11

Management of Management of Acute Mesenteric IschemiaAcute Mesenteric Ischemia

CN Shum (2CN Shum (2ndnd Year HST) Year HST)

Department of SurgeryPamela Youde Nethersole Eastern HospitalPamela Youde Nethersole Eastern Hospital

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Definition of Mesenteric IschemiaDefinition of Mesenteric Ischemia

Interruption of intestinal blood flow byInterruption of intestinal blood flow by embolism, embolism, thrombosis, or thrombosis, or a low-flow state.a low-flow state.

33

PathophysiologyPathophysiology

Ischemia

Mucosal barrier disruption

Release of bacteria, toxins, vasoactive substance

SIRS

MODS

Death

Substantial protein-rich fluid lossinto the gut

Hypovolemia

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How common is Mesenteric How common is Mesenteric Ischemia?Ischemia?

0.1% of all hospital admissions. 0.1% of all hospital admissions.

Mesenteric artery stenosis is found in Mesenteric artery stenosis is found in 17.5% of independent elderly adults. 17.5% of independent elderly adults.

•Cappell MS, et al. Cappell MS, et al. Gastroenterol Clin North AmGastroenterol Clin North Am. Dec 1998;27(4):827-. Dec 1998;27(4):827-60, vi. 60, vi. •Ha C, et al.  Ha C, et al.  Am J GastroenterolAm J Gastroenterol. Jun 2009;104(6):1445-51. . Jun 2009;104(6):1445-51. 

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Classification of Mesenteric Classification of Mesenteric IschemiaIschemia

AcuteAcute 4 distinct mechanisms4 distinct mechanisms

ChronicChronic Due to long standing Due to long standing

atherosclerosisatherosclerosis

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Causes of Acute Mesenteric Causes of Acute Mesenteric Ischemia (AMI)Ischemia (AMI)

TypeType Risk FactorsRisk Factors

Mesenteric Arterial Embolus (MAE)Mesenteric Arterial Embolus (MAE)

(> 50%)(> 50%)

Coronary artery disease, heart failure, Coronary artery disease, heart failure, valvular heart disease, atrial fibrillation, valvular heart disease, atrial fibrillation, history of arterial embolihistory of arterial emboli

Mesenteric Arterial thrombosis (MAT)Mesenteric Arterial thrombosis (MAT)

(10%)(10%)

Generalized atherosclerosisGeneralized atherosclerosis

Mesenteric Venous thrombosis (MVT)Mesenteric Venous thrombosis (MVT)

(5–15%)(5–15%)

Hypercoagulable state, inflammatory Hypercoagulable state, inflammatory conditions (eg, pancreatitis, diverticulitis), conditions (eg, pancreatitis, diverticulitis), trauma, heart failure, renal failure, portal trauma, heart failure, renal failure, portal hypertension, decompression sicknesshypertension, decompression sickness

Non-Occlusive Mesenteric Ischemia Non-Occlusive Mesenteric Ischemia (NOMI)(NOMI)

(25%)(25%)

Low flow states (eg, heart failure, shock, Low flow states (eg, heart failure, shock, cardiopulmonary bypass) and splanchnic cardiopulmonary bypass) and splanchnic vasoconstriction (eg, vasopressors, vasoconstriction (eg, vasopressors, cocaine)cocaine)

77

Clinical presentation of Clinical presentation of Acute mesenteric IschemiaAcute mesenteric Ischemia

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Symptoms & signsSymptoms & signs

In a series of 58 patients with mesenteric ischemia due In a series of 58 patients with mesenteric ischemia due to mixed causes:to mixed causes:

abdominal pain abdominal pain 95% 95% NauseaNausea 44% 44% vomiting vomiting 35% 35% diarrhea diarrhea 35% 35% heart rate > 100heart rate > 100 33%33% ShockShock 33%33% metabolic acidosismetabolic acidosis 33% 33% 'blood per rectum‘'blood per rectum‘ 16% 16% ConstipationConstipation 7% 7%

Park WM, et al. Park WM, et al. J. Vasc. Surg.J. Vasc. Surg. 3535 (3): 445–52. (3): 445–52.

