MESENTERIC ISCHEMIA- GENERALISED ABDOMINAL PAIN #surgicaleducator #epigastricabdominalpain #pepticulcerdisease #usmle #babysurgeon #surgicaltutor • Dear Viewers, • Greetings from “Surgical Educator” • Today I have uploaded a video on Mesenteric Ischemia- a didactic lecture. • It is one of the uncommon but life-threatening surgical problems you see in surgical wards. • I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology, pathology, clinical features, investigations, and treatment of Mesenteric Ischemia. • I have also included a mind map and a treatment algorithm for Mesenteric Ischemia. • I hope the video will be very useful and you will enjoy it. • You can watch all my surgical teaching videos in the following link: • youtube.com/c/surgicaleducator • Thank you for watching the video.

1. MESENTERIC
ISCHEMIA
GENERALISED ABDOMINAL PAIN
AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS;
“Surgical Educator”
Malaysia

2. MESENTERIC ISCHEMIA
 Different causes for generalized abdominal pain
 Etiology
 Pathology
 Epidemiology
 Clinical features
 Investigations
 Treatment
 Take home message
 Mindmap
 Treatment Algorithm

3. MESENTERIC ISCHEMIA
D/D for Generalised Abdominal Pain

4. MESENTERIC ISCHEMIA
ANATOMY

5. MESENTERIC ISCHEMIA
CLASSIFICATION- ETIOLOGY
 AMI-Acute Mesenteric Ischemia
-MAE- Arterial Embolus due to Atrial
Fibrillation- 40%
-MAT- Arterial Thrombus due to
Atheroscelerosis- 30%
-NOMI- Non-Occlusive Mesenteric Ischemia
due low volume blood flow – 15%
-MVT- Mesenteric Venous Thrombosis 15%
 CMI- Chronic Mesenteric Ischemia
-Atheroscelerosis 95%
-Aortic dissection, radiation, malignancy

6. MESENTERIC ISCHEMIA
PATHOLOGY
 The intestinal mucosa has a high metabolic
rate and, requiring more blood flow (normally
receiving 20 to 25% of cardiac output),
making it very sensitive to the effects of
decreased perfusion
 Ischemia disrupts the mucosal barrier,
allowing release of bacteria, toxins, and
vasoactive mediators, which in turn leads to
myocardial depression, SIRS,MODS and
death
 Mediator release may occur even before
complete infarction. Necrosis can occur as
soon as 6 h after the onset of symptoms which
eventually becomes transmural
 Hyper active phase severe abdominal pain
and passage of bloody stools. Many patients
get better and do not progress beyond this
 Paralytic phase follow if ischemia continues;
abdominal pain and tenderness becomes more,
bowel motility decreases, resulting in
abdominal bloating, no further bloody stools,
and absent bowel sounds on exam.
 Shock phase fluids start to leak through the
damaged colon. This can result in shock and
metabolic acidosis with dehydration, low blood
pressure, rapid heart rate, and confusion.

7. MESENTERIC ISCHEMIA
EPIDEMIOLOOGY
 Mesenteric ischemia is insufficient perfusion
of the mesentery to meet the metabolic
demands of the splanchnic system.
 Prompt diagnosis and treatment of this life-
threatening condition, with mortality rates
from 24% to 94% is important
 Despite the best efforts of modern medicine
mortality still exceeds 50%
 Acute mesenteric ischemia is different from
ischemic colitis, which involves only small
vessels and causes mainly mucosal necrosis
and bleeding.
 The overall incidence for Mesenteric Ischemia
is estimated at 12.9/100,000 person/year
 Incidence of Acute superior mesenteric artery
(SMA) occlusion (embolus/thrombus ratio =
1.4) is 70%
 Incidence of Mesenteric venous thrombosis
(MVT) is 15%
 Nonocclusive mesenteric ischemia (NOMI)
were found in 15%

8. MESENTERIC ISCHEMIA
Clinical Features
Acute Mesenteric Ischemia- AMI
- MAE: Mesenteric Arterial Embolism
- MAT: Mesenteric Arterial Thrombosis

9. MESENTERIC ISCHEMIA
Clinical Features
MVT- Mesenteric Vein Thrombosis NOMI- Non-Occlusive Mesenteric Ischemia

10. MESENTERIC ISCHEMIA
Clinical Features
Chronic Mesenteric Ischemia- CMI

11. MESENTERIC ISCHEMIA
Clinical Features

12. MESENTERIC ISCHEMIA
INESTIGATIONS- LABS
 White blood cell count >10.5 in 98%
 Lactic acid elevated 91%
 In very early stage these two may not be elevated
 However, in late cases both are elevated

13. MESENTERIC ISCHEMIA
INESTIGATIONS- CT Abdomen
SMA embolism. Axial contrast-enhanced CT image
shows the SMA trunk (white arrow), which lacks
contrast enhancement owing to an embolus. The
thrombosed SMA is dilated and is as large as the
adjacent SMV (black arrow).
(CT) showing dilated loops of small bowel with
thickened walls (black arrow), findings characteristic
of ischemic bowel due to thrombosis of the superior
mesenteric vein.

14. MESENTERIC ISCHEMIA
INESTIGATIONS- CT Angiography
CTA scan of acute mesenteric ischemia
secondary to occluded SMA from an
emboli. 3D reconstruction shows mid
occlusion of SMA.

15. MESENTERIC ISCHEMIA
TREATMENT
Acute Mesenteric Ischemia:
 If diagnosis is made during exploratory laparotomy, options
are surgical embolectomy, revascularization, and resection.
 A “second look” laparotomy may be needed to reassess the
viability of questionable areas of bowel.
 Patients with arterial embolism or venous thrombosis require
long-term anticoagulation with warfarin. Patients with
nonocclusive ischemia may be treated with antiplatelet
therapy.

16. MESENTERIC ISCHEMIA
TREATMENT
Chronic Mesenteric Ischemia:
 If diagnosis is made by angiography, infusion of
the vasodilator papaverine through the
angiography catheter may improve survival in both
occlusive and nonocclusive ischemia
 For arterial thrombosis, Catheter directed
thrombolysis, balloon angioplasty or surgical by-
pass surgery may be done
 Mesenteric venous thrombosis without signs of
peritonitis can be treated with papaverine followed
by anticoagulation with heparin and then
warfarin.

17. MESENTERIC ISCHEMIA
TAKE HOME MESSAGE
 Early diagnosis is critical because mortality increases significantly once
intestinal infarction has occurred.
 Initially, pain is severe but physical findings are minimal- Pain out of
proportion to physical findings
 Surgical exploration is often the best diagnostic measure for patients with
definite peritoneal signs.
 For other patients, mesenteric angiography or CT angiography is done.
 For AMI embolectomy, revascularization, and resection.
 For CMI thrombolysis, angioplasty or by-pass surgery

18. MESENTERIC ISCHEMIA
MINDMAP

19. MESENTERIC ISCHEMIA
TREATMENT ALGORITHM

20. Peripheral Arterial Diseases(PAD)