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mesentric ischemia.pptx

  1. Mesentric ischemia Ghadeer Ismail Eideh Supervised by Dr. Aref Rajabi From: step up to medicine
  2. Introduction 01 Clinical features 02 Diagnosis 03 Treatment 04 Chronic mesenteric ischemia 05 Outlines
  3. Introduction 01
  4. Acute mesentric ischemia • Acute mesenteric ischemia is a constant and severe decrease in blood flow. • Results from a compromised blood supply, usually to the superior mesenteric vessels.
  5. Arterial embolism (50% of cases): Almost all emboli are of a cardiac origin (e.g., atrial fibrillation, MI, Valvular disease). Arterial thrombosis (25% of cases). • Most of these patients have atherosclerotic disease (e.g., coronary artery disease [CAD], PVD, stroke) at other sites. • Acute occlusion occurs over pre- existing atherosclerotic disease. The acute event may be due to a decrease in cardiac output (e.g., resulting from MI, CHF) or plaque rupture. • Collateral circulation has usually developed. Types of acute mesentric ischemia
  6. Nonocclusive mesenteric ischemia (20% of cases). • Splanchnic vasoconstriction secondary to low cardiac output. • Typically seen in critically ill elderly patients. Venous thrombosis (<10% of cases). • Many predisposing factors—infection, hypercoagulable states, oral contraceptives, portal HTN, malignancy, pancreatitis. Types of acute mesentric ischemia • The overall mortality rate for all types of acute mesenteric ischemia is about 60% to 70%. If bowel infarction has occurred, the mortality rate can exceed 90%
  7. Clinical features 02
  8. Clinical features: 1. Classic presentation is acute onset of severe abdominal pain disproportionate to physical findings. Pain is due to ischemia and possibly infarction of intestines, analogous to MI in CAD. a. The abdominal examination may appear benign even when there is severe ischemia. This can lead to a delay in diagnosis. b. The acuteness and the severity of pain vary depending on the type of acute mesenteric ischemia. 2. Anorexia, vomiting. 3. GI bleeding (mild). . 4. Peritonitis, sepsis, and shock may be present in advanced disease.
  9. Differences in Presentation of Types of Acute Mesenteric Ischemia: • Embolic—symptoms are more sudden and painful than other causes • Arterial thrombosis—symptoms are more gradual and less severe than embolic causes • Nonocclusive ischemia—typically occurs in critically ill patients • Venous thrombosis—symptoms may be present for several days or even weeks, with gradual worsening
  10. Clinical features: ● Signs of intestinal infarction include hypotension, tachypnea, lactic acidosis, fever, and altered mental status (eventually leading to shock). ● Check the lactate level if acute mesenteric ischemia is suspected.
  11. Diagnosis 03
  12. Diagnosis: 1. Mesenteric angiography is the definitive diagnostic test. 2. Obtain a plain film of the abdomen to exclude other causes of abdominal pain. 3. “Thumbprinting” can be seen on barium enema due to thickened edematous mucosal folds.
  13. Treatment 04
  14. Treatment 1. Supportive measures: IV fluids and broad-spectrum antibiotics 2. Direct intra-arterial infusion of papaverine (vasodilator) into the superior mesenteric system during arteriography is the therapy of choice for all arterial causes of acute mesenteric ischemia. This relieves the occlusion and vasospasm. 3. Direct intra-arterial infusion of thrombolytics or embolectomy may be indicated in some patients with embolic acute mesenteric ischemia. 4. Heparin anticoagulation is the treatment of choice for venous thrombosis. 5. Surgery (resection of nonviable bowel) may be needed in all types of acute mesenteric ischemia if signs of peritonitis develop.
  15. Chronic mesenteric ischemia
  16. Chronic mesenteric ishcemia ● Caused by atherosclerotic occlusive disease of main mesenteric vessels (celiac artery, superior and inferior mesenteric arteries). ● Abdominal angina—dull pain, typically postprandial (when there is increased demand for splanchnic blood flow); analogous to anginal pain of CAD. Significant weight loss may occur due to abdominal angina. ● Mesenteric arteriography confirms the diagnosis. ● Surgical revascularization is definitive treatment and leads to pain relief in 90% of cases.
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