Acute Mesenteric Ischemia.pptx Addis Ababa Uriversity, Ethiopia

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Acute Mesenteric Ischemia
By: Dr.Temesgen Shume PGY1.
07-02-2023
AAU-CMHS-Department of surgery

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Anatomy and physiology.
Classification.
Clinical presentation.
Diagnosis.
Management.
CHS-Surgery Department
AAU- CHS-Surgery Department
Outline
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 Acute mesenteric ischemia (AMI) is a syndrome
caused by inadequate blood flow through the
mesenteric vessels, resulting in ischemia and eventual
gangrene of the bowel wall.
 In 1930, Cokkinis remarked, “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.”
Fortunately, since 1930, many advances have been
made that allow earlier diagnosis and treatments.-
Surgery Department
Introduction
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ARTERIAL ANATOMY
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VENOUS ANATOMY
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What is Acute Mesenteric Ischemia
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Acute mesenteric ischemia refers to sudden onset of intestinal
hypoperfusion, which can be do to reduction or cessation of blood flow.
Types of AMI?
1. Occlusive.
 Embolic
 Thrombotic
2. Non – occlusive AMI(NOMI).
3. Mesenteric venous thrombosis.
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Incidence
Bala et al. World Journal of Emergency Surgery (2022)
AMI
Occlusive
mesenteric
ischemia
Embolism –
45-50%.
Thrombosis-
25%.
Non occlusive
mesenteric
ischemia
20%
Mesenteric
venous
thrombosis
10%
Incidence is 0.09-0.2%.
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Origin:
 Left atrium(atrial fibrillation).
 Left ventricle(ventricular
thrombus).
 Atherosclerotic aorta.
Location:
 SMA(relatively large diameter
and low takeoff angle from the
aorta).
 Embolus 3-10cm distal to
the origin of SMA(sparing
proximal jejunum).
 Additional emboli in the
splenic artery and renal artery
in 20%.
Embolic occlusive AMI Aortic ostium
15%
Around middle colic artery
40%
Distal branches
45%
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Origin:
 Generalized
atherosclerosis.
Location:
 Origin of SMA.
 Origin of celiac axis.
Fear of food.
Thrombotic occlusive AMI
Aortic ostium
60-80%
Around middle colic artery
15%
Distal branches
5%
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• Relation to hemostatic mechanism.
• Insufficient perfusion despite patent vessel.
• Hypotension- maintenance of cerebral and
cardiac blood flow at expense of splanchnic
and peripheral blood flow.
Non- occlusive AMI
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Virchow's Triad:- Flow, coagulability, & endothelial injury.
Hypercoagulability:
 Protein S, protein C deficiency.
 Antithrombin deficiency.
 Antiphospholipid syndrome.
Secondary : PHT, IBD, Pancreatitis, Sepsis.
Mesenteric venous occlusion
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Depending on the type of ischemia
Risk factors
Arterial embolism Arterial
thrombosis
Non occlusive mesenteric
ischemia
Mesenteric venous
thrombosis
 Recent MI.
 Arrhythmia.
 Rheumatic fever.
 Prosthetic heart valves.
 Proximal aortic
disease. e.g. Aneurysm,
atheroma.
 Systemic
atherosclerosis.
 Aortic aneurysm
 Aortic dissection
 Arteritis
 Low flow stats- shock
 Drugs- Vasopressor agent
Inherited hypercoagulability.
 Factor V Leiden mutation.
 Protein C, S, Antithrombin
III deficiency.
Secondary hypercoagulability.
 Portal hypertension
 Inflammation
 Prior surgery
 Trauma
 Malignancy
Bala et al. World Journal of Emergency Surgery (2022)
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Deficit in blood supply or drainage.
Insufficient bowel perfusion.
Tissue hypoxia.
Abnormal drainage of metabolites.
Loss of bowel wall integrity.
Bacterial translocation-bacteremia.
Bowel perforation-peritonitis/abscess.
Sepsis-septic shock-death.
Pathophysiology
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Udassin R, et al. j surg res 1994;56:221-5

Severe abdominal pain out of proportion to clinical findings
should be assumed to be AMI until proven otherwise.
Abdominal pain….97%.
Nausea….44%.
Vomiting….35%.
Diarrhea….35%.
Blood per rectum….15%.
Clinical presentation = acute onset abdominal pain
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0-6h Hyperactive phase
Discrepancy between strong pain and clinical findings.
7-12h Paralytic phase
Distended abdomen, reduced bowel sound.
13-24h Septic phase
Volume leakage- shock.
Clinical presentation
Early diagnosis
requires high
index of
suspicion.
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Lab- nonspecific.
 WBC.
 Lactate.
 D-dimer.
Diagnosis
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Method: We reviewed 180 consecutive malpractice claims submitted
by attorneys for medical expert (ME) review during the 12 years ending
in late 1998. Seven cases involved acute mesenteric ischemia.
RESULTS: Alleged failure to make a timely diagnosis was the
basis for 5 of these claims, failure to provide anticoagulant
protection for 1, and failure to prevent nonocclusive ischemic
infarction for 1.
CONCLUSIONS: The risk of a malpractice claim is reduced by
consideration of computed tomography (CT), angiography, and surgical
consultation as soon as a patient is seen whose differential diagnosis
includes acute mesenteric ischemia.

