الرحيم الرحمن الله بسم

BY1. Abdullah Hasan Alhojaili2. Alhassan Ali Alghamdi 3. Abdulaziz Mosa Hawsawi

Mesenteric ischemia

CHRONIC MESENTERIC ISCHEMIA

Alhassan Ali Alghamdi

Anatomyceliac trunk supplies the foregut

AnatomySMA & IMA supply midgut and hindgut respectively

Anatomy

Definition

Mesenteric ischemia is defined as a condition in which the supply of oxygen or blood is too small to satisfy the needs of the intestines. Ischemia can affect the small intestine, the colon or both. It can be acute and chronic.

Mesenteric ischemic syndromes

Chronic– Atherosclerotic– Non-atherosclerotic

Acute– Occlusive • Embolic

• Thrombotic (most common)– Non-Occlusive– Mesenteric Venous Thrombosis

Chronic mesenteric ischemia

• Relatively Uncommon• Usually 2-3 vessel disease• Asymptomatic Mesenteric Stenosis

6-24%

Chronic mesenteric ischemia

• Usually Women• Younger• Smokers• 2/3 with Other Vascular Disease

– Half with abdominal bruit• Classic Symptoms

– Post-prandial Pain– Weight Loss– sitophobia??– GI ulceration

Diagnosis

Clinical: “high index of suspicion”

R/o other causes for atypical abdominal pain

Diagnosis

• PT , aPPT, INR• CBC anemia• Blood Chemistry

electrolyte abnormalities .• Urinalysis - to rule out

stones or infection• (LFTs) –

hypoalbuminemia.

• Angiography• CT & CTA • MRI & MRA• US & Duplex us

Lab studies Imaging studies

Electrocardiography (ECG) to rule out cardiac disease

angiography

Chronic mesenteric ischemia Lateral abdominal aortogram shows occlusion of the celiac and IMA Severe stenosis .

CTA

A CT angiogram

showing occlusion

of the coeliac axis

and tight stenosis

of the superior

mesenteric artery

Managment The main therapy is surgical which is :  open or endovascular revascularization . medical management is warranted only when the

risks of revascularization outweigh the benefits. Nitrate therapy may provide short-term relief but is not curative. Anticoagulation therapy with warfarin is indicated.

Superior mesenteric artery syndrome (SMAS) Superior mesenteric artery syndrome is a rare condition first

described by Rokitansky in1861. The condition results from a reduced angle between the artery at its origin from the abdominal aorta and the transverse third part of the duodenum causing duodenal obstruction. Diagnosis of the syndrome depends on high index of suspicion, augmented by the radiological features of the syndrome. Treatment can either be conservative or operative, depending on the severity of the condition.

Case report A 19-year-old female presented to the out-patient department

of King Fahad Medical City with a two-year history of recurrent abdominal pain associated with feeling of fullness and vomiting after meals together with progressive loss of weight (>40kg) in 2 years. On examination, she was emaciated with a body weight of 22kg. Her vital signs were within the normal limits. The abdominal examination revealed a slightly distended abdomen with positive succession splash. Laboratory investigations were normal. Barium follow-through showed a grossly distended stomach reaching down to the pelvis 

SMAS

Treatment

Conservative to relieve obstruction (decompression)

Options for surgery include a duodenojejunostomy or gastrojejunostomy

Medical Surgical

ACUTE MESENTERIC ISCHEMIA

Abdullah Hasan Al-hojaili

Definition 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. Although relatively rare, it is a potentially life-threatening condition.

Risk Factors & Epidemiology ▪ Atherosclerosis.▪ Arrhythmias.▪ Hypovolemia. ▪ CHF.▪ recent MI. ▪ valvular disease.▪ advanced age.▪ intra-abdominal

malignancy.▪ IBD .

▪ AMI is commonly considered a disease of the older population(>60), but may affect young !!

▪ African American people and men might be at higher risk ??

Etiology of AMI– Occlusive • Embolic (AMAE)

• Thrombotic (AMAT)

– Non-Occlusive– Mesenteric

Venous Thrombosis

AMAE has better prognosis and outcome than AMAT , why ??

Cont.

occlusiveThromboti

c 1-

atherosclerosis

2- Aortic dissection

3- Aortic aneurysm

Embolic

1- cardiac

2- ruptured

atheromatous

plaque

Cont.

