Mesenteric Ischemia in Dilated

CardiomyopathyJo Anne N. Ramos, MD

Department of Internal Medicine

SD 57/M CC: abdominal pain Admitting Diagnosis:

◦ Acute Gastroenteritis with no dehydration, Acid Peptic Disease; Dilated Cardiomyopathy in CHF, FC III, AF with RVR

FINAL DIAGNOSIS:◦ CP Arrest sec to Mesenteric Ischemia probably

sec to Massive Pulmonary Embolism; Dilated Cardiomyopathy, in CHF, FC III; HPN; Alcoholism

3 days of hospitalization

To present a case of a patient with Dilated Cardiomyopathy.

To discuss the pathophysiology that led to the demise of the patient.

Objectives:

DS57/MMarriedFilipinoSta. Rosa, N.E.

General Data

Chief Complaint

Abdominal pain

2 hours PTA •Abdominal pain on the epigastrium•No dysuria, diarrhea, fever, chest pain, nausea and vomiting observed. No consult was done or medication taken.

1 hour PTA•Persistent of abdominal pain, now diffuse in nature •Associated with 2 episodes of ½ cup per bout, watery, non-bloody, non-mucoid, stools prompted consult and thus admission.

History of Present Illness

(+) Dilated Cardiomyopathy, December 2011 sec to excessive alcohol consumption

(+) APD, Feb 2012 on Esomeprazole 40mg OD

(+) Hypertension for more than 7 years. UBP 150/90, HBP 190/100

No diabetes, asthma, cancer Previous surgery

Past Medical History

(+) Hypertension No DM, Cancer, Asthma

Family History

Works as a farmer but stopped 8 months PTA due to easy fatigability

23 pack year smoking history 9stopped for 5 months)

Drinks alcohol daily, consuming 5 glasses of gin every night for the past 26 years.

Personal and Social History

No headache, no colds, no tinnitus, no epistaxis, no throat pain

(+) easy fatigability, 3-pillow orthopnea, (-) PND, (+) palpitation

No changes in stool caliber, no diarrhea, no constipation, no hematochezia, no hematemesis

Review of Systems

No weight loss, no loss of appetite No jaundice, darkening of the neck and

alar area No hematuria, no flank pain, no frequency No polyuria, polydipsia, polyphagia,

heat/cold intolerance No easy bruising or bleeding tendency

GENERAL SURVEY: Patient is conscious, coherent, anxious

VITAL SIGNS:BP 160/100 CR 68 RR 27 T 37.6

HEENT:(-) icterisia, pink palpebral conjunctiva, (-) nasoaural discharge, (-) tonsillopharyngeal wall congestion, (-) cervicolymphadenopathy

C/L:Symmetrical chest expansion, (-) retractions, clear breath sounds

Physical Examination

HEART: Dynamic precordium, PMI at 6th ICS LAAL, normal rate, irregular rhythm, no murmur appreciated

ABDOMEN: Flabby, normoactive bowel sounds, soft, (+)

direct tenderness on the epigastrium on deep palpation, (+) tympanitic on percussion

EXTREMITIES: Grossly normal, no edema, (+) paradoxical pulses

Acute Gastroenteritis with no dehydration Acid Peptic Disease Dilated Cardiomyopathy in CHF, FC III, AF

with RVR

Admitting Impression

10 minutes at the ER•hooked to PNSS 1L to run for 30gtts/min, Esomeprazole 40mg thru IV•CBC, RBS, serum electrolytes, cardiac panel and fecalysis . •12-L ECG and CXR•AP informed

1 hour at the ER •Afforded relief from Esomeprazole

1hour 30 min at the ER •Send to ward

At the ER

CBC hgb168/hct48.9/wbc9.87/neu49.14/lym34.4/plt210RBS 116Na 141K 3.5 Cardiac panel ckmb 4.5 (0-4.3), mgb 287 (0-107), trop I 0.15 (0-0.05), bnp 624 (0-100), d dimer 1800 (0-400)

AP updated. Patient was started with Esomeprazole 40mg 1 cap OD AC, Metronidazole 500mg 2 tabs BID, Tramadol 50mg 1 tab OD, Kalium durule 2 tabs OD.

