Information about Bowel gangrene by Dr Dhaval Mangukiya. Details of Bowel gangrene, Acute Mesenteric Ischaemia, Incidence, Challenges in diagnosing mesenteric ischemia, CT scan Angiography, Case, Learning Points, Future in Imaging, Surgery, SIDS Hospital, Thrombectomy, Postoperative and case etc. https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

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

4. Incidence
• 1% of acute abdomen hospitalizations and
occurs in one in 1000 patients presenting to
emergency rooms
Brandt L, Boley S, Goldberg L, Mitsudo S, Berman A. Colitis in the elderly. A reappraisal. Am J
Gastroenterol. 1981;76:239–245.
Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: systematic review and meta
analysis. Radiology. 2010;256:93–101.
• SIDS – 17 patients in 4000 admissions
– 14 Arterial
– 3 Venous

5. • Classical picture
– Leukocytosis
– Metabolic acidosis
– Elevated Serum Lactate
– Elevated D-dimer level

6. D-dimer, had a high sensitivity for SMA-
occlusion
Blood-gas analysis more often showed
alkalosis than acidosis, due to frequent
vomiting in the early phase of bowel ischaemia
D-dimer detection does not differentiate patients with AMI from those with non-acute
mesenteric ischemia, and that there is no difference in serum D-dimer levels between
resectable and unresectable bowel necrosis lesions
Chiu YH, Huang MK, How CK, Hsu TF, Chen JD, Chern CH, Yen DH, Huang CI. D-dimer in patients with suspected acute mesenteric ischemia. Am J Emerg
Med. 2009;27:975–979.

7. Systematic Review and Pooled Estimates for the
Diagnostic Accuracy of Serological Markers for
Intestinal Ischemia
Nicholas J. Evennett, Maxim S. Petrov, Anubhav Mittal, John A. Windsor World Journal of Surgery July 2009, Volume 33, Issue 7, pp
1374-1383
•The performance of the currently available serological markers is suboptimal
•Novel markers D-lactate, GST (glutathione S-transferase), and i-FABP (intestinal fatty-
acid binding protein) may offer improved diagnostic accuracy
•Further research is required to demonstrate their clinical utility

9. CT scan Angiography
• Most accurate and acceptable
• Risk of Renal Injury
• Subjective reporting
• Demands technical specialty
• Classical signs in late stage

10. Case
• 45 year old male
• H/O ?IHD 10 years back on Anticoagulants
• Abdominal pain since 15 days
• Diarrhea since 8 days 8-10 per day
Clinically stable

11. Case
• On admission day 1
• Normal routine blood investigation (No advise
for specific inv)
• USG – enteritis
• Continued orals

12. Case
• On admission day 6
• Surgeon – surgical abdomen
• GI Surgeon – Review CT done 3 days back
• Reported as ileocolic thrombus with bowel
gangrene of terminal ileum

13. Case
• On admission day 3
• Surgical opinion for increasing counts and
abdominal signs
• CT scan – Terminal ileal thickening

14. Case
• Transferred - Operated

15. Learning Points
• High index of suspician
• Serum markers for ischaemia
• Vigilant evaluation
• Low threshold for imaging
• Preferred imaging

16. Future in Imaging
• contrast-enhanced magnetic resonance
angiography (CE-MRA)
• Non-contrast-enhanced 7 tesla magnetic
resonance imaging (7T-MRI)

17. • Nothing by mouth, nasogastric decompression
• Fluid therapy to maintain adequate intravascular volume
and visceral perfusion, and monitored as normal urine
output
• Avoidance of vasopressors which can exacerbate ischemia
• Antithrombotic therapy consists of anticoagulation
(unfractionated heparin; weight-based protocol) to limit
thrombus propagation with or without antiplatelet therapy
• Empiric broad spectrum antibiotic therapy
• Proton pump inhibitors
• Supplemental oxygen

18. Acute mesenteric ischaemia
History/Investigation
Arterial Venous
Stable vitals
No gangrene
Collaterals
“Acute on chronic”
Stable vitals
No gangrene
No collaterals
“thrombus/embolus”
Sepsis/shock
Bowel Gangrene
Conservative
Heparin
ICU
Primary
endovacular
therapy
Surgery SOS
Thrombectomy
Stable vitals
Collaterals
No Gangrene
Sepsis/shock
Gangrene
Conservative
Heparin
Antiplatelets
Further work up
Surgery

19. Surgery
• Exploratory Laparotomy
• Resection
• Thrombectomy
• Anastomosis/Stoma

21. SIDS Hospital

22. Thrombectomy
• Preop imaging and selection
• Preop resuscitation
• Bowel ischemia/segmental gangrene
• SMA at root of mesentery
• Heparin bolus
• 3or 4 no. Fogarty catheter
• Antegrade and retrograde thrombectomy
• Contraindication – extensive perforation
peritonitis, extensive gangrene

24. Postoperative
• Heparin infusion (aPTT monitoring)
• LMWH
• Warfarin (INR monitoring)
• Aspirin/clopidogril

25. Case
• 57 year old male
• Hypertensive
• No h/o IHD
• Acute presentation
Diagnosis: SMA thrombus, Ischemic bowel,
Septic shock

26. Case
• Emergency exploratory Laparotomy

27. Case
• Bowel gangrene – terminal ileum
• Ischemic proximal bowel
• Thrombectomy done
• Resection and stoma

28. Case
• Skin closure
• Heparin infusion
• Ventilatory support
• Relook after 24 hours

29. • mortality rates of 40% to 70% for acute
mesenteric ischemia
Kassahun WT, Schulz T, Richter O, Hauss J. Unchanged high mortality rates from acute occlusive intestinal ischemia: six year
review. Langenbecks Arch Surg. 2008;393:163–171.
• 2 deaths in 17 Surgeries (SIDS)