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Acute Mesenteric Ischemia due to Acute Mesenteric Ischemia due to embolisationembolisation

F:M=2:1F:M=2:1Median age 70Median age 70Typical presentationTypical presentation Sudden onset of periumbilical painSudden onset of periumbilical pain Followed by copious vomiting and explosive Followed by copious vomiting and explosive

diarrhoeadiarrhoea Abdominal signsAbdominal signs

Early: non-specificEarly: non-specificLate (likely infarction): Peritonism, Blood in stool or Late (likely infarction): Peritonism, Blood in stool or vomitusvomitus

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Acute Mesenteric Ischemia due to Acute Mesenteric Ischemia due to thrombosisthrombosis

Often a history of Often a history of intestinal anginaintestinal angina nauseanausea SitophobiaSitophobia significant wt losssignificant wt loss

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Acute Mesenteric Ischemia due to Acute Mesenteric Ischemia due to venous thrombosisvenous thrombosis

Insidious onset over weeksInsidious onset over weeks Nausea, anorexia, diarrhoeaNausea, anorexia, diarrhoea

Later clinical courseLater clinical course Diffuse abd painDiffuse abd pain

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Acute Mesenteric Ischemia due to Acute Mesenteric Ischemia due to nonocclusive disease nonocclusive disease

Occurs in patient with wide-spread Occurs in patient with wide-spread vasoconstrictionvasoconstriction Critically illCritically ill ShockShock vasopressorsvasopressors

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Diagnostic InvestigationsDiagnostic Investigations

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Blood testsBlood tests

Elevation ofElevation of WCCWCC AmylaseAmylase Phosphate Phosphate

Increases within 4 hours (75%) Increases within 4 hours (75%) Reference:Reference:

Can J Surg. 1979 Jan;22(1):40-5 Can J Surg. 1979 Jan;22(1):40-5

Metabolic acidosisMetabolic acidosis

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Plain XRayPlain XRay

Non-specific dilatation of bowelNon-specific dilatation of bowel

Late signs:Late signs: Thumb-printing (edematous bowel wall)Thumb-printing (edematous bowel wall) Pneumatosis intestinalisPneumatosis intestinalis Portal venous gasPortal venous gas

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Thumb-printingThumb-printing

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Pneumatosis IntestinalisPneumatosis Intestinalis

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Portal Venous GasPortal Venous Gas

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Doppler USGDoppler USG

Able to identify severe Able to identify severe stenosis or total stenosis or total occlusion:occlusion: Sensitivity 70-89%Sensitivity 70-89% Specificity 92-100%Specificity 92-100%

Unable to detectUnable to detect emboli beyond the emboli beyond the

proximal main vessel proximal main vessel NOMINOMI

•J Vasc Surg 14 (1991), pp. 511–518. •J Vasc Surg 14 (1991), pp. 780–786.

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AngiographyAngiography

Non-invasiveNon-invasive CTACTA

Advantages:Advantages: Better spatial Better spatial

resolutionresolution Faster acquisition Faster acquisition

timetime

MRAMRAAdvantages:Advantages:

No radiationNo radiation No need of iodinated No need of iodinated

contrastcontrast

InvasiveInvasive CatheterCatheter

•AJRAJR 2007; 188:452-461 2007; 188:452-461*J Gastrointest Surg. 2005 Dec;9(9):1262-74 *J Gastrointest Surg. 2005 Dec;9(9):1262-74

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Treatment of Acute Treatment of Acute Mesenteric Ischemia Mesenteric Ischemia

……slightly varied depending of its slightly varied depending of its causescauses

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Treatment in generalTreatment in generalSuspected case

Fluid resuscitationOxygen, NG tube

Broad spectum antibioticsStop vasopressors/ Digitalis

Invasive hemodynamic monitorsTreat arrthymia/ heart failure

Stable Unstable or Peritonism

Angiogram Laparotomy +/- revasularisation +/- bowel resection

Possibility of radiological intervention

Consider vasodilator/ anticoagulation

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Role of anticoagulation dependent on Role of anticoagulation dependent on causes of AMIcauses of AMI

Immediate after dxImmediate after dx Early post-opEarly post-op Long termLong term

Arterial embolismArterial embolism YesYes YesYes

ArterialArterial

thrombosisthrombosis

YesYes

VenousVenous

thrombosisthrombosis

YesYes Yes Yes

(esp if underlying (esp if underlying hypercoagulability hypercoagulability uncovered)uncovered)

Non-occlusiveNon-occlusive

SurgerySurgery 101101 (1987), pp. 383–388. (1987), pp. 383–388. Am SurgAm Surg 5757 (1991), pp. 573–578. (1991), pp. 573–578. Ann SurgAnn Surg 161161 (1965), pp. 516–523. (1965), pp. 516–523.

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Role of vasodilatorsRole of vasodilators

Experiences mainly on papaverineExperiences mainly on papaverine Others:Others:

tolazoline, glucagon, nitroglycerin, nitroprusside, prostaglandin E, phenoxybenzamine, and isoproterenol

For NOMIFor NOMI Mainstay of txMainstay of tx

Reduce mortality from 70-90% to 0-55% Reduce mortality from 70-90% to 0-55%

For Occlusive MIFor Occlusive MI AdjunctAdjunct Not practiced universallyNot practiced universally

Am J RadiolAm J Radiol 142142 (1984), pp. 555–562. (1984), pp. 555–562. SurgerySurgery 8282 (1977), pp. 848–855. (1977), pp. 848–855. Curr Top Surg ResCurr Top Surg Res 33 (1971), pp. 425–433. (1971), pp. 425–433. Br J SurgBr J Surg 7777 (1990), pp. 601–603. (1990), pp. 601–603.

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Role of Interventional RadiologyRole of Interventional RadiologyOptionsOptions ApplicationApplication RemarksRemarks

Catheter directed Catheter directed infusion of infusion of vasodilatorsvasodilators

Primary treatment in Primary treatment in NOMINOMI

Catheter directed Catheter directed thrombolysisthrombolysis

Anecdotal use in Anecdotal use in Occlusive MIOcclusive MI

Measures to ensure Measures to ensure bowel viability e.g. bowel viability e.g. LaparoscopyLaparoscopy

AngioplastyAngioplasty AMI: scantAMI: scant

CMI: commonCMI: common

•Regan, F,et al. Am. J. Gastroenterol. 91(5):1019–1021, 1996.

•Jamieson, A.C., et al. Aust. N. Z. J. Surg. 49:355–356, 1979.

•Flickinger, E.J., et al. Am. J. Roentgenol. 140:771–773, 1983.

•Rivitz, S.M., et al. J. Vasc. Interv. Radiol. 6(2):219–223,1995.

•Rijs, J., et al. Acta. Chir. Belg. 97(5):247–249, 1997.

•Train, J.S., et al. J. Vasc. Interv. Radiol. 9(3):461–464, 1998.

•Poplausky, M.R., et al. Gastroenterology 110(5):1633–1635, 1996.

•Walsh, R.M., et al. Surg. Endosc. 12(12):1405–1409, 1998.

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Case reports and small series of use of thrombolytic agents for SMA emboliCase reports and small series of use of thrombolytic agents for SMA emboli Study (Study (yryr) ) No. of No. of

patientpatientPartialPartial

OcclusionOcclusion

Total Total

OcclusionOcclusion

CentralCentral

LocationLocation

PeripheralPeripheral

LocationLocation

StreptokinaseStreptokinase UrokinaseUrokinase rtPArtPA OutcomeOutcome

Badiola and ScoppettaBadiola and Scoppetta54 (1997) (1997) 11 ++ ++ SuccessfulSuccessful

Bonardelli et al.Bonardelli et al.55 (1994) (1994) 11 ++ ++ Embolectomy, resectionEmbolectomy, resection

Boyer et al.Boyer et al.56 (1994) (1994) 11 ++ ++ ++ SuccessfulSuccessful

Flickinger et al.Flickinger et al.57 (1983) (1983) 11 ++ ++ ++ Embolus lysed; pt died of CHFEmbolus lysed; pt died of CHF

Gallego et al.Gallego et al.67 (1996) (1996) 22 11 11 ++ Successful by 4 hrSuccessful by 4 hr

