1 management of acute mesenteric ischemia cn shum (2 nd year hst) department of surgery pamela youde...
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Management of Management of Acute Mesenteric IschemiaAcute Mesenteric Ischemia
CN Shum (2CN Shum (2ndnd Year HST) Year HST)
Department of SurgeryPamela Youde Nethersole Eastern HospitalPamela Youde Nethersole Eastern Hospital
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Definition of Mesenteric IschemiaDefinition of Mesenteric Ischemia
Interruption of intestinal blood flow byInterruption of intestinal blood flow by embolism, embolism, thrombosis, or thrombosis, or a low-flow state.a low-flow state.
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PathophysiologyPathophysiology
Ischemia
Mucosal barrier disruption
Release of bacteria, toxins, vasoactive substance
SIRS
MODS
Death
Substantial protein-rich fluid lossinto the gut
Hypovolemia
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How common is Mesenteric How common is Mesenteric Ischemia?Ischemia?
0.1% of all hospital admissions. 0.1% of all hospital admissions.
Mesenteric artery stenosis is found in Mesenteric artery stenosis is found in 17.5% of independent elderly adults. 17.5% of independent elderly adults.
•Cappell MS, et al. Cappell MS, et al. Gastroenterol Clin North AmGastroenterol Clin North Am. Dec 1998;27(4):827-. Dec 1998;27(4):827-60, vi. 60, vi. •Ha C, et al. Ha C, et al. Am J GastroenterolAm J Gastroenterol. Jun 2009;104(6):1445-51. . Jun 2009;104(6):1445-51.
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Classification of Mesenteric Classification of Mesenteric IschemiaIschemia
AcuteAcute 4 distinct mechanisms4 distinct mechanisms
ChronicChronic Due to long standing Due to long standing
atherosclerosisatherosclerosis
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Causes of Acute Mesenteric Causes of Acute Mesenteric Ischemia (AMI)Ischemia (AMI)
TypeType Risk FactorsRisk Factors
Mesenteric Arterial Embolus (MAE)Mesenteric Arterial Embolus (MAE)
(> 50%)(> 50%)
Coronary artery disease, heart failure, Coronary artery disease, heart failure, valvular heart disease, atrial fibrillation, valvular heart disease, atrial fibrillation, history of arterial embolihistory of arterial emboli
Mesenteric Arterial thrombosis (MAT)Mesenteric Arterial thrombosis (MAT)
(10%)(10%)
Generalized atherosclerosisGeneralized atherosclerosis
Mesenteric Venous thrombosis (MVT)Mesenteric Venous thrombosis (MVT)
(5–15%)(5–15%)
Hypercoagulable state, inflammatory Hypercoagulable state, inflammatory conditions (eg, pancreatitis, diverticulitis), conditions (eg, pancreatitis, diverticulitis), trauma, heart failure, renal failure, portal trauma, heart failure, renal failure, portal hypertension, decompression sicknesshypertension, decompression sickness
Non-Occlusive Mesenteric Ischemia Non-Occlusive Mesenteric Ischemia (NOMI)(NOMI)
(25%)(25%)
Low flow states (eg, heart failure, shock, Low flow states (eg, heart failure, shock, cardiopulmonary bypass) and splanchnic cardiopulmonary bypass) and splanchnic vasoconstriction (eg, vasopressors, vasoconstriction (eg, vasopressors, cocaine)cocaine)
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Clinical presentation of Clinical presentation of Acute mesenteric IschemiaAcute mesenteric Ischemia
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Symptoms & signsSymptoms & signs
In a series of 58 patients with mesenteric ischemia due In a series of 58 patients with mesenteric ischemia due to mixed causes:to mixed causes:
abdominal pain abdominal pain 95% 95% NauseaNausea 44% 44% vomiting vomiting 35% 35% diarrhea diarrhea 35% 35% heart rate > 100heart rate > 100 33%33% ShockShock 33%33% metabolic acidosismetabolic acidosis 33% 33% 'blood per rectum‘'blood per rectum‘ 16% 16% ConstipationConstipation 7% 7%
Park WM, et al. Park WM, et al. J. Vasc. Surg.J. Vasc. Surg. 3535 (3): 445–52. (3): 445–52.
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Acute Mesenteric Ischemia due to Acute Mesenteric Ischemia due to embolisationembolisation
F:M=2:1F:M=2:1Median age 70Median age 70Typical presentationTypical presentation Sudden onset of periumbilical painSudden onset of periumbilical pain Followed by copious vomiting and explosive Followed by copious vomiting and explosive
diarrhoeadiarrhoea Abdominal signsAbdominal signs
Early: non-specificEarly: non-specificLate (likely infarction): Peritonism, Blood in stool or Late (likely infarction): Peritonism, Blood in stool or vomitusvomitus
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Acute Mesenteric Ischemia due to Acute Mesenteric Ischemia due to thrombosisthrombosis
Often a history of Often a history of intestinal anginaintestinal angina nauseanausea SitophobiaSitophobia significant wt losssignificant wt loss
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Acute Mesenteric Ischemia due to Acute Mesenteric Ischemia due to venous thrombosisvenous thrombosis
Insidious onset over weeksInsidious onset over weeks Nausea, anorexia, diarrhoeaNausea, anorexia, diarrhoea
Later clinical courseLater clinical course Diffuse abd painDiffuse abd pain
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Acute Mesenteric Ischemia due to Acute Mesenteric Ischemia due to nonocclusive disease nonocclusive disease
Occurs in patient with wide-spread Occurs in patient with wide-spread vasoconstrictionvasoconstriction Critically illCritically ill ShockShock vasopressorsvasopressors
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Diagnostic InvestigationsDiagnostic Investigations
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Blood testsBlood tests
Elevation ofElevation of WCCWCC AmylaseAmylase Phosphate Phosphate
Increases within 4 hours (75%) Increases within 4 hours (75%) Reference:Reference:
Can J Surg. 1979 Jan;22(1):40-5 Can J Surg. 1979 Jan;22(1):40-5
Metabolic acidosisMetabolic acidosis
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Plain XRayPlain XRay
Non-specific dilatation of bowelNon-specific dilatation of bowel
Late signs:Late signs: Thumb-printing (edematous bowel wall)Thumb-printing (edematous bowel wall) Pneumatosis intestinalisPneumatosis intestinalis Portal venous gasPortal venous gas
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Thumb-printingThumb-printing
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Pneumatosis IntestinalisPneumatosis Intestinalis
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Portal Venous GasPortal Venous Gas
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Doppler USGDoppler USG
Able to identify severe Able to identify severe stenosis or total stenosis or total occlusion:occlusion: Sensitivity 70-89%Sensitivity 70-89% Specificity 92-100%Specificity 92-100%
Unable to detectUnable to detect emboli beyond the emboli beyond the
proximal main vessel proximal main vessel NOMINOMI
•J Vasc Surg 14 (1991), pp. 511–518. •J Vasc Surg 14 (1991), pp. 780–786.
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AngiographyAngiography
Non-invasiveNon-invasive CTACTA
Advantages:Advantages: Better spatial Better spatial
resolutionresolution Faster acquisition Faster acquisition
timetime
MRAMRAAdvantages:Advantages:
No radiationNo radiation No need of iodinated No need of iodinated
contrastcontrast
InvasiveInvasive CatheterCatheter
•AJRAJR 2007; 188:452-461 2007; 188:452-461*J Gastrointest Surg. 2005 Dec;9(9):1262-74 *J Gastrointest Surg. 2005 Dec;9(9):1262-74
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Treatment of Acute Treatment of Acute Mesenteric Ischemia Mesenteric Ischemia
……slightly varied depending of its slightly varied depending of its causescauses
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Treatment in generalTreatment in generalSuspected case
Fluid resuscitationOxygen, NG tube
Broad spectum antibioticsStop vasopressors/ Digitalis
Invasive hemodynamic monitorsTreat arrthymia/ heart failure
Stable Unstable or Peritonism
Angiogram Laparotomy +/- revasularisation +/- bowel resection
Possibility of radiological intervention
Consider vasodilator/ anticoagulation
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Role of anticoagulation dependent on Role of anticoagulation dependent on causes of AMIcauses of AMI
Immediate after dxImmediate after dx Early post-opEarly post-op Long termLong term
Arterial embolismArterial embolism YesYes YesYes
ArterialArterial
thrombosisthrombosis
YesYes
VenousVenous
thrombosisthrombosis
YesYes Yes Yes
(esp if underlying (esp if underlying hypercoagulability hypercoagulability uncovered)uncovered)
Non-occlusiveNon-occlusive
SurgerySurgery 101101 (1987), pp. 383–388. (1987), pp. 383–388. Am SurgAm Surg 5757 (1991), pp. 573–578. (1991), pp. 573–578. Ann SurgAnn Surg 161161 (1965), pp. 516–523. (1965), pp. 516–523.
