Mesenteric Ischaemia

Introduction

Acute mesenteric ischaemia is a condition with a high mortality rate, that can be difficult to recognise and diagnose. It is typically a disease of the elderly and is more common in those with atrial fibrillation and vascular disease. The typical hallmark is an elderly person with severe abdominal pain that is out of proportion to abdominal signs on examination

Once obstruction of the mesenteric vessels has occurred, if diagnosis and intervention is not timely, perforation, peritonitis, septicaemia and eventually death will occur.

Clinical Features

 

Symptoms

Pain

  • Usually sudden onset and severe. Can be

    • generalised

    • ill-defined in location

    • periumblical

  • Often pain is very severe yet the abdominal exam can be relatively unremarkable - pain “out of proportion” to exam

GIT Symptoms

  • Nausea + vomiting

  • Diarrhoea which may or may not be bloody

Signs

  • Tachycardia (often fast a. fib)

  • Hypertension

  • Sweaty

  • Patient looks unwell

  • Abdominal Signs

    • Ranging from very little to generalised tenderness to diffuse peritonism. (suggesting perforation)

    • Bowel sounds may be hyperactive or absent if associated ileus is present

  • May be blood on PR exam

Differential Diagnosis

 

Gastrointestinal

  • Perforated Viscus

  • Bowel obstruction

  • Incarcerated hernia

  • Acute pancreatitis

  • Acute biliary pathology

Renal

  • Ureteric Colic

  • Pyelonephritis

Vascular

  • Ruptured AAA

  • Acute disection

Clinical Investigations

a fib.jpg

Bedside

  • Venous Blood Gas – lactic acidosis is often present but it’s absence doesn’t out rule the dx

  • ECG – mesenteric ischaemia is more common in atrial fibrillation

  • POCUS – Out rule AAA, Look for free fluid indicating another diagnosis e.g. perforated viscus

 
blood bottles.jpg

Laboratory

  • FBC – elevated WCC

  • CRP – often elevated

  • U&E – May be evidence of AKI or CKD.

  • LFT and amylase – help out rule other conditions

  • CoAg and Group + Hold – if suspicious and think pt may be going to theatre

Mesenteric ischaemia 2.png

Radiology

  • Erect CXR – helps exclude perforation

  • AXR – may have nonspecific signs such as dilated loops in ileus, thumb printing, portal vein gas

  • CT angiogram – 96% sensitive, 94% specific – mesenteric or bowel oedema, air in bowel wall or in the portal system, abn gas pattern, signs of perforation

    • CT angiogram not 100% sensitive or specific. Sometimes condition is only diagnosed at lapraoscopy

Management & Disposition

 

Initial Resuscitation

  • Wide bore IVC x 2

  • Fluid resuscitation with crystalloid as indicated

  • Broad spectrum antibiotics if concerned for sepsis or perforation

Symptomatic Treatment

  • IV Opioid analgesia. Titrate to response

  • IV anti-emetic

  • Nil Orally

  • NG Tube on free drainage

Specific Treatment & Disposition

  • Urgent surgical referral for consideration for laparotomy

  • Immediate OT transfer if candidate for surgery + will need ICU admission post

  • In the very elderly with significant co-morbidities they may not be candidate for significant surgery and palliative care may be most appropriate management

 

References

1.     https://litfl.com/mesenteric-ischaemia/

This blog was written by Dr. Deirdre Glynn and was last updated in October 2020

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