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Acute Mesenteric Ischemia


Presentation

  • There are very few reported cases of patients presenting with this dual pathology. CASE PRESENTATION: We report a unique case of a 53 year old Italian lady who presented with acute mesenteric ischaemia and duodenal perforation.[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: We present a case of a 27-year-old Mongolian man who presented with acute abdominal pain increasing in severity, and refractory to repeated attempts at treatment with a misdiagnosis of acute peptic ulcer disease.[ncbi.nlm.nih.gov]
  • We present a case of a middle-aged woman who developed acute focal ischemia of the small intestine without predisposing factors.[ncbi.nlm.nih.gov]
  • We present the case of an 84-year-old woman who presented to our emergency department complaining of an acute worsening of pre-existing abdominal periumbilical pain, nausea, vomiting, and diarrhea.[ncbi.nlm.nih.gov]
  • In the present retrospective study, the possible utility of the neutrophil-lymphocyte ratio (NLR) in the early diagnosis of AMI was explored.[ncbi.nlm.nih.gov]
Weight Loss
  • loss AND YOU may hear the story of “FOOD FEAR” ( Pat comes with chronic abdominal pain right after meal/ u recall angina pain that like pain with exertion) Dx; CBC/leukocytosis, Lactic/or metabolic ACIDOSIS, Amylase UP.[usmleforum.com]
  • WEIGHT LOSS CHRONIC mesenteric ischemia sometimes leads you to lose weight because, although you may feel hungry, you eat less or less frequently to avoid the pain.[vascular.org]
  • A second patient with Takayasu’s presented with a 4-month history of abdominal pain, a 50-pound weight loss, stenosis of all major mesenteric arteries, and bowel pneumatosis.[mdedge.com]
  • loss and malabsorption Bloating , nausea, occasional diarrhea Abdominal bruit caused by stenosis of mesenteric vessels A patient typically presents with postprandial abdominal pain ( abdominal angina ), food aversion, and weight loss![amboss.com]
  • Therefore, decreased blood supply to these organs cause symptoms related to eating or after-meal digestion, including: Abdominal pain after meals Weight loss Fear of eating or change in eating habits due to post-meal pain Nausea and/or vomiting Constipation[my.clevelandclinic.org]
Coronary Artery Disease
  • Causes of Acute Mesenteric Ischemia Occlusion Type Risk Factors Arterial embolus ( 40%) Coronary artery disease , heart failure , valvular heart disease , atrial fibrillation , history of arterial emboli Arterial thrombosis (30%) Generalized atherosclerosis[merckmanuals.com]
  • artery disease or heart attack)[my.clevelandclinic.org]
  • Because young adults and children typically don’t have any of the telltale associated comorbidities such as cardiac arrhythmia or coronary artery disease to point physicians in this direction, the diagnosis of mesenteric ischemia is often delayed or misinterpreted[mdedge.com]
  • Risk factors including peripheral arterial disease (27%), coronary artery disease (46%), diabetes, and hypertension are common, but not always present [8-10].[epmonthly.com]
  • SE: Standard Error; CAD: Coronary Artery Disease; CHF: Congestive Heart Failure; CVD: Cerebrovascular Disease; PVD: Peripheral Vascular Disease; COPD: Chronic Obstructive Pulmonary Disease; SIRS: Systemic Inflammatory Response Syndrome; ARDS: Acute Respiratory[aclr.com.es]
Hypoventilation
  • All patients presented hypoventilation, arterial hypotension, oliguria and,from a biological standpoint, metabolic acidosis and leucocytosis. Superior mesenteric artery angiography was the investigation method of choice.[ncbi.nlm.nih.gov]
Abdominal Pain
  • CONCLUSION: The RDW on admission is of marginal help to diagnose AMI among patients with abdominal pain.[ncbi.nlm.nih.gov]
  • Abstract A 79-yr-old man with previously documented atherosclerotic vascular disease presented with acute abdominal pain, signs of peritoneal irritation, and guaiac-positive stool.[ncbi.nlm.nih.gov]
  • METHODS: Patients, over 65, with abdominal pain were included in this study. The D-dimer test was applied to 230 (34%) of 676 abdominal pain patients admitted to our emergency service.[ncbi.nlm.nih.gov]
  • Patients aged at least 65 presenting to Emergency Departments with acute abdominal pain and no clear diagnosis after an initial work-up were enrolled.[ncbi.nlm.nih.gov]
  • Abstract Acute mesenteric ischemia resulting from mesenteric arterial thrombosis is a life-threatening cardiovascular complication with symptoms ranging from sudden-onset abdominal pain to vague symptoms of several days' duration.[ncbi.nlm.nih.gov]
Vomiting
  • We present the case of an 84-year-old woman who presented to our emergency department complaining of an acute worsening of pre-existing abdominal periumbilical pain, nausea, vomiting, and diarrhea.[ncbi.nlm.nih.gov]