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Role of vasodilatorsRole of vasodilators
Experiences mainly on papaverineExperiences mainly on papaverine Others:Others:
tolazoline, glucagon, nitroglycerin, nitroprusside, prostaglandin E, phenoxybenzamine, and isoproterenol
For NOMIFor NOMI Mainstay of txMainstay of tx
Reduce mortality from 70-90% to 0-55% Reduce mortality from 70-90% to 0-55%
For Occlusive MIFor Occlusive MI AdjunctAdjunct Not practiced universallyNot practiced universally
Am J RadiolAm J Radiol 142142 (1984), pp. 555–562. (1984), pp. 555–562. SurgerySurgery 8282 (1977), pp. 848–855. (1977), pp. 848–855. Curr Top Surg ResCurr Top Surg Res 33 (1971), pp. 425–433. (1971), pp. 425–433. Br J SurgBr J Surg 7777 (1990), pp. 601–603. (1990), pp. 601–603.
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Role of Interventional RadiologyRole of Interventional RadiologyOptionsOptions ApplicationApplication RemarksRemarks
Catheter directed Catheter directed infusion of infusion of vasodilatorsvasodilators
Primary treatment in Primary treatment in NOMINOMI
Catheter directed Catheter directed thrombolysisthrombolysis
Anecdotal use in Anecdotal use in Occlusive MIOcclusive MI
Measures to ensure Measures to ensure bowel viability e.g. bowel viability e.g. LaparoscopyLaparoscopy
AngioplastyAngioplasty AMI: scantAMI: scant
CMI: commonCMI: common
•Regan, F,et al. Am. J. Gastroenterol. 91(5):1019–1021, 1996.
•Jamieson, A.C., et al. Aust. N. Z. J. Surg. 49:355–356, 1979.
•Flickinger, E.J., et al. Am. J. Roentgenol. 140:771–773, 1983.
•Rivitz, S.M., et al. J. Vasc. Interv. Radiol. 6(2):219–223,1995.
•Rijs, J., et al. Acta. Chir. Belg. 97(5):247–249, 1997.
•Train, J.S., et al. J. Vasc. Interv. Radiol. 9(3):461–464, 1998.
•Poplausky, M.R., et al. Gastroenterology 110(5):1633–1635, 1996.
•Walsh, R.M., et al. Surg. Endosc. 12(12):1405–1409, 1998.
