acute mesenteric ischemia is a silent snake

1. Dr.Asif Mian Ansari
DNB resident
Dept. of General Surgery
Max hospital, Mohali

2.  Sudden interruption of blood supply to segment of intestine
 Rare (0.09-0.2%) but life threatening (50-80% mortality)
Bowel ischemia
Cellular
damage
Bowel
necrosis

3. AMI
Occlusive
Embolism
(AMAE-50%)
Thrombosis
(AMAT-15-25%)
Venous thrombosis
(MVT-5-15%)
Non-occlusive

7. ACUTE MESENTRIC ARTERIAL EMBOLISM
Sources of embolism:
Left atrium-cardiac arrythmia
Left ventricle-global myocardial dysfunction
with poor EF
Endocarditis
Rarely-atherosclerotic aorta
3-10 cm distal to origin of SMA-sparing proximal jejunum
& colon

8. ACUTE MESENTRIC ARTERIALTHROMBOSIS
•Pre existing chronic atherosclerosis
•H/O post prandial abdominal pain, weight loss, food fear
•SMA thrombosis
•Takes time to progress critical obstruction
• Associated with collaterals – symptomatic when
accompanies with celiac occlusion

9. MESENTRIC VENOUSTHROMBOSIS
< 1% cases of MI
FollowsVirchow’sTriad 80%
20% ideopathic
portal HTN, Pancreatitis, IBD, sepsis & trauma

11.  Severe pain abdomen – 95%
 Nausea –44%
 Vomiting – 35%
 Diarrhoea – 35%
 Bleeding per rectum – 16%
 Triad of pain + fever + blood in stools – 1/3rd patients
 Signs of peritonitis – irreversible bowel ischemia with necrosis
 Delayed presentation – septic shock

12.  Risk factors may be found on evaluation

13.  High index of suspicion in cases with clinical features with
 Abnormally highTLC
 Metabolic acidosis
 Elevated lactates >2 mmol/L
 These cases should undergo early CT angiography
 D-Dimer: >0.9 mg/L, reflecting ongoing clot formation &
fibrinolysis

14.  Should be done in any suspected case as soon as possible

16.  Irreversible bowel ischemia:
 Dilated bowel
 Pneumatosis intestinalis
 Portal venous gas
 Free intraperitoneal gas

17.  At the time of diagnosis:
 Fluid and electrolyte resuscitation
 Naso-gastric suction
 Broad spectrum antibiotics
 Heparin therapy
 Vasopressors: used with caution, dobutamine, low dose dopamine
and milrinone cause less impact on mesenteric blood flow
 Continued monitoring of lactates
 Prompt laparotomy in unstable, perforation peritonitis cases

18.  Goal of surgery:
 Re-establishment blood supply to the ischemic bowel.
 Resection of all non-viable regions.
 Preservation of all viable bowel.
 Damage control surgery:
 choice in case of critical ill with AMI
 Planned 2nd look laparotomy after resuscitation in ICU
 Examination of stapled bowel

19.  AMAE – Embolectomy & primary/patch angioplasty
 AMAT– Bipass procedure
 NOMI – treatment of underlying condition
 MVT – continued heparin therapy

20.  Jatinder Kumar Gosain 67/male
 Admitted on 21st sept 2017
 Acute mesenteric venous thrombosis with ischemia

21.  Post operatively, patient developed septic shock and MODS
 Died on oct 2nd, 11:05 AM

22.  Darshan singh 65/male
 15 days history
 Admitted on 20th oct, 2017 and discharged on 2nd Nov 2017

24.  Severe abdominal pain out of proportion to physical findings
is assumed to be AMI
 Early CT angiography
 Prompt resuscitation, antibiotics & anticoagulation
 Inotropes must be used with caution
 MVT – anticoagulation is mainstay of treatment