Mesenteric Ischemia: Silent Killer - Lieberman's...

Joseph M Reardon, HMS3

Gillian Lieberman, MD

3/2012

Mesenteric Ischemia: Silent Killer



Beth Israel Deaconess Medical Center

Harvard Medical School



3/2012

Agenda

• Patient Presentation

• Differential Diagnosis

• Available Imaging Modalities

• Relevant Anatomy

• Radiologic Findings

• Pathophysiology

• Related Cases

• Patient Management & Disposition

• Take-Home Points 2



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Agenda






• Pathophysiology

• Related Cases





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Patient Presentation Hx: 83yo F with 4d of nausea, vomiting, diarrhea. No abdominal pain or fever/chills. Found by EMS unable to get out of bed or take POs PMH: HTN, CKD (baseline Cr 1.7-2), HLD, hypothyroidism, osteoporosis, non-Hodgkin lymphoma s/p radiation therapy in remission since 2001, Hx endometrial cancer Meds: atenolol, levothyroxine, pravastatin SH: Retired radiation researcher; lives with disabled relative for whom she is primary caretaker Exam: Hypotensive to 70s, A&Ox3, conversant, lungs CTAB, RRR, abd soft, NT/ND, no CVA tenderness Labs: WBC 14.1 with L shift, INR 1.5, BUN 26, Cr 2.0, LFTs, Trop 0.08, nl CK-MB, TSH 6.2, Lactate 5.0, ABG 65/27/7.4

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Agenda






• Pathophysiology

• Related Cases





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Clinical DDx: N/V/D, Hypotension

“V I T A M I N C D” Vascular Mesenteric ischemia Hypovolemia Embolism MI

Infection/Inflammation Sepsis Gastritis Gastroenteritis Acute Hepatitis Cholecystitis Abscess UTI Perforated ulcer Trauma Fall

Autoimmune IBD Allergy

Metabolic DKA Pancreatitis Acute Renal Failure

Iatrogenic Ventral hernia Partial obstruction / Adhesions

Neoplastic Recurrent lymphoma Gastric cancer Colon cancer Pancreatic cancer Hepatic cancer Carcinoid

Congenital Intestinal volvulus Adrenocortical insufficiency

Drugs B-blocker overdose Thyroid storm EtOH TSS, Food poisoning (Staph Toxin A)

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Agenda






• Pathophysiology

• Related Cases





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Imaging Modalities For our patient with N/V/D, BP

• CT- abdomen & pelvis with contrast to evaluate for bowel inflammation, perforation, looping, vascular supply (Rating 8)

• Ultrasound – RUQ U/S for biliary pathology (Rating 6) • MRI – T1 to assess abnormal fat distribution; T2 to

assess for edema, 1st line in pregnant patient (Rating 6) • XR – KUB to evaluate for free air or dilated loops

(Rating 5) • Nuclear Medicine – Ga-67 scan to evaluate for sites of

metabolic activity (Rating 4) • Invasive – ultrasound-guided fluid drainage, ostomy

placement via Seldinger technique Based on: “Acute Abdominal Pain and Fever or Suspected Abdominal Abscess.” ACR Appropriateness Criteria. American College of Radiology, 2008.

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Fu

• Use of IV Contrast in CT:

– Contraindicated in chronic renal insufficiency

– Contraindicated in acute kidney injury

– Weigh risks and benefits

• Concern for renal damage:

– Use Visipaque (iodixanol) rather than Optiray (ioversol)

– Ensure adequate pre-hydration

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Imaging and Use of Contrast



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Balance of Benefits & Burdens

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• Renal Damage • Radiation Risk • Cost

• Speed • Information

CT



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Agenda






• Pathophysiology

• Related Cases





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Anatomy Review

From Gray’s Anatomy

Celiac artery

http://commons.wikimedia.org/wiki/File:Gray532.png



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Anatomy Review, continued

From Gray’s Anatomy http://en.wikibooks.org/wiki/File:Gray534.png http://en.wikibooks.org/wiki/File:Gray537.png

Superior Mesenteric Artery Inferior Mesenteric Artery Most tenuous blood supply – Marginal artery of Drummond

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http://en.wikibooks.org/wiki/File:Gray534.png

http://en.wikibooks.org/wiki/File:Gray537.png



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Agenda






• Pathophysiology

• Related Cases





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Posterior Right Portal Vein thrombosis

Fat Stranding Fluid tracking along portal vein

NG Tube

Anterior Right Portal Vein obliteration

Left hydronephrosis

Axial CT (Portal Venous Phase)

Axial C+ CT; PACS, BIDMC Note margin of liver hypoattenuation

*



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Bowel wall edema & hyperenhancing mucosa

Hydronephrosis * Fat Stranding

Gallbladder wall edema

*

CT Abdomen (3):

Mesenteric Ischemia on Axial CT

Axial C+ CT; PACS, BIDMC



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Free fluid in pelvis

Bowel wall edema

Pelvic Free Fluid on Axial CT




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Extravasation from attempted femoral line insertion

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Arterial Extravasation on Axial CT




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• How can

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How can we link the patient’s presentation with disease

processes?