Non occlusive hypotensi

onDigitalis !!

Vasopressors

Cocaine

Acute mesenteric ischemia

Relatively Uncommon Difficult Diagnosis High Complication Rate High Mortality Rate 70%

Presentation “Half” with prior

symptoms of CMI Abdominal Pain :sudden , sever , diffuse , non localized , constant. ► AMAT vs AMAE ?? This pain is disproportionate to physical examination findings & not responding to opioid .

Nausea and vomiting are found in 75%.

Anorexia and diarrhea progressing to obstipation.

Abdominal distention and gastrointestinal (GI) bleeding.

In NOMI Symptoms typically develop over several days.

Examination

 normal abdominal examination in the face of severe abdominal pain.

No signs of peritonitis.

abdominal tenderness ,guarding , rigidity .

These signs develop when bowel become necrotic or perforated.

Sign of septicemia may be predicted .

Early late

Diagnosis

PT aPPT INR CBC hi WBCs Blood Chemistry acidosis , hi

LDH .

N.B. These laboratory findings are nonspecific and generally unreliable.

AXR Angiography CT & CTA MRI & MRA US & Duplex us

N.B.Positive findings on plain abdominal radiography are usually late and nonspecific  .

Lab studies Imaging studies

AXR

Pneumatosis intestinalis (black stripes of air)

in advanced acute mesenteric ischemia (AMI) with gangrenous bowel.

AXR

Thumbprinting of bowel, characteristic of mesenteric artery ischemia.

angiogram

Aortogram showing narrowing of superior mesenteric artery.

CT & CTA

• CTA sagittal view showing an SMA thrombus (white arrow)

• pneumatosis intestinalis (black arrow).

• (B) CTA coronal view showing pneumatosis

CT

CT scan (with contrast) of nonocclusive mesenteric ischemia with resulting bowel wall edema (arrows).

Management

Papaverine : is phosphodiesterase inhibitor, which acts to relax vascular smooth muscle.

Thrombolytics : The infusion must be started within 8 hours of symptom onset.

Antibiotics & pain killer

Laparotomy

Revascularization

-embolectomy -thrombectomy Determine

viability Second-look

Medical Surgical

Determine viability Inspection: color,

pulses, peristalsis

Hand-held doppler

Second look Laparotomy

A second-look laparotomy is the most reliable method of determining bowel viability. 

Usually within 24 hours

gross specimen showing hemorrhagic dead bowel after resection from patient with acute mesenteric ischemia.

Conclusion

• High index of suspicion• Rapid preoperative evaluation• Revascularization with open

surgical techniques• Resection of non-viable bowel• Liberal use of second-look

Conclusion

• Timely revascularization of symptomatic patients with C.M.I. Will hopefully reduce the incidence and subsequent high morbidity/mortality of A.M.I.

MESENTERIC VENOUS THROMBOSIS Abdul-Aziz Mosa Hawsawi

Portal system

There are three veins that carry blood from the intestines:

1. the superior mesenteric vein

2. the inferior mesenteric vein

3. the splenic vein

Definition Mesenteric venous thrombosis

occurs when a blood clot forms in one or more of the major veins that drain blood from your intestines. This condition is rare, but it can lead to life-threatening complications without prompt treatment.

Etiology of MVT • 20% Idiopathic• Hypercoagulable States• Low-flow (CHF, Cirrhosis with PH,

Budd-Chiari)• Intra-abdominal inflammatory or

suppurative processes and malignancies

• Smoking, prior DVT or thrombosis

Diagnosis

• Plain Films• CT• Mesenteric Venography

CT

Coronal and axial views of a computed tomographic scan of the abdomen showing enlargement of the superior mesenteric vein. An intraluminal clot is seen (arrows), showing extensive thrombosis of the superior mesenteric vein.

Treatment • Systemic Anticoagulation• Exploration with resection of non-viable

bowel for peritonitis.

Median arcuate ligament syndrome Celiac Artery

Compression Syndrome Etiology - Compression

of CA by the median arcuate ligament.

Female 20-40 years old Symptom - post-

prandial epigastric abdominal pain

Treatment - release the median arcuate ligament

Angio/CTA

Angioplasty