MESENTERIC ISCHEMIA THE FORGOTTEN DIAGNOSIS. Richard M. Gore, MD North Shore University Health System University of Chicago Evanston, Illinois

Transcription

1 MESENTERIC ISCHEMIA THE FORGOTTEN DIAGNOSIS Richard M. Gore, MD North Shore University Health System University of Chicago Evanston, Illinois SCBT/MR 2010 San Diego, California March 8, :00-16:10 16:10

2 TYPE 1: WHITE VASODILATION WITH HYPEREMIA ACUTE IBD INJURY TO INTRA- MURAL VESSELS CONTRAST LEAK: SHOCK BOWEL, RE- PERFUSION AFTER ISCHEMIA HEMORRHAGE

3 TYPE 1: WHITE VASODILATION WITH HYPEREMIA ACUTE IBD INJURY TO INTRA- MURAL VESSELS CONTRAST LEAK: SHOCK BOWEL, RE- PERFUSION AFTER ISCHEMIA HEMORRHAGE

4 TYPE 1: WHITE VASODILATION WITH HYPEREMIA ACUTE IBD INJURY TO INTRA- MURAL VESSELS CONTRAST LEAK: SHOCK BOWEL, RE- PERFUSION AFTER ISCHEMIA HEMORRHAGE

5 TYPE 1: WHITE VASODILATION WITH HYPEREMIA ACUTE IBD INJURY TO INTRA- MURAL VESSELS CONTRAST LEAK: SHOCK BOWEL, RE- PERFUSION AFTER ISCHEMIA HEMORRHAGE

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7 ARTERIAL INSUFFICIENCY WITHOUT REPERFUSION

8 ARTERIAL INSUFFICIENCY WITHOUT REPERFUSION

9 ARTERIAL INSUFFICIENCY WITH REPERFUSION

10 TYPE 1: WHITE VASODILATION WITH HYPEREMIA ACUTE IBD INJURY TO INTRA- MURAL VESSELS CONTRAST LEAK: SHOCK BOWEL, RE- PERFUSION AFTER ISCHEMIA HEMORRHAGE

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12 WHITE GRAY TARGET WATER TARGET FAT GAS

13 TYPE 2: GRAY HOMOGENEOUS ENHANCEMENT ~SK MUSCLE CHRONIC CROHN S DISEASE ISCHEMIA NEOPLASM

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15 ARTERIAL INSUFFICIENCY WITHOUT REPERFUSION

16 TYPE 3: TARGET-WATER MOST COMMON PATTERN IBD INFECTION ISCHEMIA RADIATION

17 ISCHEMIA

18 INFARCTION

19 MESENTERIC ISCHEMIA Mesenteric ischemia is a complex, multifaceted condition State of the systemic circulation Degree of functional or anatomic vascular compromise Number and caliber of vessels affected

20 MESENTERIC ISCHEMIA Response of the vascular bed to diminished perfusion Nature and capacity of the collateral circulation Duration of the ischemic insult Metabolic requirements of the involved segment of gut

21 ACUTE MESENTERIC ISCHEMIA Superior mesenteric artery embolism (SMAE) Nonocclusive mesenteric ischemia (NOMI) Superior mesenteric artery thrombosis (SMAT) Superior mesenteric vein thrombosis (SMVT)

22 ACUTE MESENTERIC ISCHEMIA SMA embolism (50%) NOMI (20-30%) SMA thrombosis (15-25%) SMV thrombosis (5%)

23 PATHOLOGIC DAMAGE MDCT FINDINGS VASODILATION MURAL HYPERDENSITY VASOCONSTRICTION MURAL PERMEABILITY MUCOSAL CELLULAR NECROSIS TRANSMURAL NECROSIS ABSENT OR MURAL ENHANCEMENT MURAL THICKENING BOWEL DISTENTION PNEUMATOSIS PORT-MES VEIN GAS PNEUMOPERITONEUM PNEUMORETROPERITONEUM

24 SMAE The wide caliber and narrow take off angle of the SMA off the aorta make it particularly vulnerable to embolic events. The offending emboli usually originate from a left atrial or ventricular mural thrombus or vegetations on a heart valve

25 SMAE Nearly one half of patients with SMAE will have synchronous extramesenteric emboli including peripheral artery emboli and 20% have synchronous emboli to the spleen, kidneys or other organs

26 SMAE Nearly one half of patients with SMAE will have synchronous extramesenteric emboli including peripheral artery emboli and 20% have synchronous emboli to the spleen, kidneys or other organs

27 SAME: CLINICAL FEATURES Sudden onset of severe periumbilical or right umbilical fossa abdominal pain. Severe pain is usually out of proportion to an often innocent physical examination which may reveal a soft abdomen with some tenderness on palpation. Nausea, vomiting, or diarrhea may occur. Query patient about cardiac disease such as previous myocardial infarction, arrythmias, cardiac valve disease, and previous arterial and venous embolism.

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29 IMPAIRED VENOUS DRAINAGE

30 IMPAIRED VENOUS DRAINAGE

31 IMPAIRED VENOUS DRAINAGE WITH REPERFUSION

32 IMPAIRED VENOUS DRAINAGE WITH INFARCTION

33 ISCHEMIC COLITIS LOW FLOW: CHF, HYPOVOLEMIA 80% ARTERIAL THROMBUS OR EMB 10% VENOUS THROMBOSIS 5% VASCULITIS (SLE) 5%

34 ISCHEMIC COLITIS PAIN OUT OF PROPORTION TO PHYSICAL EXAM, BLOODY DIARRHEA, NAUSEA, VOMITING ELDERLY: LEFT SIDED INVOLVEMENT DUE TO HYPOVOLEMIA YOUNG: RIGHT SIDED INVOLVEMENT DUE TO HEMORRHAGIC SHOCK OR TRAUMA (POOR COLLATERAL BLOOD FLOW, INCON- SISTENT MARGINAL ARTERY OF RT COLON)

35 TYPE 5-5 PNEUMATOSIS ISCHEMIA INFECTION TRAUMA BENIGN CAUSES CONNECTIVE TISSUE IBD OBSTRUCTION COPD