guide line: acute mesenteric sichemia
TRANSCRIPT
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Acute mesenteric ischemia
Presenter: R 蔡逸文
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Method
Literature review. MEDLINE/PubMed MeSH term keyword: “mesenteric
ischemia”, “bowel ischemia”, and “bowel infarction”
Exclusion: Isolated colonic ischemia and focal segmental ischemia secondary to adhesions, hernias or other forms of extrinsic compression.
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Level of evidence
Classification system used to determine strength of evidence
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Presentation and clinical diagnosis etiology
Diagnosis Image
Treatment Vascular procedure Damage control surgery prevention
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Which clinical factors should arouse suspicion of AMI in the acute abdomen?
Presentation and clinical diagnosis
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Which clinical factors should arouse suspicion of AMI in the acute abdomen?
Acute abdominal pain is disproportionate to the physical examination findings
Early: Nausea, vomiting and initial forced
evacuation
Late if transmural infarction: Fever, bloody diarrhea and shock
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Are there any clinical features to distinguish the
etiology of AMI?
Presentation and clinical diagnosis
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Arterial thrombosis (TAMI): 25%
Arterial Embolic (EAMI): 45%
Non-occlusive (NOMI): 20%
Venous thrombosis (VAMI): 10%
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Embolic MI
CHARACTERISTICS The sudden onset of
severe pain spontaneous
emptying of the bowel (vomiting and diarrhea)
no significant physical findings(40-80%)
RISK FACTOR Atrial fibrillation Rheumatic heart
disease Myocardial infarction Prosthetic valve Ventricular aneurism
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Arterial thrombosis MI
CHARACTERISTICS Acute episode, may
be recurrent Prodromal symptoms
of mesenteric angina postprandial abdominal
pain Nausea weight loss
RISK FACTOR Atherosclerosis Dyslipidemia History of other
vascular events, previous vascular surgery
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Venous thrombosis MI
CHARACTERISTICS Subacute abdominal
pain Vague complaints Younger population
Thromboembolic AMI in the over 60s
VAMI in the over 40s
RISK FACTOR Hypercoagulability states Abdominal trauma Acute pancreatitis Malignancy Nephrotic syndrome, portal hypertension or
cirrhosis or splenomegaly
Oral contraceptives Pregnancy and the
puerperium
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Non-occlusive MI
CHARACTERISTICS Critically ill, sedated
and artificially ventilated Vague complaints
Acute or insidious pain (without defecation)
Mesenteric hypoperfusion secondary to circulatory shock or vasoactive drugs
RISK FACTOR Shock, hypovolemia,
hypotension Digitalis Diuretics beta-blockers, alpha-
adrenergics Enteral nutrition, Critical care support
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Can we predict prognosis at presentation, to help
the decision making process?
Presentation and clinical diagnosis
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Risk factor for mortality Older age Bandemia, Elevated serum aspartate
aminotransferase, Increased blood urea nitrogen, Metabolic acidosis
Significant co-morbidities and poor performance status
Intestinal necrosis Increased elapsed time to laparotomy(24hr) When the colon was involved
Aliosmanoglu I et al. Int Surg. 2013
Huang HH, et al. Chin Med Assoc. 2005
Gupta PK et al. Surgery. 2011
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What is the most sensitive and specific test for the
detection of AMI?
Presentation and clinical diagnosis
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Multi-detector computerized tomography scanning (MDCT) with intravenous contrast (LOE: III)
Percutaneous angiography for suspected NOMI (LOE:III)
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Radiological features associated with AMI
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Pneumatosis intestinalis + hepatic portal or portomesenteric venous gas
↑the likelihood of transmural bowel infarction
Lisa M. Ho, et al. American Journal of Roentgenology. 2007Melanie S. Morris, et al .The American Journal of Surgery. 2008
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Is there a role for vasopressor drugs?
Treatment
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Vasopressor drugs should be avoided in AMI.
Minimal effect on the splanchnic circulation Dobutamine, low dose dopamine, or milrinone
Cardiac glycosides should not be used as first line treatment of atrial fibrillation/flutter in AMI (LOE: IV).
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What is the specific treatment for AMI?
Treatment
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Arterial embolism (EAMI)Treatment
Open embolectomy Endovascular embolectomy
percutaneous mechanical aspiration or thrombolysis
percutaneous transluminal angioplasty (PTA) with or without stenting
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Arterial thrombosis (TAMI)Treatment-1
Endovascular procedure PTA and stenting Percutaneous aspiration thrombectomy,
local fibrinolysis or intra-arterial drug perfusion
Retrograde open mesenteric stenting After resection of ischemic bowel Failed percutaneous treatment
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Arterial thrombosis (TAMI)Treatment-2 Bypass procedures
Antegrade bypass from supraceliac aorta to superior mesenteric trunk
Retrograde bypass from the infra-renal aorta and iliac arteries
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Non‑occlusive mesenteric ischemia (NOMI)Treatment
Correcting the underlying cause Improving mesenteric perfusion by
direct infusion of vasodilators. Prostaglandin E1 (alprostadil): 20 mcg
bolus followed by 60–80 mcg/24 h infusion;
papaverine (30–60 mg/h) Infarcted bowel resection(LOE: III)
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Venous ischemia (VAMI)Treatment
Systemic anticoagulation (LOE: III) Vascular
Failed medical therapy Transjugular intrahepatic portosystemic
shunting (TIPS) with mechanical aspiration thrombectomy and direct thrombolysis
Percutaneous transhepatic thrombolysis Indirect thrombolysis via the SMA
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How should a patient with peritonitis secondary to
AMI be managed?