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Putting Together the Findings

History of Nausea, Vomiting, Diarrhea

Hypotension

Coagulopathy

Aggressive Resuscitation

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Underlying Liver Disease

? Sepsis

Elevated Cardiac Enzymes

? MI

? UTI ? Acalculous Cholecystitis

Mesenteric Ischemia

Clinical Findings Contributing Factors



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• How can

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How do the disease processes manifest radiologically?



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Putting Together the Findings (2)

Mesenteric Ischemia

Bowel Wall Edema

Bowel Wall Mucosal Enhancement

Fat Stranding

Contributing Factors Radiologic Findings



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Gallbladder Wall Edema

Periportal edema

Aggressive Resuscitation

? Acalculous Cholecystitis

Contributing Factors Radiologic Findings



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Arterial Extravasation

Portal Vein Thrombosis

Clinical Findings Radiologic Findings Contributing Factors

Hypotension Coagulopathy

? Underlying Liver Disease



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Agenda






• Pathophysiology

• Related Cases





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What is Mesenteric Ischemia?

• Development

– Lack of perfusion to bowel mesentery

– Causes:

• Infarction – arterial or venous

• Embolism

• Low-Flow State

• Pathophysiology:

– Anoxia Buildup of metabolites (H+, K+) Cell death Necrosis

From Al-Shraim MM, Zafer MH, Rahman GA. Acute occlusive mesenteric ischemia in high altitude of southwestern region of Saudi Arabia. Ann Afr Med 2011;1:5-10.

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Presentation of Mesenteric Ischemia • S/Sx:

– Abdominal pain – Vomiting – Abdominal distension – Fever – Melena

• Hx: May have Afib, hypercoagulability • DDx: thromboembolic disease, digitalis toxicity,

drug reaction, small bowel obstruction, cecal volvulus, gastroenteritis, compression from tumor, complicated diverticulitis, inflammatory bowel disease, cholecystitis, appendicitis, peptic ulcer disease

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Why is Mesenteric Ischemia a Silent Killer? Mortality Rates of Comparable Conditions

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Mo

rtal

ity

Rat

e (%

)



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Radiologic Diagnostic Signs

• Mucosal hyperenhancement

• Bowel wall hypoattenuation

(edema)

• Bowel wall thickening >3mm

From Macari M, Balthazar, EJ. “CT of Bowel Wall Thickening: Significance and Pitfalls of Interpretation.” Am J Roentgenology. 2001;5:1105-1116.

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Radiologic Diagnostic Signs, Contd

• Mesenteric vessel occlusion (+/-)

• Mesenteric fat stranding

• Ascites

From NYPEmergency.org

From meddean.luc.edu

From Johnson PT, Horton KM, Fishman EK. “Nonvascular Mesenteric Disease: Utility of Multidetector CT with 3D Volume Rendering.” RadioGraphics. 2009;29:721-740.

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CT Hypotension Complex

• “Shock Bowel” – Mucosal enhancement

– Submucosal edema

– Luminal distension

• Other: – Collapsed vena cava

– Adrenal hyperenhancement

– Peripancreatic fat stranding

– Hypoenhancing spleen

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3/2012

Agenda






• Pathophysiology

• Related Cases





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Comparison Patient

• 41yo F with Hx IBS, colitis, HLD, atherosclerosis who presented with LUQ/LLQ pain and leukocytosis

• History notable for smoking, obesity, & family history of heart disease

• Intermittent flare-ups of acute, diffuse abdominal pain over preceding 3 yrs, associated with loose stools and 35 lb weight loss

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Comparison Patient 1

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1 month prior to presentation

Occluded Celiac Artery

Stenosed SMA

PACS Axial C+ CT; PACS, BIDMC



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Portal venous gas Pneumatosis Coli




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• 78yo F transferred from OSH for 2 days of NB/NB emesis, nonbloody diarrhea, and bilateral lower abdominal pain

• WBC 6.9, 77% PMNs

• VS on arrival: HR 120 BP 90/52 T99 O2 95% on 1L

• Abdominal distention with palpable loop of bowel

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37 Axial CT with PO Contrast; PACS, BIDMC

Portal venous gas Aortic calcification

Bowel wall thickening



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Agenda






• Pathophysiology

• Related Cases





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Management of Mesenteric Ischemia

Options:

• Emergent Surgery – Bowel Resection

• Stenting

• Thrombolysis

Prognosis:

• 50-90% mortality rate – Lactate level correlates with mortality

Julio Murra-Saca, gastrointestinalatlas.com

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Our Patient

• ~23:00 – Patient calls EMS; hypotensive to 70s; taken to ED

• ~23:30 – Patient arrives in ED; lactate of 5.0; central line placed; empiric antibiotics started

• 00:10 – Anterior T-wave inversions; Cards consult

• 00:30 – Bedside echo suggests decreased cardiac output and possible ischemia heparinized

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Our Patient, Contd • 01:30 – Patient complains of feeling “unwell”,

then becomes unresponsive, HR 40s, BP 50s, resuscitated with 1 round of CPR, atropine & Ca, intubated

• 02:05 – CT chest/abdomen with contrast shows mesenteric ischemia

• ~03:00 – Transfer to MICU

• Immediately after transfer, patient develops PEA arrest; CPR resumed

• After 10 more minutes of CPR, futility is determined and patient expires.