Hillers et al.Hillers et al.58 (1990) (1990) ++

Hirota et al.Hirota et al.59 (1997) (1997) 11 ++ SuccessfulSuccessful

Kwauk et al.Kwauk et al.60 (1996) (1996) 11 ++ ++ SuccessfulSuccessful

McBride and GainesMcBride and Gaines61 (1994) (1994) 11 ++ SuccessfulSuccessful

Pillari et al.Pillari et al.62 (1983) (1983) 11 ++ ++ ++ Successful by 36 hrSuccessful by 36 hr

Ramirez et al.Ramirez et al.63 (1990) (1990) 11 SuccessfulSuccessful

Regan et al.Regan et al.64 (1996) (1996) 11 ++ ++ ++ SuccessfulSuccessful

Rodde et al.Rodde et al.65 (1991) (1991) 11 ++ ++ ++ SuccessfulSuccessful

Schoenbaum et al.Schoenbaum et al.68 (1992) (1992) 44 22 22 ++ Resection needed in 1 patientResection needed in 1 patient

Sicard et al.Sicard et al.69 (1984) (1984) 22 SuccessfulSuccessful

Simo et al.Simo et al.70 (1997) (1997) 1010 ++ Embolysis 90%; Clinical success Embolysis 90%; Clinical success 70%; Laparotomy 30%70%; Laparotomy 30%

Turegano Fuentes et al.Turegano Fuentes et al.71 (1995) (1995) 22 11 11

Vujic et al.Vujic et al.66 (1984) (1984) 11 ++ ++ Successful by 30 h rSuccessful by 30 h r

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Role of surgeryRole of surgery

Allow assessment of bowel viabiltiyAllow assessment of bowel viabiltiy

Allow resection of non-viable bowelAllow resection of non-viable bowel

Allow specific procedure Allow specific procedure

Types of AMITypes of AMI Specific surgical Specific surgical procedureprocedure

MAEMAE EmbolectomyEmbolectomy

MATMAT BypassBypass

MVTMVT Venous thrombectomy is not usually recommended

as it often recurs and results in distal diffuse extention(Surg Clin North Am 1997;77:327–38.)

NOMINOMI NoNo

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Laparotomy findings in arterial embolismLaparotomy findings in arterial embolism

Location of embolismLocation of embolism usually just distal to the middle colic arteryusually just distal to the middle colic artery

Sparing Sparing proximal jejunum & distal large bowelproximal jejunum & distal large bowel

Next procedure:Next procedure: EmbolectomyEmbolectomy

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Embolectomy Embolectomy

(A) Exposure of superior (A) Exposure of superior mesenteric artery by reflection mesenteric artery by reflection of Ligament of Treitz. of Ligament of Treitz. (B) A transverse arteriotomy is (B) A transverse arteriotomy is performed transversely, performed transversely, proximal to the middle colic proximal to the middle colic branch of the superior branch of the superior mesenteric artery. mesenteric artery. (C) Embolectomy is performed (C) Embolectomy is performed with a 4-F embolectomy with a 4-F embolectomy catheter. catheter. (D) Artery is closed with (D) Artery is closed with interrupted praline suture.  interrupted praline suture. 

Kazmers A: Ann Vasc Surg 12:191, 1998.

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Laparotomy findings in arterial thrombosisLaparotomy findings in arterial thrombosis

Location of thrombosisLocation of thrombosis usually at the origin of SMAusually at the origin of SMA

No sparingNo sparing the entire small bowel and proximal large bowel appear ischemic the entire small bowel and proximal large bowel appear ischemic

Next procedureNext procedure BypassBypass

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BypassBypass

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After revascularization After revascularization (embolectomy or bypass)(embolectomy or bypass)

Alert anesthetist before Alert anesthetist before reperfusion reperfusion can lead to sudden physiologic and metabolic can lead to sudden physiologic and metabolic

derangements, including hypotension, derangements, including hypotension, hyperkalemia, and profound acidosis. hyperkalemia, and profound acidosis.

