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
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC