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Ischemic Bowel Disease Flashcards

(49 cards)

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1
Q

What are the patterns of Ischemic Bowel Disease?

A

Small and/or large bowel
Diffuse or localized
Segmental or focal
Superficial or transmural

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2
Q

4 Main Causes of Acute Mesenteric Ischemia

A

SMA embolism (50%)
SMA thrombosis (15-25%)
Non-occlusive ischemia (20-30%)
Mesenteric venous thrombosis (5%)

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3
Q

How much cardiac output does the intestine take?

A

10-35%

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4
Q

Regulation of Intestinal Circulation

A 
Perfusion pressure
Neural & hormonal mechanisms
Sympathetic nervous system
Renin-angiotensis system
Vasopressin
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5
Q

Activity of Vasopressin

A

Causes mesenteric arterial vasoconstriction & venous dilation
Reduces portal venous pressure in patients bleeding with portal HTN

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6
Q

Hallmarks of Clinical Presentation of Ischemic Bowel Disease

A

Severe, cramping abdominal pain
Pain out of proportion to physical findings
Poorly localized
May be able to hear bruits

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7
Q

Clinical Presentation as Ischemia Worsens

A 
Abdominal distention
Absent bowel sounds
Peritoneal signs
\+/- feculant odor to the breath
N/V
Frequent BM
Occult blood in stool
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8
Q

Occlusive Clinical Syndromes

A

Mesenteric arterial embolism
Mesenteric arterial thrombosis
Mesenteric venous thrombosis

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9
Q

Non-occulusive Clinical Syndromes

A

Hypoperfusion

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10
Q

Risk Factors with Acute Mesenteric ARTERIAL Embolism

A 
Advanced age
CAD
Cardiac valvular disease
Hx of dysrhythmias
Post-mycardial infarction mural thrombi
Hx of thromboembolic disease
Aortic surgery
Aortography
Coronary angiography
Aortic dissection
CHF
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11
Q

Epidemiology of Mesenteric ARTERIAL Embolism

A

Median age:70
SMA often involved
Near middle colic artery

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12
Q

Where is the thrombus for a mesenteric arterial embolism usually from?

A

Left atrium
Left ventricle
Cardiac valves

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13
Q

Which is more favorable, mesenteric arterial embolism or mesenteric arterial thrombosis?

A

Mesenteric arterial embolism

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14
Q

Usual Suspects for Mesenteric Arterial Thrombosis

A

Atherosclerotic disease
Traum
Infection

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15
Q

What is usually the site of blockage for a mesenteric arterial thrombosis?

A

Origin of SMA

Celiac axis

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16
Q

Epidemiology of Mesenteric Venous Thrombosis

A

Usually ages 48-60
Primary: clot from somewhere else & ended up in the venous system
Secondary: DVT, strangulated hernia

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17
Q

Signs/Symptoms of Mesenteric Venous Thrombosis

A 
Diffuse pain
Anorexia
Vomiting
Diarrhea
Constipation
Hematemesis
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18
Q

Risk Factors for Mesenteric Venous Thrombosis

A 
Hyper coagulable state
Portal HTN
Abdominal infections
Blunt abdominal trauma
Pancreatitis
Splenectomy
Malignancy in portal region
Personal or family Hx of DVT or PE
Dehydration
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19
Q

Mesenteric Venous Thrombosis Pathophysiology

A 
Decreased blood flow
Bowel wall edema
Fluid efflux into the bowel lumen
Systemic hypotension
Increase in blood viscosity
Diminished arterial flow
Submucosal hemorrhage
Bowel infarction
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20
Q

What is non-occlusive mesenteric ischemia a result of?

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A

Splanchnic hypoperfusion & vasoconstriction

21
Q

Main Risk Factor for Non-occlusive Mesenteric Ischemia

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A

Atherosclerotic disease

22
Q

Signs/Symptoms of Non-occlusive Mesenteric Ischemia

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A

Progressive abdominal pain
Bloating
N/V
Mental status change

23
Q

Signs/Symptoms of Ischemia in the Colon

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A

Mild abdominal pain
Tenderness
Rectal bleeding
Bloody diarrhea

24
Q

What is the procedure of choice to determine if ischemia is in the colon?

25
Etiologies of Arterial Emboli
A. fib | MI
26
Etiology of Arterial Thrombosis
Atherosclerotic disease
27
Etiologies of Venous Thrombosis
Underlying disorder in coagulation | Neoplasm
28
Etiology of Non-occlusive Mesenteric Ischemia
Low flow states
29
Work Up of Acute Ischemia
Labs | Imaging: plain abdominal x-rays, abdominal CT
30
Lab Results for Acute Ischemia
Increased WBCs, hematocrit, amylase, phosphate, & serum lactate Metabolic acidosis
31
Findings on Plain Films for Acute Ischemia
``` Pneumatosis intestinalis Portal venous gas Thickened bowel wall with thumb-printing Air-fluid levels Dilated bowel loops Gasless abdomen ```
32
Define Pneumoatosis Intestinalis
Gas cysts in the bowel WALL which is suggestive of necrotizing enterocolitis
33
Define Portal Venous Gas
Accumulation of gas in the portal vein & it's branches
34
What views do you want for plain films in an acute bowel?
Upright & supine
35
What is the preferred imaging study for an acute bowel?
CT
36
What kind of contrast do you need for an abdominal CT looking for acute bowel ischemia?
Oral IV CTA: just IV
37
CT Findings in Acute Ischemia
``` Bowel wall thickening Bowel dilation Fat stranding Ascites Varying degrees of attenuation Pneumatosis & portomesenteric gas ```
38
Define Fat Stranding
Caused by fluid & inflammation that has gone out into the fat
39
What study is better at diagnosing venous occlusions, CTA or MRA?
MRA
40
Indications for Mesenteric Percutaneous Ateriography
Diagnosis in doubt after non-invasive measures | Diagnosis fairly certain & need consideration for percutaneous treatment or surgical planning
41
Contraindication for Mesenteric Percutaneous Arteriography
Venous occlusion
42
Treatment of Acute Bowel Ischemia in General
``` Hemodynamic monitoring & support Correction of metabolic acidosis Broad spectrum antibiotics NG tube for gastric decompression Vasopressors with less effect on bowel perfusion: dobutamine, low dose dopamine, milrinone Anticoagulation Correction of arrhythmias Imaging ```
43
What is the gold standard diagnostic study for acute arterial ischemia?
Mesenteric Angiography
44
Treatment for Mesenteric Arterial Embolism
Surgery & embolectomy | Local infusion of thrombolytic therapy
45
Treatment for Mesenteric Arterial Thrombosis
Surgery with thrombectomy & revascularization or heparinization
46
Treatment for Mesenteric Venous Thrombosis
Heparinization + resection of infarcted bowel
47
Treatment for Non-occlusive Mesenteric Ischemia
Papaverine infusion during angiography Reverse underlying conditions Repeat angiography in 24 hours Surgical exploration in patients with peritoneal signs
48
Care for Ischemic Bowel Disease Patients
``` Cardiac monitor Venous access Oxygen Fluid resuscitation Broad-spectrum antibiotics Surgery ```
49
Chronic Mesenteric Ischemia
Intestinal angina Episodic or constant intestinal hypoperfusion Secondary to atherosclerosis Strongly associated with meals

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