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3/2012

Agenda






• Pathophysiology

• Related Cases





3/2012

Pearls • In patients such as ours, mesenteric ischemia may be a

marker of other life-threatening conditions even if it is not the primary cause of death

• Mesenteric ischemia can be acute (from hypotension, hypovolemia, embolism) or chronic (from atherosclerosis)

• In patient with risk factors, always get abdominal CT with contrast to rule out mesenteric ischemia

• Weigh the risks and benefits of IV contrast in patients at risk for renal damage

• If mesenteric ischemia is on the differential must be excluded IMMEDIATELY no matter how remote

• Use radiologic findings to guide both prediction of outcome and amenability to therapy

• Keep VESSELS on list of organs that could cause pain when examining films.

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References • “Acute Abdominal Pain and Fever or Suspected Abdominal Abscess.” ACR

Appropriateness Criteria. American College of Radiology, 2008. • Al-Shraim MM, Zafer MH, Rahman GA. Acute occlusive mesenteric ischemia in high

altitude of southwestern region of Saudi Arabia. Annals of African Medicine 2011;1:5-10.

• Ames JT, Federle, MP. “CT Hypotension Complex (Shock Bowel) is not always due to traumatic hypovolemic shock.” Am J Roentgenology. 2009:192:W230-W235.

• “Ascites.” Surgery Curriculum, Loyola University-Chicago. http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/Ascites.htm

• Broder, JS. “Mesenteric Ischemia.” Feature Article CME. EMedHome.com. 2011, Jan 1. • Donnan GA, Fisher M, Macleod M, Davis SM. “Stroke.” Lancet 2008;371:1612-1623. • Furukawa A, Kansaki S, Naoaki K et al. “CT Diagnosis of Acute Mesenteric Ischemia from

Various Causes.” Gastrointestinal Imaging. 2009;192:408-416. • Gray’s Anatomy of the Human Body, 20th Edition. • Helton WS, Fisichella PM. “Intestinal Obstruction” in ACS Surgery. WebMD. 2004. 4:10. • Johnson PT, Horton KM, Fishman EK. “Nonvascular Mesenteric Disease: Utility of

Multidetector CT with 3D Volume Rendering.” RadioGraphics. 2009;29:721-740. • Kaewlai R, Kurup D, Singh A. “Imaging of Abdomen and Pelvis: Uncommon Acute

Pathologies.” Seminars in Roentgenology. 2009;228-236. • Levy AD. “Mesenteric Ischemia.” Radiologic Clin N Am. 2007;593-599. • Macari M, Balthazar, EJ. “CT of Bowel Wall Thickening: Significance and Pitfalls of

Interpretation.” Am J Roentgenology. 2001;5:1105-1116. 45



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References, contd • “Mesenteric Panniculitis.” New York – Presbyterian Emergency Medicine. Sept 2008.

http://nypemergency.org/radiology/radiology_2008/case-of-the-month-0908.html

• “Mesenteric Ischemia” in El Salvador Atlas of Gastrointestinal Video Endoscopy. http://www.gastrointestinalatlas.com/English/Jejuno_and_Ileum/Etc__Etc_/etc__etc_.html

• Mirvis SE, Shanmuganathan K, Erb R. “Diffuse Small-Bowel lschemia in Hypotensive Adults After Blunt Trauma (Shock Bowel): CT Findings and Clinical Significance.” Am J Roentgenology. 1994;163:1375-1379.

• Nishijima DK, Su M. “Mesenteric Ischemia in Emergency Medicine.” Medscape eMedicine. http://emedicine.medscape.com/article/758674-overview

• Oldenburg WA, Lau LL, Rodenberg TJ et al. “Acute Mesenteric Ischemia: A Clinical Review.” Arch Int Med. 2004;164:1054-1062

• Reeder MM. “G-69: Mesenteric Vascular Compromise.” in Reeder & Felson’s Gamuts in Radiology. Springer, 2003.

• Rha SE, H HK, Lee SH, et al. “CT and MR Imaging Findings of Bowel Ischemia from Various Causes.” RadioGraphics. 2000;20:29-42.

• “Universal differential diagnosis.” Musculoskeletal Radiology, University of Washington. http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/general-principles

• Zafari AM. “Myocardial Infarction.” Medscape eMedicine. http://emedicine.medscape.com/article/155919-overview

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3/2012

Acknowledgements

• Gillian Lieberman, MD

• Mark Masciocchi, MD, PGY1 reviewed the presentation and provided comparison cases

• Elizabeth Asch, MD, PGY2 reviewed the presentation and index case

• Grant Smith, HMS3; Christian Strong, HMS3; Michael Honigberg, HMS3

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