Acute Mesenteric Ischemia Michael Klein, MD SUNY Downstate Medical Center August 20, 2015
85F www.downstatesurgery.org 5 months of intermittent diffuse abdominal pain Approximately 30-lb weight loss Abdominal distention PMH: HTN; on captopril/asa Social: Ex-smoker, many years
Exam www.downstatesurgery.org NAD, AAOx3, comfortable Sitting upright and smiling Abdomen soft, NT, ND; (+)pulsatile mass in midline
Laboratory www.downstatesurgery.org
The daughter shows up... Every time she eats, she has stomach pains, then she stops eating.
Re-evaluation www.downstatesurgery.org Comfortable No complaints of pain Abdomen soft, NT, ND (+) pulsatile abdominal mass
Re-evaluation www.downstatesurgery.org Comfortable No complaints of pain Abdomen soft, NT, ND (+) pulsatile abdominal mass What next?
Repeat labs www.downstatesurgery.org Lactate: 10 Lactate: 12.7 2L crystalloid WBC: 8 WBC: 14
Repeat labs www.downstatesurgery.org Lactate: 10 Lactate: 12.7 2L crystalloid WBC: 8 WBC: 14 What next?
Exploratory laparotomy Negative for ischemia; Gut well-perfused, normal color. SMA with strong pulse, no thrill. SMV fills instantaneously.
Exploratory laparotomy EBL: 5 ml IVF: 1000 ml www.downstatesurgery.org End-case lactate: 12.7 Transferred to SICU, remained intubated.
Medicine/Nephrology Consultations Hepatitis panel- (+) HAV TTE- EF 20-25% Salicylate level- neg Acetaminophen level- neg
Hospital course www.downstatesurgery.org POD #0 Lactate 12.5 8.0 3.9 2.5 1.7 POD #1 Extubated (+) HAV
Hospital course www.downstatesurgery.org 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
Esophagram www.downstatesurgery.org Normal swallowing. Normal motility. No GE reflux. No delay in gastric emptying.
Hospital Course POD #5 Lactic acidosis resolved LFT s trending down Tolerating diet, no abdominal pain Discharged home with close followup
POD #20 www.downstatesurgery.org Seen in vascular clinic with other daughter:
POD #20 www.downstatesurgery.org Seen in vascular clinic with other daughter: She doesn t eat due to loss of appetite -- she DOES NOT have abdominal pain after eating.
Lactic Acidosis Differential Diagnosis www.downstatesurgery.org 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
Acute Mesenteric Ischemia Diagnosis and Imaging Michael Klein, MD SUNY Downstate Medical Center August 20, 2015
Questions www.downstatesurgery.org (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?
Pick your flavor www.downstatesurgery.org
Mesenteric Arterial Supply
Mesenteric Arterial Supply
Mesenteric Arterial Supply +Arc of Riolan
Superior Mesenteric Artery
SMA www.downstatesurgery.org
SMA www.downstatesurgery.org
IMA www.downstatesurgery.org
IMA www.downstatesurgery.org
Acute Mesenteric Ischemia Uncommon, life threatening Early diagnosis is key Classic presentation: Abdominal pain out of proportion to physical exam
Embolic www.downstatesurgery.org Sudden-onset pain Classic triad in 1/3rd of patients Pain Fever (+) FOBT Occlusion distal to SMA origin
Thrombotic Same presentation as embolic Difference: HISTORY of www.downstatesurgery.org postprandial abdominal pain Occlusion at origin of SMA
Nonocclusive www.downstatesurgery.org Due to hypotension, hypovolemia, shock or vasopressor use In rare cases, papaverine infusion may help Prognosis almost always poor
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
Workup: acute www.downstatesurgery.org Physical exam Peritonitis LAPAROTOMY No peritonitis...
Workup: acute www.downstatesurgery.org No specific laboratory tests leukocytosis lactic acidosis elevated AST, AlkP amylasemia dehydration
Workup: acute Imaging www.downstatesurgery.org Need to evaluate mesenteric vascular flow XR Duplex ultrasonography CT angiography MR angiography Biplanar angiography
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
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
MR Angiography Similar to CTA Gadolinium less toxic than iodinated contrast Cannot evaluate distal SMA branches Not readily available More expensive
Cannot evaluate for MVT Not readily available www.downstatesurgery.org 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
So what s the answer?
So what s the answer?
So whats the answer?
Questions www.downstatesurgery.org (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?