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Junior Surgery- GI > Bowel ischaemia > Flashcards

Bowel ischaemia Flashcards

1
Q

What are the 3 main types of bowel ischaemia?

A
  • Acute mesenteric ischaemia
  • Chronic mesenteric ischaemia
  • Ischaemic colitis/Chronic colonic ischaemia
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2
Q

What is acute mesenteric ischaemia?

A

ACute interruption in the blood supply to the mesentery. It can result from occlusion of arterial inflow, occlusion of venous outflow or failure of perfusion

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3
Q

What are causes of acute mesenteric ischaemia?

A
  • SMA thrombosis/embolism
  • AF
  • Mesenteric vein Thrombosis
  • Low flow states - heart failure
  • Trauma
  • VAsculitis
  • Radiotherapy
  • Strangulation
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4
Q

How do those with acute mesenteric ischaemia tend to present?

A

Triad of

  • Acute severe abdominal pain - constant, periumbilical or concentrated to RIF
  • Features of hypovolaemic shock
  • Distended, tender abdomen, with absent bowel sounds

Can also have in later stages

  • Haematochezia/malaena
  • Diarrhoea

Degree of illness is far out of proportion with signs

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5
Q

If you suspected acute mesenteric ischaemia, what investigations would you consider doing?

A
  • Bloods - FBC, U+E’s, ABG
  • ECR
  • Erect CXR
  • AXR
  • CT/MR angiography/Formal arteriography
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6
Q

What might you see on FBC in someone with acute mesenteric ischaemia?

A
  • Increased Hb - due to increased plasma loss
  • Increased WCC
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7
Q

What might you see on U+E’s in someone with acute mesenteric ischaemia?

A
  • Uraemia
  • Elevated creatinine
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8
Q

What might you see on ABG in someone with acute mesenteric ischaemia?

A
  • Acidosis
  • Elevated lactate
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9
Q

What might you find on ECG in someone with acute mesenteric ischaemia?

A

Indication of cause

  • AF
  • Arrhythmia
  • ACute MI
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10
Q

What might you find on AXR in someone with suspected acute mesenteric ischaemia?

A

May inidicate aetiology

  • Air fluid levels
  • Bowel dilation
  • Bowel wall thickening
  • Pneumatosis
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11
Q

How would you manage someone with acute mesenteric ischaemia?

A

ABCDE

  • Supportive - NG tube, Fluid resiscitation, Antibiotics
  • LMWH - cases of venous thrombosis
  • Consider Local thrombolytics
  • Surgical
    • Revascularisation
    • Resection
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12
Q

What are life-threatening complications of acute mesenteric ischaemia?

A
  • Septic peritonitis
  • SIRS
  • Multi-organ failure
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13
Q

What are features of chronic mesenteric ischaemia?

A

Triad of:

  1. Severe colicky, post-prandial abdominal pain - ‘gut cluadication’
  2. Weight loss - eating hurts
  3. Upper abdominal bruit

May also have

  • Bloating
  • PR bleeding
  • Malabsorption
  • Nausea + Vomiting
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14
Q

What tests would you do if you suspected chronic mesenteric ischaemia?

A

CT angiography/Contrast enhanced MR angiography

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15
Q

How would you manage someone with chronic mesenteric ischaemia?

A
  • Percutaneous transluminal angioplasty + stent insertion
  • Consider open revascularisation - not really used anymore
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16
Q

What is chronic mesenteric ischaemia also known as?

A

Intestinal angina

17
Q

What are symptoms of ischaemic colitis?

A

Hyperactive phase - > 80% do not progress past this

  • Sudden onset of crampy abdominal pain (usually left lower quadrant)
  • Bloody, loose stools

Paralytic phase

  • Pain more diffuse
  • Bowel sounds become absent.
  • Bloating
  • Bloody stools cease

Shock phase

  • Acute abdomen with abdominal guarding and rebound tenderness
  • Signs of septic shock
18
Q

What arteries are often implicated in ischaemic colitis?

A
  • SMA
  • IMA
19
Q

What are signs of ischaemic colitis?

A

Distended and tender abdomen

20
Q

What investigations would you consider doing in someone with suspected ischaemic colitis?

A
  • Bloods - ABG, CK, FBC
  • AXR - to exclude other disorders
  • Consider Colonoscopy
  • Exploratory laparotomy
21
Q

What is the following?

A

Thumb print sign - a radiographic sign of large bowel wall thickening, usually caused by oedema, related to an infective or inflammatory process (colitis). It can be seen in ischaemic colitis

22
Q

How would you manage someone with ischaemic colitis?

A

Conservative

  • Supportive care - IV fluids, bowel rest, nasogastric tube in case of an ileus
  • Antiplatelet drugs
  • Reduce risk of atherosclerosis
  • Severe forms (signs of peritonitis, sepsis): surgical intervention (laparotomy and bowel resection)
23
Q

What complication can commonly develop after an attack of ischaemic colitis?

A

Ischaemic strictures

24
Q

Where is the most common site for mesenteric ischaemia to occur?

A

Splenic flexure - watershed between SMA and IMA

25
Q

What is the most common cause of acute mesenteric ischaemia?

A

Acute arterial embolism - 50% of cases

  • AF
  • MI
  • Valvular heart disease
  • Endocarditis
26
Q

What is the second commonest cause of acute mesenteric iscahemia?

A

Arterial thrombosis - 25%

  • Atherosclerosis
  • Artertitis
  • Aortic aneurysm
  • Dissection
27
Q

If someone had abrupt onset of acute abdominal pain out of proportion with clinical signs?

A

Acute mesenteric embolism - Abdominal apoplexy

28
Q

What is the general clinical course of mesenteric ischaemia caused by thrombosis?

A

Presentation less severe because patients have better collateral supply

29
Q

How does someone with mesenteric ischaemia caused by embolism present?

A

Abrupt onset

  • Severe abdominal pain
  • Fever
  • Bloody diarrhea
  • Leukocytosis
  • Atrial fibrillation
30
Q

What would you want to ask about in PMH in someone with suspected ischaemic bowel/mesentery?

A
  • AF
  • CVS disease
  • PVD
  • Symptoms of chronic mesenteric ischaemia

Junior Surgery- GI (43 decks)

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