Mesenteric Ischaemia

OVERVIEW

  • Mesenteric ischaemia = inadequate blood flow through mesenteric circulation -> ischaemia -> gangrene

CAUSES

Arterial disease

  • embolism: MI, mitral stenosis, AF, endocarditis, mycotic aneurysm, prosthetic grafts, myxoma
  • thrombosis: plaque rupture
  • occlusive disease: atherosclerosis, vasculitis, autoimmune disease
  • non-occlusive disease: decreased perfusion (septic shock, hypovolaemia, vasopressors, pancreatitis)

Venous disease

  • intra-abdominal infection with portal pyemia
  • hypercoagulable states
  • portal hypertension/mass effect from tumours -> stasis
  • direct trauma from surgery
  • band adhesions

HISTORY

  • abdominal pain
  • N+V
  • diarrhoea

Arterial embolic

  • abrupt, painful abdominal pain
  • vomiting
  • diarrhoea
  • recent: AF, MI, valvular heart disease

Arterial occlusive disease

  • associated with eating
  • pain out of proportion to physical findings
  • unresponsive to opioids
  • N+V
  • distension
  • GI haemorrhage

Arterial thrombosis

  • often have a history of mesenteric angina
  • associated with CCF, MI -> drop in Q

Non-occlusive disease

  • associated with MODS

Venous thrombosis

  • symptoms may been present for weeks
  • patients may have a history of hypercoagulability

EXAMINATION

  • tenderness
  • peritonism
  • palpable mass
  • bowel sounds absent -> hyperactive
  • septicaemia
  • AF
  • heart murmurs

INVESTIGATIONS

  • bloods: unreliable diagnostically
  • ABG: metabolic state
  • lactate: elevation
  • xray: exclude perforation, thumb printing, portal vein gas
  • CT: angiogram (96% sensitive, 94% specific), pneumotosis intestinalis, portal vein gas, bowel or mesenteric oedema, abnormal gas patterns, streaking of mesentery and solid organ infarction
  • MRI/MRA: highly sensitive and specific

MANAGEMENT

  • IVF
  • NBM
  • opioid analgesia
  • antiemetics
  • antibiotics
  • surgery
  • angiographical infused thrombolytics
  • angioplasty
  • heparin for venous thrombosis

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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