Imaging
1. Erect abdominal x-ray.
Diagnosis
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Imaging
Tumb-
printing
sign-
significant
bowel wall
edema &
thickening.
Diagnosis
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Pneumatocis
intestinalis.
Diagnosis
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2. Doppler ultrasonography
Able to identify severe stenosis, total or partial occlusion and velocity of blood
flow through the vessels.
Unable to detect
 Emboli beyond the proximal main vessel.
 Non- occlusive mesenteric ischemia.
Diagnosis
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3. Contrast enhanced Abdominal CT.
 Sensitivity 93%, specificity 97.9%.
 Excludes other cases of abdominal pain.
 No time delay.
Intestinal pneumatosis
Worrisome if combined with
 Soft tissue bowel wall thickening.
 Free intraperitoneal fluid.
 Peri-intestinal soft tissue stranding.
 Abnormal bowel wall enhancement.
Diagnosis
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Imaging
Diagnosis
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4. Angiography.- Gold standard
method.
Non invasive
CTA.71-96% vs 92-94%
MRA. 100% vs 91%
Invasive
Catheter
Finding
Filing defect
Stenosis or blockage
Diagnosis
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Finding on imaging
Diagnosis
Acute mesenteric
Arterial embolism
Acute mesenteric
Arterial thrombosis
Non occlusive
mesenteric ischemia
Mesenteric venous
thrombosis
Occlusion of arteries Diffuse atherosclerotic
disease
Occlusion of artery
Bowel ischemia
Free fluid with open
mesenteric vessel
Thrombus in superior
mesenteric or portal vein.
bala et al, AMI guideline WSES, 2022
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Management
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1. Resuscitation.
 Fluid
Enhance visceral perfusion.
Correct electrolyte.
Correct metabolic acidosis.
 Broad spectrum antibiotics.
 IV Heparin.
Management
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Surgical exploration.
Midline laparotomy
1. Assessment of bowel viability.
2. Determination of the underlying cause.
3. Mesenteric revascularization.
4. Resection of necrotic bowel.
5. Second look laparotomy.
Management
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1. Clinical signs:
 Visible palpable pulsation.
 Normal color and appearance.
 Peristalsis.
 Bleeding from cut surface.
2. Doppler USG:
- Hand-heled Doppler (detects mesenteric blood flow).
3. Fluorescein:
- Injection of IV sodium fluorescein(1gm) IV and inspection
under wood’s lump (viable bowel has smooth, uniform
fluorescence).
How to asses intraoperative bowel viability
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Determination of the underlying pathology:
Thrombosis or embolism?
Palpate the main trunk of SMA
(At the base of small bowel mesentery)
Pulse present proximally
but not distally
No pulse Weak pulse Normal pulse
Proximal jejunum and
transverse colon spared
from ischemia
SMA embolism
Diffuse mid gut bowel
ischemia is noted.
SMA thrombosis
NOMI
Mesenteric venous
thrombosis
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Mesenteric revascularization
Ballon catheter embolectomy Thrombectomy
+/- vein patch angioplasty
Bypass grafting Reimplantation of SMA.
Post revascularization papaverine.
Embolism Thrombosis
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1. Endovascular intervention.
2. Surgery.
3. Hybrid approach.

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 Using the National Inpatient Sample database, admissions from 2005 through 2009 were
identified.
 23,744 patients presenting with AMI, 4665 underwent interventional treatment from 2005
through 2009.
 A total of 679 patients underwent vascular intervention; 514 (75.7%) underwent open surgery
and 165 (24.3%) underwent endovascular treatment overall during the study period.
 Mortality was significantly more commonly associated with open revascularization compared
with endovascular intervention (39.3% vs 24.9%; P = .01).
 Length of stay was also significantly longer in the patient group undergoing open
revascularization (12.9 vs 17.1 days; P = .006).
 During the study time period, 14.4% of patients undergoing endovascular procedures required
bowel resection compared with 33.4% for open revascularization.

Resection of necrotic bowel
Frankly necrotic bowel segments.
Resection.
Marginal- viable bowel (Equivocal viability).
May improve over hours.
Consider second-look laparotomy.
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AMI
 Laparoscopy in AMI.
 Damage control surgery (DCS).
 Postoperative intensive care.
 Treatment of AMI is optimal in a dedicated center using a focused care
bundle and a multidisciplinary team.
 Massive gut necrosis.
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Critical lengths of remaining bowel to avoid short bowel syndrome.

