Acute Mesenteric Ischaemia

Question 1

What are the causes of Acute mesenteric ischaemia?

Answer 1

Thrombus in situ 
Embolism 
Non-occlusive cause 
Venous occlusion and congestion 
other rarer causes such as Takayasu arteritis, fibromuscular dysplasia

Question 2

What are the clinical features of Acute Mesenteric ischaemia?

Answer 2

Generalised abdominal pain
Diffuse and constant pain
75% of cases have associated N+V

Question 3

What are the risk factors?

Answer 3

Smoking
hyperlipidaemia
hypertension
hx of AF increases risk of clots forming
previous history of DVT/PE
Active neoplasm/antiphospholipid syndome - hypercoaguable states

Question 4

What are the ddx?

Answer 4

Other diagnoses which present as acute abdomen

• peptic ulcer disease
• bowel obstruction
• symptomatic AAA

Question 5

What will be the findings of the examination?

Answer 5

Often unremarkable

may find it difficult to localise pain

Question 6

Which investigations will be done?

Answer 6

bedside obs
bloods –> FBC, U+Es, LFTs (if coeliac trunk affected then may cause liver derangement) Amylase (to exclude pancreatitis but also raised in mesenteric ishcaemia), clotting esp if anticoagulated, group and save
ABG - may show acidosis and lactate

Question 7

Which imaging methods are used?

Answer 7

CT angiography
If suspect of bowel perforation
- erect CXR
- AXR initially -> CT abdo with contrast

Question 8

What other conditions can amylase be raised in other than pancreatitis?

Answer 8

Mesenteric Ischaemia
Ectopic Pregnancy
Bowel perforation
DKA

Question 9

What is the initial management?

Answer 9

SURGICAL EMERGENCY 
Senior involvement early 
IV fluids 
2 cannulas 
Catheter 
Fluid balance chart 
Confirmed cases: broad spectrum abx - risk of faecal contamination in case of perforation 
Early ITU input - significant acidosis and increased risk of developing multi organ failure

Question 10

What is the definitive management?

Answer 10

Excision of necrotic/non-viable bowel - if NOT suitable for revascularisation

Revascularisation of bowel - removal of thrombus or embolism via radiological intervention

Question 11

What is the post op for excision of necrotic bowel?

Answer 11

Post op in ITU under sedation
24-48hrs later relook laparatomy
Covering loop or end stoma
High chance of short gut syndrome

Question 12

Which factors affect whether revascularisation of the bowel occurs?

Answer 12

State of patient - how unwell they are
Bowel
angiographic appearance of the mesenteric vessels

Question 13

What are the complications?

Answer 13

Bowel necrosis and perforation
Mortality 50-80%
Short gut syndrome - malabsorption disorder and lack of functional small intestine