie mésentérique chronique:
Souffle épigastrique... otherwise not very specific or important
26
How to diagnose angine mésentérique?
Pretty difficult.... must first eliminate other **ddx** Must have: **Sx cliniques typiques + occlusion ≤ 2 a. splanchniques show by:** * Doppler * Angiographie via CT-Scan * IRM * Arterial catheter... VERY INVASIVE —\> RARELY USED
27
How is angine mésentérique treated?
**Revascularization** (restore perfusion): tuteur endovasculaire (stent), pontage aorto-coeliaque et AMS si bon candidat pour chx
28
Which arteries irrigate the right part of the colon?
Branches de AMS
29
Which arteries irrigate the left and sigmoid parts of the colon?
AMI
30
Which arteries irrigate the transverse colon?
AMS and AMI —\> 2 apports en connection par l'a. marginale de Drummond
31
Which arteries irrigate the angle splénique?
extrémité des territoires d'irrigation des 2 a. mésentériques —\> **Zone de Watershed**
32
Which arteries irrigate the rectum?
a. rectale supérieure (issue de l'AMI) a. rectales moyennes et inférieures (issues d'a. ilique interne)
33
Overview of colonic circulation:
34
Which veins irrigate each part of the colon?
Les veins suivent les artères VMS et VMI —\> VP a. rectales moyennes et inférieures —\> v. iliaques internes
35
What is colite ischémique?
mostly in right colon associated with isch. mésentérique most common form of intestinal ischemia urgence et dx difficile et tx difficile **REMEMBER:** **If colon d. touchée —\> think to exclude isch. mésentérique associée (atteinte de l'AMS)**
36
Which vessels are associated with colite ischémique?
mésentériques supérieurs
37
What is the most common form of ischémie colique?
Colite isch. transitoire —\> no tx available
38
What causes colite ischémique?
Reduction in arterial flow to colon (usually AMI) due to vascular occlusion (arthéromatose, artérite, embolie) or dim. in débit de perfusion (hypovolémie, choc, déshydratation)
39
What are some risk factors for colite ischémique?
Frequency increases with age Pt-type: personne âgée avec facteurs de risque CV **(HTA, DB, DLPD, MCAS, MVAS —\> vaisseaux malades)** If young patient (\< 40): cocaine, vasculitis, thrombophilias, marathons (hypovolémie), rx (oral contraceptives, AINS) or obstructive lesions
40
What areas are at risk for colite ischémique?
**Zones de watershed:** watershed area is the medical term referring to regions of the body that receive dual blood supply from the most distal branches of two large arteries ex: angle splénique (AMS + AMI), angle recto-sigmoïdien (AMI + a. rectales)
41
What is the typical clinical presentation of colite ischémique?
Dlrs abdo. subites —\> diarrhea containing blood Light fever RARE: only if severe colitis —\> signes de péritonisme (inflammation du péritoine)
42
How is colite ischémique dx?
**TDM** —\> zones de colite **Colonoscopie**: atteinte segmentaire (usually splénique/sigmoide), erythème avec érosions, muqueuse bleutée (isch), voire noirâtre, hémorragies sous-épithéliales, zones nécrotiques
43
How is colite ischémique tx?
**Support**: solute for hydration with anesthetic if in pain, observation for 48-72 hrs, optimize FDR, transfusion PRN if necessary If **transmural involvement with severe colitis** —\> antibiotics to dim. risk of bacterial translocation **Chx/ressection colique au besoin**: VERY RARE —\> if perforation or uncontrollable bleeding... usually due to severe necrosis
44
How is the evolution of colite ischémique?
Quite favourable... isolated and non repetitive Healing usually complete without complications (rare delayed complications —\> stenosis)
45
Why and how would you go about doing supplementary investigations for colite ischémique?
**If \< 40 and no FDR...** * Echographie cardiaque * ECG * Abdominal Doppler * Holter * Bilan de coagulation

MD1 GI - EXAM 1 (15 decks)

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