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Case reports and small series of use of thrombolytic agents for SMA emboliCase reports and small series of use of thrombolytic agents for SMA emboli Study (Study (yryr) ) No. of No. of
patientpatientPartialPartial
OcclusionOcclusion
Total Total
OcclusionOcclusion
CentralCentral
LocationLocation
PeripheralPeripheral
LocationLocation
StreptokinaseStreptokinase UrokinaseUrokinase rtPArtPA OutcomeOutcome
Badiola and ScoppettaBadiola and Scoppetta54 (1997) (1997) 11 ++ ++ SuccessfulSuccessful
Bonardelli et al.Bonardelli et al.55 (1994) (1994) 11 ++ ++ Embolectomy, resectionEmbolectomy, resection
Boyer et al.Boyer et al.56 (1994) (1994) 11 ++ ++ ++ SuccessfulSuccessful
Flickinger et al.Flickinger et al.57 (1983) (1983) 11 ++ ++ ++ Embolus lysed; pt died of CHFEmbolus lysed; pt died of CHF
Gallego et al.Gallego et al.67 (1996) (1996) 22 11 11 ++ Successful by 4 hrSuccessful by 4 hr
Hillers et al.Hillers et al.58 (1990) (1990) ++
Hirota et al.Hirota et al.59 (1997) (1997) 11 ++ SuccessfulSuccessful
Kwauk et al.Kwauk et al.60 (1996) (1996) 11 ++ ++ SuccessfulSuccessful
McBride and GainesMcBride and Gaines61 (1994) (1994) 11 ++ SuccessfulSuccessful
Pillari et al.Pillari et al.62 (1983) (1983) 11 ++ ++ ++ Successful by 36 hrSuccessful by 36 hr
Ramirez et al.Ramirez et al.63 (1990) (1990) 11 SuccessfulSuccessful
Regan et al.Regan et al.64 (1996) (1996) 11 ++ ++ ++ SuccessfulSuccessful
Rodde et al.Rodde et al.65 (1991) (1991) 11 ++ ++ ++ SuccessfulSuccessful
Schoenbaum et al.Schoenbaum et al.68 (1992) (1992) 44 22 22 ++ Resection needed in 1 patientResection needed in 1 patient
Sicard et al.Sicard et al.69 (1984) (1984) 22 SuccessfulSuccessful
Simo et al.Simo et al.70 (1997) (1997) 1010 ++ Embolysis 90%; Clinical success Embolysis 90%; Clinical success 70%; Laparotomy 30%70%; Laparotomy 30%
Turegano Fuentes et al.Turegano Fuentes et al.71 (1995) (1995) 22 11 11
Vujic et al.Vujic et al.66 (1984) (1984) 11 ++ ++ Successful by 30 h rSuccessful by 30 h r
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Role of surgeryRole of surgery
Allow assessment of bowel viabiltiyAllow assessment of bowel viabiltiy
Allow resection of non-viable bowelAllow resection of non-viable bowel
Allow specific procedure Allow specific procedure
Types of AMITypes of AMI Specific surgical Specific surgical procedureprocedure
MAEMAE EmbolectomyEmbolectomy
MATMAT BypassBypass
MVTMVT Venous thrombectomy is not usually recommended
as it often recurs and results in distal diffuse extention(Surg Clin North Am 1997;77:327–38.)
NOMINOMI NoNo
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Laparotomy findings in arterial embolismLaparotomy findings in arterial embolism
Location of embolismLocation of embolism usually just distal to the middle colic arteryusually just distal to the middle colic artery
Sparing Sparing proximal jejunum & distal large bowelproximal jejunum & distal large bowel
Next procedure:Next procedure: EmbolectomyEmbolectomy
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Embolectomy Embolectomy
(A) Exposure of superior (A) Exposure of superior mesenteric artery by reflection mesenteric artery by reflection of Ligament of Treitz. of Ligament of Treitz. (B) A transverse arteriotomy is (B) A transverse arteriotomy is performed transversely, performed transversely, proximal to the middle colic proximal to the middle colic branch of the superior branch of the superior mesenteric artery. mesenteric artery. (C) Embolectomy is performed (C) Embolectomy is performed with a 4-F embolectomy with a 4-F embolectomy catheter. catheter. (D) Artery is closed with (D) Artery is closed with interrupted praline suture. interrupted praline suture.
Kazmers A: Ann Vasc Surg 12:191, 1998.
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Laparotomy findings in arterial thrombosisLaparotomy findings in arterial thrombosis
Location of thrombosisLocation of thrombosis usually at the origin of SMAusually at the origin of SMA
No sparingNo sparing the entire small bowel and proximal large bowel appear ischemic the entire small bowel and proximal large bowel appear ischemic
Next procedureNext procedure BypassBypass
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BypassBypass
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After revascularization After revascularization (embolectomy or bypass)(embolectomy or bypass)
Alert anesthetist before Alert anesthetist before reperfusion reperfusion can lead to sudden physiologic and metabolic can lead to sudden physiologic and metabolic
derangements, including hypotension, derangements, including hypotension, hyperkalemia, and profound acidosis. hyperkalemia, and profound acidosis.
