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What is Mesentric Ischemia?
• A medical condition in which inflammation and injury of the small intestine occurs due to inadequate blood supply.
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Types
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Acute Mesentric Ischemia
• Acute Mesentric Ischemia is a syndrome caused by inadequate blood flow through the mesenteric vessels, resulting in ischemia and eventual gangrene of the bowel wall
• Classification
• Arterial-
a) Non occlusive mesenteric ischemia (NOMI) due to spasm of artery
b) Occlusive mesenteric arterial ischemia (OMAI) Subdivision – Acute mesenteric arterial thrombosis (AMAT) , Acute mesenteric arterial embolism (AMAE)
• Venous - mesenteric venous thrombosis (MVT)
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Chronic Mesentric Ischemia
• Occurs gradually as the main visceral arteries narrow
• It also can occur suddenly as a result of a blood clot severely restricting blood flow (acute on chronic mesenteric ischemia)
• Lack of oxygen-rich blood can permanently damage the intestines
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Risk Factors
• Smoking
• Hypertension
• Diabetes mellitus
• Hypercholesterolemia
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Symptoms
• Abdominal pain
• Bloody stools
• Bloating
• Nausea/Vomiting
• Diarrhoea/Constipation
• Weight loss
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Complications
• Gangrene of intestine
• Multi organ failure
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Diagnosis
• CT / MR Angiography
• Mesenteric angiography
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Medical Treatment
• After initial medical or surgical stabilization, patients with AMI typically have a prolonged inpatient recovery time.
• Inpatient medications:
- Papaverine
- Heparin/low-molecular-weight heparin
- Warfarin
- Broad-spectrum antibiotics and pain medications & Supportive medicines
- Thrombolytics
• Note: Treat any predisposing cause(s) of AMI
• Acute mesenteric arterial embolism (AMAE) - Papaverine infusion, surgical embolectomy, and intra-arterial thrombolysis.
• Acute mesenteric arterial thrombosis (AMAT) - Papaverine infusion and arterial.
reconstruction, either through aortosuperior mesenteric arterial bypass grafting or through re implantation of the superior mesenteric artery (SMA) into the aorta.
• Non occlusive mesenteric ischemia (NOMI) - Papaverine infusion.
• Mesenteric venous thrombosis (MVT) - Anticoagulation with heparin or warfarin, either alone or in combination with surgery; immediate heparinization should be started even when surgical intervention is indicated.
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Surgery
• All cases of mesenteric ischemia with signs of peritonitis or possible bowel infarction, regardless of etiology, generally warrant immediate surgical intervention for the resection of ischemic or necrotic intestines.
• Hemodynamic instability can also be an indication for surgery
• Surgical treatment may be contraindicated if the risks from comorbid conditions preclude survival after general anesthesia
• If the ischemia is thought to be caused by vasospasm, surgery is not indicated. Medical management with anticoagulants and intra-arterial vasodilators is appropriate
• A second-look procedure is indicated whenever bowel of questionable viability is not resected
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Percutaneous Endovascular Interventions (in selected cases)
• Especially in isolated spontaneous dissection of the SMA, stent placement may be the preferred option.
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Long Term Monitoring
• Cardiac and renal status
• Carotid duplex studies - if diffuse atherosclerotic disease
• Outpatient medications –
- antiarrhythmics for patients with atrial fibrillation (AF)
- warfarin for MVT or AF ( for at least 6 months or for life if a hypercoagulable state was dis covered during treatment )
- Treatment of predisposing factors
- Periodic evaluation of coagulation status -the international normalized ratio (INR)