At the Ward (1st day of hospitalization)

S O A P

(+) DOB(+) dull abdominal pain on the epigaastrium

Patient is anxiousBP 130/80, CR 91 RR 31

HEENT: (+) NVEC/L: diffuse crackles on both lung fieldsAbd: (+) direct tenderness on epigastrium (-) rebound

Acute Pulmonary EdemaAcid Peptic Disease

Furosemide 60mg IV pushTramadol 25mg slow IV pushVS monitoring q1AP inforemed

10 hours after the admission

12 hours after the admission

S O A P

(+) DOB(+) severe, dull abdominal pain on the epigastrium

Patient is anxiousBP 120/80, CR 91 RR 31

HEENT: (+) NVEC/L: dec crackles on both lung fieldsAbd: (+) direct tenderness on epigastrium (-) rebound

Acute Pulmonary EdemaAcid Peptic Disease

Tramadol 25mg slow IV pushVS monitoring q1Cardiac panel

Transfer to ICUAP ordered:Heparin 7,500 IU IV push Dabigatran 150mg BID and Fondaparinux 5mcg SQ OD.

Cardiac Panelckmb 4.5, mgb >580, trop I 0.10, BNP 3060, d dimer

3840

16 hours after the admission

S O A P

(-) DOB(+) severe dull abdominal pain on the epigaastrium(+) bloatedness

Patient is anxiousBP 120/80, CR 91 RR 28 o2sat 95%

HEENT: (-) NVEC/L: occ cracklesAbd: (+) direct tenderness on epigastrium (-) rebound

Acute Pulmonary EdemaAcid Peptic Disease with Dysmotility Disorder

Bisacodyl suppository and Mosaopride 5mg TID NPO temporarily.

2nd day of hospitalization

S O A P

(-) DOB(+) tolerable, dull abdominal pain on the epigastrium(+) bloatedness

Patient is anxiousBP 120/80, CR 91 RR 28 o2sat 95%

HEENT: (-) NVEC/L: occ cracklesAbd: (+) direct tenderness on epigastrium (-) rebound

Acute Pulmonary EdemaAcid Peptic Disease with Dysmotility Disorder vs Acute Pancreatits vs Mesenteric Ishemia

Lactulose 30ccNalbuphine 5mg IV q 12Serum amylase, alkaline phosphatase, SGPT/SGOTMaintain on NPO

3rd day of hospitalization

S O A P

(+) fresh blood stools

Patient is drowsy to obtundedBP palp 70, CR 53 RR 14 O2sat 80-85%

C/L: diffuse cracklesAbd: (+) direct tenderness on epigastrium (-) rebound

Acute Pulmonary EdemaAcute Pancreatitis vs Mesenteric Ischemia

RBS statLevophed drip inc to 30gtts/minD50-50 1 vial IV pushIntubate patient

56 mg/dL

15 minutes after intubation

S O A P

45 minutes

Patient is drowsy to obtundedBP unappreciatedCR OC/L: diffuse cracklesECG- pulseless electrical activity

BP 0 CR 0 Pupils fixed dilated

Mesenteric Ischemia

CP Arrest sec to Mesenteric Ischemia sec to Massive Pulmonary Embolism

CPR startedEpinephrine 1mg/amp every 3 minutes

Pathophysiology

Excessive alcohol

consumption

 Increased systemic blood

pressure

Alcohol metabolites

 IncreasesOxidative

stress

Formation of oxygen radicals

Endothelial and tissue

dysfunction

Chronic myocardial dysfunction

Surviving myocytes hypertrophy to

accommodate the increased burden of

wall stress

Dynamic remodeling of the interstitial

scaffolding

Dilated cardiomyopathy

Dilated Cardiomyopathy

Mitral regurgitation

Atrial fibrillation

Insufficient perfusion to

intestinal tissue

Ischemic tissue injury

Disruption of blood flow by an

embolus or progressive thrombosis

Arterial insufficiency causes tissue

hypoxia, leading to initial bowel

wall spasm

DiarrheaMucosal

sloughingFresh blood

stools

Visceral abdominal

painMucosal barrier

disruption

Bacteria, toxins and vasoactive substance released into the

systemic circulation

Cardiovascular collapseShock

Final Diagnosis

Immediate Cause :CP Arrest sec to Mesenteric

Ischemia probably sec to Massive Pulmonary EmbolismAntecedent Cause:

Dilated Cardiomyopathy, in CHF, FC IIIUnderlying Cause:

Hypertensive Cardiovascular Disease

Alcoholism