Information about Acute mesenteric ishaemia by Dr Dhaval Mangukiya. Details of Acute mesenteric ishaemia, Pathophysiology, Symptoms, Cilinical scenario, NOMI, Blood Investigation, Imaging, Anticoagulation, Treatment - Scenario 1, Treatment - Scenario 2, Treatment - Scenario 3, Treatment - Scenario 4, Treatment - Scenario 5, Tharombectomy https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. Acute Mesenteric Ischaemia
Dr Dhaval Mangukiya
Surgical Gastroenterologist
SIDS Hospital

2. Pathophysiology
• Acute arterial Embolism
• Acute arterial Thrombosis
• Non occlusive mesenteric ischaemia
• Acute venous thrombosis

3. Symptoms
• Severe abdominal pain
• Nausea
• Vomiting
• Diarrhea
• Bleeding PR
• 95%
• 44%
• 35%
• 35%
• 16
• Severe abdominal pain out of proportion to physical
examination findings should be assumed to be AMI
until disproven

4. Clinical scenario differentiates AMI as
mesenteric arterial emboli, mesenteric
arterial thrombosis, NOMI or
mesenteric venous thrombosis.

5. NOMI
• Patients surviving cardiopulmonary resuscita-
tion who develop bacteremia and diarrhea
(with or without abdominal pain) should be
suspected of having NOMI.
• Right-sided abdominal pain associated with
the passage of maroon or bright red blood in
the stool is highly suggestive of NOMI in these
patients.

6. Blood Investigation
• CBC
• ABG
• D - Dimer
• Leucocytosis (90%)
• Metabolic Acidosis
(88%) with elevated
lactate level > 2
• Specificity (82%)
Sensitivity (60%)
Accuracy (79%)

7. Imaging
• X-ray
• CT scan

8. Imaging
• Computed tomography angiography (CTA)
should be performed as soon as possible for
any patient with suspicion for AMI.
(Recommendation 1A)

9. Imaging
• Surgery - Irreversible ischemia (intestinal
dilatation and thickness, reduction or absence
of visceral enhancement, pneumatosis
intestinalis, and portal venous gas) and free
intraperitoneal air

10. Anticoagulation
• Unfractionated Heparin – loading f/b Infusion
• Low molecular – Post op
• Antiplatelets – Arterial – life long
• Warfarin – Venous – 6 month – workup
(Factor V Leiden, prothrombin mutation, protein S deficiency,
protein C deficiency, antithrombin deficiency, and
antiphospholipid syndrome )

11. Treatment - Scenario 1
• 56 year old male - businessmen
• Symptom duration few hours
• Acute arterial Emboli
• No peritonitis
• ABG – Acidosis
• D- Dimer – >4000
• CT – Block at root SMA

12. Treatment Scenario 1
• Conventinal Angio
• Removal of block
• Stenting
• Followed by Surgery
• Surgery
• Open thrombectomy

13. Treatment – Scenario 2
• 62 year female – wife of a businessman
• Acute Abdomen since 6 days
• Peritonitis
• CT – Arterial block, No bowel perfusion
• Laparotomy – extensive gangrene req massive
resection of small bowel
• Viable – 40 cm from DJ 10 cm from IC

14. Treatment – Scenario 2
• Thrombectomy
• Stoma and re feed
• Closure
• Counseling

15. Treatment – Scenario 3
• 48 year old male – Rikshaw driver
• Acute abdomen – 2 days
• Rebound tenderness
• CT – Scan – arterial thrombus, No free fluid
• Laparotomy – 80 cm viable jejunum 40 cm
ischaemic small bowel Gangrene upto
transeverse colon

16. Treatment – Scenario 3
• Thrombectomy
• Relook
• Anastomosis

17. Treatment Scenario 4
• 38 year old male – Job
• Alcoholic
• Venous thrombosis
• Rebound tenderness
• CT – Long segment jejunal loop thickening

18. Treatment – Scenario 4
• Heparin
• Warfarin
• Close follow up
• Consequeces

19. Treatment – Scenario 5
• 76 year old female – Retired from everything
except life
• IHD, EF 40%
• Pain and malaena – 4 days
• Peritonitis
• D-Dimer – >8000
• CT Scan – Block long segment SMA, No bowel
perfusion proximal jejunum upto caecum

20. Treatment – Scenario 5
• Overeducated family
• Decent socioeconomic status
• No understanding
• Daily same question
• 12 doctors seeing patient
• Surgeon on fire line

21. Thrombectomy