Mesenteric Ischaemia Flashcards
Mesenteric ischaemia has a gender distribution of F2:1M. Mesenteric ischaemis is most commonly caused by thrombosis or embolic events?
Can be either but embolic is more likely so beware of A.fib. Thrombosis is being increasingly represented with time
Mesenteric ischaemia has several types. what are they?
Arterial:
a) Occlusive (emboli or thrombosis)
b) Non-occlusive (hypoperfusion)
Venous thrombosis: Sepsis
Irreversible damage occurs how long after ischaemia in mesenteric ischaemia?
6 hours just like any other ischaemia
The distribution of ischaemia in mesenteric ischaemia varies due to anatomical variations in Kirk’s arcade and Arcs of Buhler and Barkow. Despite that, they have the same presentation. What is the characteristic presentation of mesenteric ischaemia?
Typically an elderly patient with A.fib (or hx of embolic events) presenting with Severe sudden onset pain needing morphine despite little to no signs
Signs typically develop after perforation but at that point it is too late
Fact: only 30% actually have guarding
Ischaemic pain does not go with morphine
Describe the pain in mesenteric ischameia including location
Sudden onset severe pain not relieved by morphine
It occurs typically peri-umbilically as it is small bowel most of the time. It is not generalised pain as that would be peritonitis.
Is lactate levels a reliable marker for ischaemia in mesenteric ischaemia?
No it is not reliable but must be ordered as part of your investigations
What is the most important imaging that must be done promptly in an elderly patient with A.fib presenting with Severe pain needing morphine despite little to no signs?
CT Angiography with IV contrast
What is the door to CT angio time in mesenteric ischaemia?
What about revascularisation?
CT within 60 mins
Surgery within 3hrs
In general what is the management pathway of Mesenteric ischaemia
10 steps
CT angio within 60 minutes
Door to operation time 3 hours
If patient has no signs of peritonitis and done promptly, revascularisation can be done via IR
If peritonitis => gangrenous => surgical indication
What is revascularisation in mesenteric ischaemia?
What about the surgery?
What drug is often administered alongside these procedures?
Think logically
IR->Either of the following can be done
Thrombolysis (alteplase)
Mechanical thrombectomy/embolectomy
Stenting
Surgery
1) Surgical embolectomy (done with a fogarthy catheter too)
2) Resection of diseased segment and anastomosis
3) Bypass procedure
Vasodilators are often given alongside these as vasospasm may cause this (non-occlusive)
Rememebr there may be multiple emboli (not uncommon)
Mesenteric ischaemia may also be venous. Discuss the difference?
What vein is often involved?
How is it managed?
What non-vascular cause may lead to venous thrombosis and what is the management?
This would be more gradual onset and is usually compensated
Portal vein is often involved => tx is anticoagulation with consideration for TIPS.
Non-vascular would be sepsis => IV antibiotics may work
What is meant by non-occlusive mesenteric ischaemia?
What are the characteristic scenarios you would see this in?
This is seen in hypoperfusion states such as post-cardiac surgery or long term renal dialysis patients
