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Ischemia bowel

Ischemia bowel

"Occlusion of the mesenteric vessels is


apt to be regarded as one of those
conditions of which the diagnosis is
impossible, the prognosis hopeless, and
the treatment almost useless" (Cokkinis,
1926).

Ischemia bowel
inadequate blood flow to or from the
involved mesenteric vessels supplying a
particular segment of bowel.
The organs typically affected are the small
bowel or colon.

Ischemia bowel

Patients with inflammatory bowel disease and infectious


colitis can present with similar s/s: cramping

abdominal pain, diarrhea, leukocytosis, and


hematochezia. Bowel-wall thickening.

however, the pattern of vascular distribution


can sometimes narrow the differential diagnosis.

Ischemia bowel

acute or chronic.
arterial or venous
occlusive or nonocclusive.

Pathophysiology
Arterial sources v.s. venous sources:
proximately 9:1. Similarly, arterial
occlusive disease occurs more frequently
than nonocclusive disease approximately
9:1
The SMA and IMA, and their branches,
are more frequently than the celiac artery.

Pathophysiology (a. source)


Acute:
1.atheromatous plaque with intimal
calcifications
2.embolic from cardiac disease
3. abdominal aortic aneurysms with dissection
into SMA
4. hypoperfusion secondary to hypovolemic
shock or low-flow cardiac failure.

Pathophysiology (a. source)


Chronic :
1.atherosclerosis
2.fibromuscular dysplasia
3.vasculitis.

Both occlusive and nonocclusive subtypes can


occur .

Pathophysiology (v. source)

are less frequently.


In these cases, bowel ischemia results from

decreased mesenteric outflow of


deoxygenated blood rather than from
decreased perfusion of oxygen-rich blood

Mortality rates generally are low.


SMV is involved more often than the IMV.

Pathophysiology (v. source)


The particular cause often is not clear.
Predisposing risk factors :
1. thrombosis
2. recent abdominal surgery
3. infection
4. hypercoagulable states.

Pathophysiology

Additional rare causes of mesenteric ischemia


include :
1.bowel herniation
2. adhesions
3. intussusception
4. antiphospholipid antibody syndrome (APS).
APS is associated with hypercoagulable states secondary to circulating
immunoglobulins that interact with phospholipids in cell membranes.
In a recent study by Kaushik et al, 13 (31%) of 42 patients with APS had
CT findings of bowel ischemia.

Acute Ischemia bowel


is divided into:
1.Embolic acute mesenteric ischemia
2.thrombolic acute mesenteric ischemia
3. NOMI
4. mesenteric venous thrombosis
all types of AMI share many similarities and a final
common pathway ( bowel infarction and death, if not
properly treated),they are discussed together

1.Embolic acute mesenteric


ischemia

has the most abrupt and painful presentation of


all types.

abdominal apoplexy.

initial :soft , no tenderness,

vomiting and diarrhea (gut emptying) are observed.


most emboli are of cardiac origin ( atrial fibrillation
or a recent MI . a history of valvular heart disease or
previous embolic episode.)

2.Thrombotic acute mesenteric ischemia


(TAMI)

happens when an artery already partially


blocked by atherosclerosis becomes completely
occluded.
20-50% of these patients have a history of
abdominal angina.( postprandial abdominal pain
starting soon after eating and lasting for up to 3
hours.)
Weight loss, food fear ,early satiety, and altered
bowel habits may be present

2.Thrombotic acute mesenteric ischemia


(TAMI)
The precipitating event :
1. a sudden drop in C.O. ( MI or CHF or a
ruptured plaque). 2.Dehydration.
gradual progression and frequently have a
better collateral supply. Bowel viability is better
preserved.
Symptoms tend to be less intense and of more
gradual onset.
have a history of atherosclerotic disease at
other sites or a history of aortic reconstruction

3.Nonocclusive mesenteric
ischemia

more frequently in older patients than other


forms and often already in an ICU setting .
Symptoms typically develop over several days,
and may have had a prodrome of malaise and
vague abdominal discomfort.
When infarction occurs, increased pain
associated with vomiting,hypotensive and
tachycardic, with loose bloody stool.

