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Hahn, Frank (ID # 3425602440)
Shortness of breath, nausea, vomiting. Pain characterized as pressure on chest with radiation to the left arm. Duration more than 20 min.
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  Ischemic Heart Dz    
 

{GI: Other Dz}

Mesenteric Ischemia

Pathophysiology

  1. Focal (arterial) or diffuse (venous) necrosis bowel d/t decr blood supply; w/arterial emboli (from heart/arrhythmia or valve dz), thrombosis, or extension of aortic dissection
  2. Significant third spacing develops
  3. Mucosa dies & sloughs bleeding
  4. Bacteria crossing into tissues sepsis

Diagnosis

  1. Pts w/vascular insufficiency may present w/few symptoms, mimic other dz processes
  2. Recognize risk factors
    • Afib
    • CAD
    • Low-flow states (CHF, shock)
    • Hx of abd angina
  3. Spectrum of illness of abdominal angina
    • Nonocclusive intestinal infarction (poor perfusion, transmural infarct +/- limited to mucosal layer)
    • Acute mesenteric infarct (occl of SMA/branches)
    • Mesenteric venous thrombosis (occl of SMV 95%; 10% of all small bowel ischemia; 70% of hx w/2-3 days of pain, incr slowly, N/V/D; develops peritonitis)
  4. Abdominal pain: crampy, dull, diffuse, worse w/eating, periumbilical 15 min to 30 min post-prandial
    • Sudden onset
    • Insidious onset w/venous thrombosis
    • 50% pts have a hx of abd angina
    • Fear of eating, wt loss
  5. GI bleed (most pts); frank bleeding more indicative colonic dz, w/small bowel dz us. occult, rare hematochezia
  6. Abdominal tenderness: pain out-of-proportion to exam classically, +/- abd bruit
  7. Hypovolemia, possible shock
  8. +/- signs of obstruction (abd distension, tympani& borborygmi)
  9. Labs: CBC (leukocytosis's +/-), lytes, LFT's, lipase & amylase, CPK, LDH, PO4; metabolic acidosis w/out another source is hallmark of intestinal infarction
  10. CXR & EKG
  11. Obstructive series: dilated small bowel, AF level, valvulae conniventes, demonstration of arterial obstruction; may show ileus early in course
  12. Angiography confirms dx: occlusion of SMA or branches
    • MUST MAKE DX BEFORE HARD SIGNS APPEAR TO DECR MORTALITY
  13. CT: suggestive of infarction, bowel edema, ileus, calcified vessels; not standard

Treatment

  1. IVF replacement prior to angiography
  2. Triple abxs (clindamycin; 900 mg IV q8h, gentamicin 5 mg/kg IV 1st dose & 500 mg IV q8h metronidazole)
  3. STAT surgical consult
    • Resection & bypass for arterial lesions
  4. Anticoagulation therapy for venous lesions
  5. Non-occlusive mesenteric ischemia
    • Rehydration
    • Intraarterial papaverine
    • Exploratory laparotomy if necrosis is suspected
  6. Chronic mesenteric ischemia
    • If lesions are localized, bypass is a possibility
  7. AVOID drugs with negative effects on circulation
    • Digoxin, propranolol, pitressin & vasopressors

Disposition

  1. Admission & surgical consultation
  2. If pain is mild & brief, then observe

 

 

 

 

 

 

 

 

 

 

 

 

   
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