THE MORNING REPORT

The Best in FOAM Education

  • Matthew Tanzi, MD

Understanding Mesenteric Ischemia

A 65 year-old male with a past medical history of hypertension, hyperlipidemia, peripheral vascular disease, diverticulosis, and paroxysmal atrial fibrillation (only on aspirin due to a spontaneous subarachnoid hemorrhage 10 years ago) presents to the emergency department complaining of diffuse and band-like abdominal pain for the past hour. It started about 30 minutes after eating dinner. He became nauseous and described pain as 8/10. It occurred once prior about one month ago. He has not taken any medications prior to arrival. He had one episode of non-bloody, non-bilious emesis that was largely his dinner. He denies fever, chest pain, shortness of breath, diarrhea, constipation, melena, hematochezia, dysuria, hematuria, medication changes, or unusual ingestions.

Vital Signs:

HR: 130, RR: 22, BP: 98/62, O2: 99% on RA. Afebrile 

PSH:

ILR implanted, Hemicolectomy 2/2 Diverticulitis flare 5 years ago 


Social:

  • 1-2 glasses wine/week

  • Previously a 1/2 PPD smoker but quit 10 years ago for a total of 30 Pack-years

  • No illicit drugs 

Meds:

HCTZ-Lisinopril, ASA, Metoprolol, Lipitor 

Physical Exam

  • General: Uncomfortable appearing, non-toxic, mild distress 

  • Neuro: AxO x 3; no focal deficits 

  • HEENT: Dry mucous membranes 

  • CV: A-Fib at 130 bpm, no edema, mild chronic stasis changes to bilateral lower extremity

  • Lungs: Clear to auscultation, no wheezes/crackles/rhonchi/rales 

  • Abd: Soft with mild distension; he cannot localize pain but is voluntary guarding; pain out of proportion is apparent. Hyperactive bowel sounds in all 4 quadrants. Previous surgical scar well-healed in the left lower quadrant. No hemorrhoids. Neg Stool Occult 

  • GU: Within normal limits

  • Skin/Ext: Warm extremities and soft compartments, Pulses 2+ in upper extremities and 1+ in lower extremities

Differential diagnosis:

Mesenteric ischemia, gastroenteritis, colitis, obstruction, cholecystitis, PUD, perforated viscous, AAA, diverticulitis, etc.

Take Away #1 - Categories of Mesenteric Ischemia: 


1) Arterial Emboli

a) Typically, from AFIB or Endocarditis 

b) 50% of cases 


2) Arterial Thrombus 

a) Stenosis --> Angina --> CAD of the gut 

b) ~ 20-30% of cases 


3) Non-occlusive 

a) i.e hypoperfusion 2/2 CHF, hypotension, sepsis, post-prandial pain due to exercising the gut, etc. 

b) ~ 15-25% 


4) Mesenteric Venous Thrombosis 

a) 2/2 hypercoaguable state or previous inflammation in abd 

b) ~ 10% 

Take Away #2 - Have a low threshold to image elderly with abdominal pain --> This population has an approximate 10% mortality from underlying cause.

  • CT Angio of Abd with venous phase included --> Superior mesenteric artery is the most common, then inferior mesenteric artery, then the celiac artery 

  • CT findings include bowel wall thickening, ascites, mesenteric edema, pneumatosis intestinalis (late), and perforation (late) 

Take Away #3 - Work-up and Treatment

  • Basic labs but include troponin, lactic acid, T&S, coags

  • EKG, IVF, NPO

  • Imaging including CXR to rule out perforation, CT Angio abd/pelvis

  • Antibiotics

  • Pain control

  • Heparin gtt

  • Vascular and Surgical Consult

  • BE MINDFUL of VASOPRESSORS --> many pressors lead to splanchnic vasoconstriction. But if the patient is crashing in front of you then you obviously need them.

Matthew Tanzi, MD is a current third year resident at Stony Brook Emergency Medicine. He can be found on Twitter @mtanzi2791.


References:

  • Lo B (2020). Lower gastrointestinal bleeding. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill.


Edited by Bassam Zahid, MD

Stony Brook
EMergency Medicine

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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