mesenteric ischemia in dilated cardiomyopathy
TRANSCRIPT
Mesenteric Ischemia in Dilated
CardiomyopathyJo Anne N. Ramos, MD
Department of Internal Medicine
SD 57/M CC: abdominal pain Admitting Diagnosis:
◦ Acute Gastroenteritis with no dehydration, Acid Peptic Disease; Dilated Cardiomyopathy in CHF, FC III, AF with RVR
FINAL DIAGNOSIS:◦ CP Arrest sec to Mesenteric Ischemia probably
sec to Massive Pulmonary Embolism; Dilated Cardiomyopathy, in CHF, FC III; HPN; Alcoholism
3 days of hospitalization
To present a case of a patient with Dilated Cardiomyopathy.
To discuss the pathophysiology that led to the demise of the patient.
Objectives:
DS57/MMarriedFilipinoSta. Rosa, N.E.
General Data
Chief Complaint
Abdominal pain
2 hours PTA •Abdominal pain on the epigastrium•No dysuria, diarrhea, fever, chest pain, nausea and vomiting observed. No consult was done or medication taken.
1 hour PTA•Persistent of abdominal pain, now diffuse in nature •Associated with 2 episodes of ½ cup per bout, watery, non-bloody, non-mucoid, stools prompted consult and thus admission.
History of Present Illness
(+) Dilated Cardiomyopathy, December 2011 sec to excessive alcohol consumption
(+) APD, Feb 2012 on Esomeprazole 40mg OD
(+) Hypertension for more than 7 years. UBP 150/90, HBP 190/100
No diabetes, asthma, cancer Previous surgery
Past Medical History
(+) Hypertension No DM, Cancer, Asthma
Family History
Works as a farmer but stopped 8 months PTA due to easy fatigability
23 pack year smoking history 9stopped for 5 months)
Drinks alcohol daily, consuming 5 glasses of gin every night for the past 26 years.
Personal and Social History
No headache, no colds, no tinnitus, no epistaxis, no throat pain
(+) easy fatigability, 3-pillow orthopnea, (-) PND, (+) palpitation
No changes in stool caliber, no diarrhea, no constipation, no hematochezia, no hematemesis
Review of Systems
No weight loss, no loss of appetite No jaundice, darkening of the neck and
alar area No hematuria, no flank pain, no frequency No polyuria, polydipsia, polyphagia,
heat/cold intolerance No easy bruising or bleeding tendency
GENERAL SURVEY: Patient is conscious, coherent, anxious
VITAL SIGNS:BP 160/100 CR 68 RR 27 T 37.6
HEENT:(-) icterisia, pink palpebral conjunctiva, (-) nasoaural discharge, (-) tonsillopharyngeal wall congestion, (-) cervicolymphadenopathy
C/L:Symmetrical chest expansion, (-) retractions, clear breath sounds
Physical Examination
HEART: Dynamic precordium, PMI at 6th ICS LAAL, normal rate, irregular rhythm, no murmur appreciated
ABDOMEN: Flabby, normoactive bowel sounds, soft, (+)
direct tenderness on the epigastrium on deep palpation, (+) tympanitic on percussion
EXTREMITIES: Grossly normal, no edema, (+) paradoxical pulses
Acute Gastroenteritis with no dehydration Acid Peptic Disease Dilated Cardiomyopathy in CHF, FC III, AF
with RVR
Admitting Impression
10 minutes at the ER•hooked to PNSS 1L to run for 30gtts/min, Esomeprazole 40mg thru IV•CBC, RBS, serum electrolytes, cardiac panel and fecalysis . •12-L ECG and CXR•AP informed
1 hour at the ER •Afforded relief from Esomeprazole
1hour 30 min at the ER •Send to ward
At the ER
CBC hgb168/hct48.9/wbc9.87/neu49.14/lym34.4/plt210RBS 116Na 141K 3.5 Cardiac panel ckmb 4.5 (0-4.3), mgb 287 (0-107), trop I 0.15 (0-0.05), bnp 624 (0-100), d dimer 1800 (0-400)
AP updated. Patient was started with Esomeprazole 40mg 1 cap OD AC, Metronidazole 500mg 2 tabs BID, Tramadol 50mg 1 tab OD, Kalium durule 2 tabs OD.