  • Pancreatitis Portal hypertension/cirrhosis Medications Vasopressor medications Beta-blockers Digoxin Diuretics Clinical signs and symptoms Severe abdominal pain out of proportion to physical exam Pain initially of a visceral nature and poorly localized Nausea Vomiting[learningradiology.com]
  • -SMA/Celiac axis/IMA Acute: -Thrombosis/Emboli/ HypOtension/ Shock / time vasoconstriction ( vasospasm) venous block from thrombosis -On exam, pat pain out proportion ( hematochezia &/OR melena ) Chronic: History of atherosclerotic - As usual Nausea/vomiting[usmleforum.com]
  • Anorexia, nausea, vomiting, diarrhea, and hematochezia are common. Unfortunately, the clinical manifestations of AMI overlap with other, more common clinical entities, such as bowel obstruction, pancreatitis, diverticulitis, and peritonitis.[radiologykey.com]
  • Other early symptoms including vomiting, diarrhea, distension, and bloody stool are common, but not always present. The early vomiting and diarrhea are due to bowel ischemia, causing “gut-emptying.”[epmonthly.com]
Diarrhea
  • We present the case of an 84-year-old woman who presented to our emergency department complaining of an acute worsening of pre-existing abdominal periumbilical pain, nausea, vomiting, and diarrhea.[ncbi.nlm.nih.gov]
  • ISCHEMIC COLITIS You see pat L side abdominal pain with BLOODY DIARRHEA/[Note: in mild cases pat usually have blooding diarrhea but no abdominal pain] (due to mucosal or mural infarction) as u know MC site splenic flexure and rectum most commonly spared[usmleforum.com]
  • […] hypertension/cirrhosis Medications Vasopressor medications Beta-blockers Digoxin Diuretics Clinical signs and symptoms Severe abdominal pain out of proportion to physical exam Pain initially of a visceral nature and poorly localized Nausea Vomiting Diarrhea[learningradiology.com]
  • Anorexia, nausea, vomiting, diarrhea, and hematochezia are common. Unfortunately, the clinical manifestations of AMI overlap with other, more common clinical entities, such as bowel obstruction, pancreatitis, diverticulitis, and peritonitis.[radiologykey.com]
  • […] with acute arterial embolism typically presents with severe abdominal pain , fever , bloody diarrhea , leukocytosis and atrial fibrillation ![amboss.com]
Nausea
  • We present the case of an 84-year-old woman who presented to our emergency department complaining of an acute worsening of pre-existing abdominal periumbilical pain, nausea, vomiting, and diarrhea.[ncbi.nlm.nih.gov]
  • Pancreatitis Portal hypertension/cirrhosis Medications Vasopressor medications Beta-blockers Digoxin Diuretics Clinical signs and symptoms Severe abdominal pain out of proportion to physical exam Pain initially of a visceral nature and poorly localized Nausea[learningradiology.com]
  • […] injury -SMA/Celiac axis/IMA Acute: -Thrombosis/Emboli/ HypOtension/ Shock / time vasoconstriction ( vasospasm) venous block from thrombosis -On exam, pat pain out proportion ( hematochezia &/OR melena ) Chronic: History of atherosclerotic - As usual Nausea[usmleforum.com]
  • Anorexia, nausea, vomiting, diarrhea, and hematochezia are common. Unfortunately, the clinical manifestations of AMI overlap with other, more common clinical entities, such as bowel obstruction, pancreatitis, diverticulitis, and peritonitis.[radiologykey.com]
  • You may also experience nausea, vomiting, diarrhea or flatulence. WEIGHT LOSS CHRONIC mesenteric ischemia sometimes leads you to lose weight because, although you may feel hungry, you eat less or less frequently to avoid the pain.[vascular.org]
Severe Abdominal Pain
  • The diagnosis of mesenteric ischemia should be considered in patients of any age presenting with recurrent or severe abdominal pain, particularly when no alternative cause is apparent.[ncbi.nlm.nih.gov]
  • abdominal pain out of proportion to physical exam Pain initially of a visceral nature and poorly localized Nausea Vomiting Diarrhea GI bleeding may be present Imaging Plain abdominal radiographs (abnormal in 20-60% of cases) Thumbprinting Non-specific[learningradiology.com]
  • A 69-year-old lady with previous endarterectomy of SMA and extensive small bowel resection presented with severe abdominal pain, emesis, leukocytosis, and imaging finding of new SMA flush occlusion. She refused to consent for a laparotomy.[ncbi.nlm.nih.gov]
  • Mesenteric ischemia must be considered in any patient 50 with known risk factors or predisposing conditions who develops sudden, severe abdominal pain.[merckmanuals.com]
  • If you have severe abdominal pain, along with other symptoms of mesenteric ischemia, seek medical care right away.[saintlukeshealthsystem.org]
Mitral Valve Prolapse
  • Echocardiography showed enlargement of the aortic root and mitral valve prolapse. Abdominal computed tomography scan revealed acute mesenteric ischemia due to abdominal aortic dissection.[ncbi.nlm.nih.gov]