Consider postrevascularization Consider postrevascularization papaverinepapaverine
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After reperfusionAfter reperfusion
Allow 30 minutesto assess bowel
viability
Primary markers:•peristalsis •color•palpable arterial pulsations
Doppler probesiv fluorescein
followed by Wood’sLamp exam
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For non-viable looking bowelFor non-viable looking bowel
Frankly necrotic bowel segmentsFrankly necrotic bowel segments resectionresection
Marginal-viable bowelMarginal-viable bowel may improve over hoursmay improve over hours consider second-look laparotomyconsider second-look laparotomy
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PrognosisPrognosis
Depends on time & typeDepends on time & type
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Mortality rates for AMI Mortality rates for AMI Study (Study (yryr) ) No. of patientsNo. of patients Mortality rate (%)Mortality rate (%)
BraunBraun2 (1985) (1985) 5252 6464
Clavien et al.Clavien et al.3 (1987) (1987) 8181 8383
Cohen Solal et al.Cohen Solal et al.4 (1993) (1993) 3030 6767
Finucani et al.Finucani et al.5 (1989) (1989) 3232 6666
GeorgievGeorgiev6 (1989) (1989) 175175 9393
Inderbitzi et al.Inderbitzi et al.7 (1992) (1992) 100100 6868
Kach and LargiaderKach and Largiader8 (1989) (1989) 4545 6060
Koveker et al.Koveker et al.9 (1985) (1985) 3939 8585
Levy et al.Levy et al.10 (1990) (1990) 92*92* 5959
MishimaMishima11 (1988) (1988) 162162 6565
Ritz et al.Ritz et al.12 (1997) (1997) 141141 7171
Voltolini et al.Voltolini et al.13 (1996) (1996) 4747 7272
Zan et al.Zan et al.14 (1993) (1993) 3232 7272
**Patients with NOMI excluded. Patients with NOMI excluded.
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Studies showing the importance of Studies showing the importance of early diagnosis of AMI on survival early diagnosis of AMI on survival
Study (Study (yryr) ) No. of patients No. of patients Mortality % Mortality %
(No gangrene )(No gangrene )
Mortality % (Gangrene Mortality % (Gangrene ))
Mortality %Mortality %
(<24H of symptoms)(<24H of symptoms)
Mortality %Mortality %
(>24H of symptoms)(>24H of symptoms)
Batellier and KienyBatellier and Kieny15 (1990) (1990)
6565 2525 6868
Boley et al.Boley et al.18 (1981) (1981) 4747 5757 7373
Inderbitzi et al.Inderbitzi et al.7 (1990) (1990)
8383 17 (a)17 (a) 8888
KienyKieny16 (1990) (1990) 9898 2626 7171
Lazaro et al.Lazaro et al.17 (1986) (1986) 2323 2525 7575
Levy et al.10 (1990) Levy et al.10 (1990) 9292 3131 7373
Ritz et al.12 (1997) Ritz et al.12 (1997) 141141 44 (b)44 (b) 9292
Vellar and Doyle19 Vellar and Doyle19 (1977) (1977)
5252 5454 9595
aa<12 hours, mortality = 0%. <12 hours, mortality = 0%. bb<12 hours, mortality = 0%.<12 hours, mortality = 0%.
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Mortality of different types of AMIMortality of different types of AMI
arterial embolismarterial embolism 54%54%
arterial thrombosisarterial thrombosis 77%77%
venous thrombosisvenous thrombosis 32%32%
non-occlusive ischemianon-occlusive ischemia 73%73%
Brandt LJ, Boley SJ (2000). “AGA technical review on Brandt LJ, Boley SJ (2000). “AGA technical review on intestinal ischemia. American Gastrointestinal intestinal ischemia. American Gastrointestinal Association”. Association”. GastroenterologyGastroenterology 118118 (5): 954–68. (5): 954–68.
Schoots IG, Koffeman GI, Legemate DA, Levi M, van Schoots IG, Koffeman GI, Legemate DA, Levi M, van Gulik TM (2004). "Systematic review of survival after Gulik TM (2004). "Systematic review of survival after acute mesenteric ischaemia according to disease acute mesenteric ischaemia according to disease aetiology". aetiology". The British journal of surgeryThe British journal of surgery 9191 (1): 17–27. (1): 17–27.
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Acute Mesenteric Acute Mesenteric IschemiaIschemia
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