At the Ward (1st day of hospitalization)
S O A P
(+) DOB(+) dull abdominal pain on the epigaastrium
Patient is anxiousBP 130/80, CR 91 RR 31
HEENT: (+) NVEC/L: diffuse crackles on both lung fieldsAbd: (+) direct tenderness on epigastrium (-) rebound
Acute Pulmonary EdemaAcid Peptic Disease
Furosemide 60mg IV pushTramadol 25mg slow IV pushVS monitoring q1AP inforemed
10 hours after the admission
12 hours after the admission
S O A P
(+) DOB(+) severe, dull abdominal pain on the epigastrium
Patient is anxiousBP 120/80, CR 91 RR 31
HEENT: (+) NVEC/L: dec crackles on both lung fieldsAbd: (+) direct tenderness on epigastrium (-) rebound
Acute Pulmonary EdemaAcid Peptic Disease
Tramadol 25mg slow IV pushVS monitoring q1Cardiac panel
Transfer to ICUAP ordered:Heparin 7,500 IU IV push Dabigatran 150mg BID and Fondaparinux 5mcg SQ OD.
Cardiac Panelckmb 4.5, mgb >580, trop I 0.10, BNP 3060, d dimer
3840
16 hours after the admission
S O A P
(-) DOB(+) severe dull abdominal pain on the epigaastrium(+) bloatedness
Patient is anxiousBP 120/80, CR 91 RR 28 o2sat 95%
HEENT: (-) NVEC/L: occ cracklesAbd: (+) direct tenderness on epigastrium (-) rebound
Acute Pulmonary EdemaAcid Peptic Disease with Dysmotility Disorder
Bisacodyl suppository and Mosaopride 5mg TID NPO temporarily.
2nd day of hospitalization
S O A P
(-) DOB(+) tolerable, dull abdominal pain on the epigastrium(+) bloatedness
Patient is anxiousBP 120/80, CR 91 RR 28 o2sat 95%
HEENT: (-) NVEC/L: occ cracklesAbd: (+) direct tenderness on epigastrium (-) rebound
Acute Pulmonary EdemaAcid Peptic Disease with Dysmotility Disorder vs Acute Pancreatits vs Mesenteric Ishemia
Lactulose 30ccNalbuphine 5mg IV q 12Serum amylase, alkaline phosphatase, SGPT/SGOTMaintain on NPO
3rd day of hospitalization
S O A P
(+) fresh blood stools
Patient is drowsy to obtundedBP palp 70, CR 53 RR 14 O2sat 80-85%
C/L: diffuse cracklesAbd: (+) direct tenderness on epigastrium (-) rebound
Acute Pulmonary EdemaAcute Pancreatitis vs Mesenteric Ischemia
RBS statLevophed drip inc to 30gtts/minD50-50 1 vial IV pushIntubate patient
56 mg/dL
15 minutes after intubation
S O A P
45 minutes
Patient is drowsy to obtundedBP unappreciatedCR OC/L: diffuse cracklesECG- pulseless electrical activity
BP 0 CR 0 Pupils fixed dilated
Mesenteric Ischemia
CP Arrest sec to Mesenteric Ischemia sec to Massive Pulmonary Embolism
CPR startedEpinephrine 1mg/amp every 3 minutes
Pathophysiology
Excessive alcohol
consumption
Increased systemic blood
pressure
Alcohol metabolites
IncreasesOxidative
stress
Formation of oxygen radicals
Endothelial and tissue
dysfunction
Chronic myocardial dysfunction
Surviving myocytes hypertrophy to
accommodate the increased burden of
wall stress
Dynamic remodeling of the interstitial
scaffolding
Dilated cardiomyopathy
Dilated Cardiomyopathy
Mitral regurgitation
Atrial fibrillation
Insufficient perfusion to
intestinal tissue
Ischemic tissue injury
Disruption of blood flow by an
embolus or progressive thrombosis
Arterial insufficiency causes tissue
hypoxia, leading to initial bowel
wall spasm
DiarrheaMucosal
sloughingFresh blood
stools
Visceral abdominal
painMucosal barrier
disruption
Bacteria, toxins and vasoactive substance released into the
systemic circulation
Cardiovascular collapseShock
Final Diagnosis
Immediate Cause :CP Arrest sec to Mesenteric
Ischemia probably sec to Massive Pulmonary EmbolismAntecedent Cause:
Dilated Cardiomyopathy, in CHF, FC IIIUnderlying Cause:
Hypertensive Cardiovascular Disease
Alcoholism