4.Mesenteric venous thrombosis


in a much younger patient population than other types .

acute or subacute abdominal pain involvement of the


small intestine rather than the colon.

The

symptoms are frequently less dramatic. 27%


have symptoms for >30 d.

Many

patients have a history of the risk factors for


hypercoagulability. include oral contraceptive use,
deep vein thrombosis (DVT), liver disease, tumor, or
portocaval surgery.

Pathophysiology
Large or smaller segments : depending on
the location of the occlusion.
mucosal layer becomes anoxic, cell
fragility and irreversible cell death. Then,
the patient experiences malabsorption,
which causes diarrhea and rectal bleeding

Mortality/Morbidity
The major cause of mortality is bowel
necrosis
Mortality from all causes is as high as 70%.
However, several factors (particularly, the
adequacy of collateral vessels) account for
variability in mortality rates.

Ischemia bowel
Race: No race predilection is known.
Sex: No sex predilection is known.
Age: Most patients are older than 50
years. Venous causes tend to affect a
wider range of patients.

Clinical Details (acute)

Symptoms are usually nonspecific


( D / D with diverticulitis, appendicitis, Crohn
disease, peptic ulcer disease, or pelvic
inflammatory disease. )

typical : presents with acute abdominal


pain ( initially is characterized as cramping
pain, followed by a continuous dull pain. )

Clinical Details (acute)


depending on the particular segment
involved, the pain may be more localized
to one side of the abdomen.
SMA : tends to be more diffuse
IMA: Ischemic pain toward the left side

Clinical Details(acute)

As ischemia progresses, bloody diarrhea,


gross bleeding per rectum, and/or
leukocytosis are delayed manifestations

Clinical Details (chronic)


postprandial abdominal pain, typically
within several minutes of a meal.
reluctant to eat, similar to patients with
peptic ulcer disease.
weight loss and chronic diarrhea from
malabsorption.

Preferred Examination
history and a physical examination ,
particularly :
1. the timing of the event. 2.localizing
signs and symptoms 3.vascular
distribution of the pain.
Unless the patient is unstable, imaging is
the criterion standard for diagnosis.

Preferred Examination

1. Upright and supine plain abdominal


radiographs :
should be requested first to evaluate for
free air, obstruction, ileus, intussusception, or
volvulus.

2. CT by using oral and, preferably,


intravenous contrast :
may be needed if the cause is not
apparent on plain radiographs.

Mesenteric artery ischemia. Radiograph showing bowel spasm, an early sign of


ischemia

Mesenteric artery ischemia. Thumbprinting of the bowel.

Mesenteric artery ischemia. Gas in the colon wall, typical of advanced ischemia.

Preferred Examination

3.Sonography, barium enema study, and


angiography :
Typically, if additional imaging are needed, ultrasound or
angiography is the next step in the workup.

MRA is occasionally used to evaluate the patency


of the SMA and IMA. It plays a limited role in the
diagnosis.

Differential
Appendicitis
Trauma
Pseudomembranous colitis
Adenocarcinoma
Diverticulitis
Crohn Disease
Necrotizing Enterocolitis
Pneumatosis Intestinalis
Typhlitis
Ulcerative Colitis

Treatment:

NPO :prepare for surgery and to reduce oxygen


demand on the ischemic bowel

surgery
Interventional radiology: angiographic drug

infusions or angioplasty.

Treatment:

. acute occlusive mesenteric ischemia :


usually surgical resection of the infarcted
bowel segment.
Chronic mesenteric ischemia :
not a surgical emergency and may be treated
conservatively.
Nonocclusive mesenteric ischemia :
usually nonsurgically. Depending on the cause

Complications:

Bowel necrosis (requiring bowel resection)


Septic shock
Death
Patients in whom the diagnosis is missed until infarction
occurs have a mortality rate of 90%. Even with good
treatment, up to 50-80% of patients die.
Survivors of extensive bowel resection face lifelong
disability.

Take home message:

Hx: High risk patient ( Af hx, old age,


hypercoagulation state)
PE: Localized pain
Lab: CBC/DC, BCS+e, ABG,amylase ,lipase
Image (Angiography:)
:.infarction
:
Tx: NPO,antibiotics, fluid +electrolite correction,
surgery or intervention..

Thank you for your attention