 Correct underlying conditions.
 Address hemodynamic instability and minimize use of vasopressor.
 Catheter directed infusion of vasodilatory/antispasmodic agent.
 E.g. Papavarine(30-60mg/hr), PGE1(alprostadil a dose of 40 micg/day).
 Laparotomy if peritoneal sign present
NOMI: Non surgical management
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 Anticoagulation!
 Workup for hypercoagulability.
 Laparotomy if peritoneal signs develop.
 Only 5% receiving conservative therapy deteriorates.
 Trans hepatic, percutaneous mechanical thrombectomy.
 Thrombolysis.
 Surgical exploration: open thrombectomy, resection in indicated.
Mesenteric vein thrombosis: Non surgical management
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Prognosis
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Mortality
Correlation between lethality and duration of
intestinal ischemia.
Luther, L. M., et.al, AMI. Visceral Medicine, 2018.
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Mortality of AMI
Aetiology Occlusive mesenteric
ischemia
Non occlusive
mesenteric ischemia
Mesenteric venous
thrombosis
Mortality
(n=4527,
1912/2247)
27 study
…..63%
73.9% 68.5% 44.2%
No significant reduction in hospital mortality in the last decade
F Adaba et al. colorectal Dis. 2015 jul.
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 Managing comorbidity and risk factors.
E.g. smoking cessation, BP management.
 Antiplatelet thromboprophylaxis.
lifelong ASA for occlusive diseases.
 Oral anticoagulation.
Atrial fibrillation, mesenteric vein thrombosis, inherited or acured
thrombophilia.
 Surveillance imaging.
Follow up
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AMI
 Rare disease with often fatal outcome (mortality is as high as 80%).
 We have less time for investigation, so early recognition(high clinical
suspicion) is important.
 Every minutes we waste is every centimeter of small bowel we loose.
 Type of ischemia determine treatment.
 Prompt imaging enables rapid resuscitation and further therapy.
 Interdisciplinary approach – immediate revascularization.
Take home message
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1) Bala, M., Kashuk, J., Moore, E.E., Kluger, Y., Biffl, W., Gomes, C.A., Ben-Ishay, O., Rubinstein, C., Balogh, Z.J.,
Civil, I., Coccolini, F., Leppaniemi, A., Peitzman, A., Ansaloni, L., Sugrue, M., Sartelli, M., Di Saverio, S., Fraga,
G.P. and Catena, F. (2022). Acute mesenteric ischemia: guidelines of the World Society of Emergency
Surgery. World Journal of Emergency Surgery, 12(1). doi:10.1186/s13017-017-0150-5.
2) https://emedicine.medscape.com/article/189146-overview#:~:text=%3E%20General%20Surgery-
,Acute%20Mesenteric%20Ischemia,-Updated%3A%20Apr%2029.
3) Uptodate%202018/d/topic.htm?path=acute-mesenteric-arterial-occlusion#:~:text=Contents-
,Acute%20mesenteric%20arterial%20occlusion,-Topic%20Outline.
4) Moore, K.L., Dalley, A.F. and A M R Agur (2014). Moore clinically oriented anatomy. Philadelphia, Pa. ; London:
Wolters Kluwer Health/Lippincott Williams & Wilkins
5) Adaba, F., Askari, A., Dastur, J., Patel, A., Gabe, S.M., Vaizey, C.J., Faiz, O., Nightingale, J.M.D. and
Warusavitarne, J. (2015). Mortality after acute primary mesenteric infarction: a systematic review and meta-
analysis of observational studies. Colorectal Disease, 17(7), pp.566–577. doi:10.1111/codi.12938.
References
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6. Bayrak, S., Bektas, H., Duzkoylu, Y., Guneyi, A. and Cakar, E. (2014). Acute Abdomen
Resulting from Concurrent Thrombosis of Celiac Trunk and Superior Mesenteric
Artery. Case Reports in Gastrointestinal Medicine, 2014, pp.1–3. doi:10.1155/2014/142701.
7. Ogi, K., Sanui, M., Iizuka, Y., Aomatsu, A., Nakashima, I., Hamamoto, K., Okochi, T. and Lefor,
A.K. (2017). Successful treatment of nonocclusive mesenteric ischemia after aortic valve
replacement with continuous arterial alprostadil infusion: A case report. International
Journal of Surgery Case Reports, 35, pp.8–11. doi:10.1016/j.ijscr.2017.03.037.
8. Kühn, F., Schiergens, Tobias S. and Klar, E. (2020). Acute Mesenteric Ischemia. Visceral
Medicine, 36(4), pp.256–263. doi:10.1159/000508739.
9. Oderich, G.S. (2016). Mesenteric Vascular Disease. Springer.
10. Sreenarasimhaiah, J. (2003). Diagnosis and management of intestinal ischaemic
disorders. BMJ, 326(7403), pp.1372–1376. doi:10.1136/bmj.326.7403.1372.
References
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Thank you !!!
Discussion
10/02/2023 45

Acute Mesenteric Ischemia.pptx Addis Ababa Uriversity, Ethiopia

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