Consider postrevascularization Consider postrevascularization papaverinepapaverine

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After reperfusionAfter reperfusion

Allow 30 minutesto assess bowel

viability

Primary markers:•peristalsis •color•palpable arterial pulsations

Doppler probesiv fluorescein

followed by Wood’sLamp exam

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For non-viable looking bowelFor non-viable looking bowel

Frankly necrotic bowel segmentsFrankly necrotic bowel segments resectionresection

Marginal-viable bowelMarginal-viable bowel may improve over hoursmay improve over hours consider second-look laparotomyconsider second-look laparotomy

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PrognosisPrognosis

Depends on time & typeDepends on time & type

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Mortality rates for AMI Mortality rates for AMI Study (Study (yryr) ) No. of patientsNo. of patients Mortality rate (%)Mortality rate (%)

BraunBraun2 (1985) (1985) 5252 6464

Clavien et al.Clavien et al.3 (1987) (1987) 8181 8383

Cohen Solal et al.Cohen Solal et al.4 (1993) (1993) 3030 6767

Finucani et al.Finucani et al.5 (1989) (1989) 3232 6666

GeorgievGeorgiev6 (1989) (1989) 175175 9393

Inderbitzi et al.Inderbitzi et al.7 (1992) (1992) 100100 6868

Kach and LargiaderKach and Largiader8 (1989) (1989) 4545 6060

Koveker et al.Koveker et al.9 (1985) (1985) 3939 8585

Levy et al.Levy et al.10 (1990) (1990) 92*92* 5959

MishimaMishima11 (1988) (1988) 162162 6565

Ritz et al.Ritz et al.12 (1997) (1997) 141141 7171

Voltolini et al.Voltolini et al.13 (1996) (1996) 4747 7272

Zan et al.Zan et al.14 (1993) (1993) 3232 7272

**Patients with NOMI excluded. Patients with NOMI excluded.

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Studies showing the importance of Studies showing the importance of early diagnosis of AMI on survival early diagnosis of AMI on survival

Study (Study (yryr) ) No. of patients No. of patients Mortality % Mortality %

(No gangrene )(No gangrene )

Mortality % (Gangrene Mortality % (Gangrene ))

Mortality %Mortality %

(<24H of symptoms)(<24H of symptoms)

Mortality %Mortality %

(>24H of symptoms)(>24H of symptoms)

Batellier and KienyBatellier and Kieny15 (1990) (1990)

6565 2525 6868

Boley et al.Boley et al.18 (1981) (1981) 4747 5757 7373

Inderbitzi et al.Inderbitzi et al.7 (1990) (1990)

8383 17 (a)17 (a) 8888

KienyKieny16 (1990) (1990) 9898 2626 7171

Lazaro et al.Lazaro et al.17 (1986) (1986) 2323 2525 7575

Levy et al.10 (1990) Levy et al.10 (1990) 9292 3131 7373

Ritz et al.12 (1997) Ritz et al.12 (1997) 141141 44 (b)44 (b) 9292

Vellar and Doyle19 Vellar and Doyle19 (1977) (1977)

5252 5454 9595

aa<12 hours, mortality = 0%. <12 hours, mortality = 0%. bb<12 hours, mortality = 0%.<12 hours, mortality = 0%.

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Mortality of different types of AMIMortality of different types of AMI

arterial embolismarterial embolism 54%54%

arterial thrombosisarterial thrombosis 77%77%

venous thrombosisvenous thrombosis 32%32%

non-occlusive ischemianon-occlusive ischemia 73%73%

Brandt LJ, Boley SJ (2000). “AGA technical review on Brandt LJ, Boley SJ (2000). “AGA technical review on intestinal ischemia. American Gastrointestinal intestinal ischemia. American Gastrointestinal Association”. Association”. GastroenterologyGastroenterology 118118 (5): 954–68. (5): 954–68.

Schoots IG, Koffeman GI, Legemate DA, Levi M, van Schoots IG, Koffeman GI, Legemate DA, Levi M, van Gulik TM (2004). "Systematic review of survival after Gulik TM (2004). "Systematic review of survival after acute mesenteric ischaemia according to disease acute mesenteric ischaemia according to disease aetiology". aetiology". The British journal of surgeryThe British journal of surgery 9191 (1): 17–27. (1): 17–27.

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Acute Mesenteric Acute Mesenteric IschemiaIschemia

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