Treatment
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Immediate surgery if comorbidities and clinical condition make curative treatment possible (LOE: III)
Patients considered unsalvageable should have palliative care (LOE: IV)
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What is the role of Damage Control Surgery in
AMI?
Treatment
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Laparotomy with resection of ischemic bowel (and no anastomosis or stoma)
open thrombectomy (if indicated) A temporary abdominal closure via a
negative pressure wound therapy
ICU and continue resuscitation
scheduled ‘second-look’ procedure within 48 h (LOE: III)
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How should bowel viability be assessed at operation?
Treatment
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Reassessed after adequate fluid resuscitation and revascularization.
Intra-operative assessment: Doppler ultrasound of the vascular arcade,
fluorescein angiography, indocyanine angiography
A second-look procedure for the doubts of viability of the bowel(LOE: IV).
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What limits should be observed in extensive
bowel resection?
Treatment
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What limits should be observed in extensive bowel resection?
Restoration of bowel continuity following extensive resection (LOE: III). Improve functional results May avoid the need for long term TPN
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Short bowel syndrome often occurs when residual small bowel length <200 cm
The following minimum remaining intestinal lengths must be respected : 100 cm for terminal jejunostomy (colon
removed) 65 cm for jejunocolic anastomosis (colon
retained) 35 cm for jejunoileal anastomosis with retention
of the ileocecal region.Messing B, et al. Gastroenterology.1999
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In the elderly patients and in those with significant co-morbidities Significant risk of resection
In younger patients Long term parenteral nutrition The option of subsequent intestinal
transplantation
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When is the most appropriate time to
perform an anastomosis in a patient with AMI who needs bowel resection?
Treatment
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Anastomosis should be avoided in patients with shock or multiple organ
dysfunction. (LOE: III)
Stoma avoid risks of anastomotic failure and permit easy examination
of the bowel by inspection or endoscopy
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What is the role of second‑look laparotomy
Treatment
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Access bowel viability after revascularization and resuscitation
possible progression of bowel ischemia? If doubt about the viability of the bowel,
resection of it (LOE: IV).
Bowel anastomosis(LOE: III). Close the wound
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Can we improve outcomes in terms of mortality and
morbidity?
Treatment
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Symptoms >24hr=> Mortality increases dramatically
Symptoms <12hr=> lowest mortality
Gut viability 100% when <12h 56% when 12~24hr 18% when >24hr
Aliosmanoglu I et al. Int Surg. 2013
Lobo Martinez E , et al. Rev Esp Enferm Dig. 1993
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Revascularization performed within 12 h from the onset of symptoms. (LOE: III)
Resection of non-viable bowel should be performed without delay. (LOE: III)
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Is there a role for prevention?
Treatment
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~60% TAMI have previous symptoms of chronic mesenteric ischemia
~30% EAMI have inadequately treated atrial fibrillation at presentation
Edwards MS, et al. Ann Vasc Surg. 2003
Edwards MS, et al. Ann Vasc Surg. 2003
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Elective revascularization for patients with proven CMI (LOE: IV)
Anticoagulants or antiplatelet therapy and statin therapy for patients with mesenteric artery thrombosis (LOE: IV). High risk of coronary thrombosisBj ¨ ornsson S, et al. J Gastrointest Surg 2013
Cho JS, et al. J Vasc Surg. 2002
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Life-long anticoagulation, unless contraindicated, for EAMI, prevent recurrence (LOE: IV).
A minimum of 6 months of anticoagulation and survey for thrombophilia or hypercoagulability for VAMI. (LOE: III). Klempnauer J, Surgery.
1997
Daniel G. et al. N Engl J Med 2016
Acosta S, et al. Br J Surg 2008;
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Take home message
History, physical examination prompt diagnosis should be achieved
and revascularization performed within 12 h from the onset of symptoms.
Resection of non-viable bowel should be performed without delay
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Are there sensitive and specific laboratory tests
for early detection of AMI?
Presentation and clinical diagnosis
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Routine laboratory tests reflect disease progression in AMI (LOE: III). Leukocytosis, metabolic acidosis with high anion
gap High level of Lactate, amylase, AST(GOT), lactate
dehydrogenase(LDH) and creatine phosphokinase(CPK)
A normal serum lactate level does not exclude AMI and not be used for diagnosis (LOE: III).