Acute Mesenteric Ischemia. Michael Klein, MD SUNY Downstate Medical Center August 20, 2015
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1 Acute Mesenteric Ischemia Michael Klein, MD SUNY Downstate Medical Center August 20, 2015
2 85F 5 months of intermittent diffuse abdominal pain Approximately 30-lb weight loss Abdominal distention PMH: HTN; on captopril/asa Social: Ex-smoker, many years
3 Exam NAD, AAOx3, comfortable Sitting upright and smiling Abdomen soft, NT, ND; (+)pulsatile mass in midline
4 Laboratory
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13 The daughter shows up... Every time she eats, she has stomach pains, then she stops eating.
14 Re-evaluation Comfortable No complaints of pain Abdomen soft, NT, ND (+) pulsatile abdominal mass
15 Re-evaluation Comfortable No complaints of pain Abdomen soft, NT, ND (+) pulsatile abdominal mass What next?
16 Repeat labs Lactate: 10 Lactate: L crystalloid WBC: 8 WBC: 14
17 Repeat labs Lactate: 10 Lactate: L crystalloid WBC: 8 WBC: 14 What next?
18 Exploratory laparotomy Negative for ischemia; Gut well-perfused, normal color. SMA with strong pulse, no thrill. SMV fills instantaneously.
19 Exploratory laparotomy EBL: 5 ml IVF: 1000 ml End-case lactate: 12.7 Transferred to SICU, remained intubated.
20 Medicine/Nephrology Consultations Hepatitis panel- (+) HAV TTE- EF 20-25% Salicylate level- neg Acetaminophen level- neg
21 Hospital course POD #0 Lactate POD #1 Extubated (+) HAV
22 Hospital course POD #2 Regular diet started (and fully consumed) Daughter: 80 lb, not 30 lb, weight loss over 1.5 years; difficulty swallowing for several weeks
23 Esophagram Normal swallowing. Normal motility. No GE reflux. No delay in gastric emptying.
24 Hospital Course POD #5 Lactic acidosis resolved LFT s trending down Tolerating diet, no abdominal pain Discharged home with close followup
25 POD #20 Seen in vascular clinic with other daughter:
26 POD #20 Seen in vascular clinic with other daughter: She doesn t eat due to loss of appetite -- she DOES NOT have abdominal pain after eating.
27 Lactic Acidosis Differential Diagnosis Ischemic Pharmacologic Genetic Other Hypoxia Biguanides (metformin) F16P deficiency Decreased clearance (hepatic disease) Hypoperfusion (shock) Isoniazid G6PD Lymphoma Hypoperfusion (regional) RTase inhibitors Pyruvate dehydrogenase deficiency Sepsis Nucleoside analogues Pyruvate carboxylase deficiency Overtraining Cyanide poisoning Biotinidase deficiency Ethanol toxicity MELAS syndrome GRACILE syndrome
28 Acute Mesenteric Ischemia Diagnosis and Imaging Michael Klein, MD SUNY Downstate Medical Center August 20, 2015
29 Questions (1) What is this patient s diagnosis? (2) Was everything done that could have been? (a) Is there additional imaging that could have helped? (b) Is there additional intervention that could have helped?
30 Pick your flavor
31 Mesenteric Arterial Supply
32 Mesenteric Arterial Supply
33 Mesenteric Arterial Supply +Arc of Riolan
34
35 Superior Mesenteric Artery
36 SMA
37 SMA
38 IMA
39 IMA
40 Acute Mesenteric Ischemia Uncommon, life threatening Early diagnosis is key Classic presentation: Abdominal pain out of proportion to physical exam
41 Embolic Sudden-onset pain Classic triad in 1/3rd of patients Pain Fever (+) FOBT Occlusion distal to SMA origin
42 Thrombotic Same presentation as embolic Difference: HISTORY of postprandial abdominal pain Occlusion at origin of SMA
43 Nonocclusive Due to hypotension, hypovolemia, shock or vasopressor use In rare cases, papaverine infusion may help Prognosis almost always poor
44 Mesenteric Venous Thrombosis 10% of cases May be caused by occlusion of the SMV (70%) IMV splenic vein portal vein Hypercoagulable state is a major risk factor
45 Workup: acute Physical exam Peritonitis LAPAROTOMY No peritonitis...
46 Workup: acute No specific laboratory tests leukocytosis lactic acidosis elevated AST, AlkP amylasemia dehydration
47 Workup: acute Imaging Need to evaluate mesenteric vascular flow XR Duplex ultrasonography CT angiography MR angiography Biplanar angiography
48 Duplex ultrasonography Limited role in acute mesenteric ischemia Ileus, bowel edema and bowel gas makes the study technically difficult Cannot detect distal emboli Strong role in chronic mesenteric ischemia
49 CT Angiography Can evaluate patency and stenosis of vessels, condition of bowel Can evaluate for MVT May find other causes of abdominal pain Quick, cheap, readily available
50 MR Angiography Similar to CTA Gadolinium less toxic than iodinated contrast Cannot evaluate distal SMA branches Not readily available More expensive
51 Cannot evaluate for MVT Not readily available Biplanar angiography Gold standard (?) Can visualize aorta down to several orders of distal branches Allows performance of interventions Allows evaluation of flow in real-time
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56 So what s the answer?
57 So what s the answer?
58 So whats the answer?
59 Questions (1) What is this patient s diagnosis? (2) Was everything done that could have been? (a) Is there additional imaging that could have helped? (b) Is there additional intervention that could have helped?
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