Workup

  • On further workup, our patient was diagnosed with isolated protein S deficiency. We started lifelong thromboprophylaxis with warfarin to prevent recurrence and our patient was asymptomatic on the latest follow-up 5 months after discharge.[ncbi.nlm.nih.gov]

Treatment

  • CONCLUSION: The key point to improve survival rate of AMI was early diagnosis and treatment.[ncbi.nlm.nih.gov]
  • The treatment strategy is straightforward aiming at rapid restoration of blood flow to the intestine. Bowel resection is performed on demand.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Endovascular treatment of the AMI with the use of thrombectomy devices proved to be technically feasible and reasonably fast procedure. Early diagnosis and adequate treatment remains the cornerstone of the treatment.[ncbi.nlm.nih.gov]
  • A combined treatment plan for AMI devides to combat the unrelenting disease process on different levels involving early operation, perioperative intraarterial fibrinolytic and vasodilative treatment and anticoagulation, selective small bowel decontamination[ncbi.nlm.nih.gov]
  • Severity of comorbidities, as measured by the Charlson index, did not differ significantly between the treatment groups.[ncbi.nlm.nih.gov]

Prognosis

  • The prognosis of AMI is extremely poor. The main mechanism of AMI is NOMI, occurring in approximately 80% of patients. Further progress should be performed on prevention and earlier diagnosis.[ncbi.nlm.nih.gov]
  • CONCLUSION: MPI and P/L ratio are simple and reliable methods to predict the prognosis of AMI.[ncbi.nlm.nih.gov]
  • CONCLUSION: Early management in the intensive care unit and appropriate surgical intervention maximised the patient's chances of survival despite the poor prognosis associated with her dual pathology.[ncbi.nlm.nih.gov]
  • Early diagnosis of acute mesenteric ischemia and correction of blood circulation before necrosis occurs are important factors affecting prognosis.[ncbi.nlm.nih.gov]
  • Ischemia due to mesenteric venous thrombosis has a good prognosis compared to arterial cause and can be managed conservatively with early diagnosis.[ncbi.nlm.nih.gov]

Etiology

  • Acuity of presentation, presence of bowel infarction, etiology of the ischemia, and risk factors may influence a planned treatment approach.[ncbi.nlm.nih.gov]
  • Second, there are four etiologies of AMI that need to be distinguished as they differ in treatment: superior mesenteric artery embolism, mesenteric arterial occlusive disease, mesenteric venous thrombosis, and non-occlusive mesenteric ischemia.[ncbi.nlm.nih.gov]
  • The etiological categorization of AMI should be practical and guide the therapy.[ncbi.nlm.nih.gov]
  • Risk factors for AMI vary depending on the underlying etiology.[radiologykey.com]
  • The etiology of AMI was embolism in 18 (36 %) and thrombosis in 32 (64 %) patients. EVT was technically successful in 44 (88 %) patients. Mortality after successful or failed EVT was 32 %.[ncbi.nlm.nih.gov]

Epidemiology

  • Epidemiological data, CT findings, and the primary end point defined as the composite of intestinal ischemia or necrosis based on surgical finding and in-hospital mortality were investigated.[ncbi.nlm.nih.gov]
  • Epidemiology The incidence of ischaemic colitis has risen from 6.1 cases/100 000 person-years in 1976-80 to 22.9/100 000 in 2005-09 [ 5 ]. Many mild cases may go unreported.[patient.info]
  • […] flow to the small intestine (arterial or venous) that can result in bowel infarction Chronic mesenteric ischemia : constant or episodic hypoperfusion of the small intestine, usually due to atherosclerosis References: [1] [2] [3] [4] Ischemic colitis Epidemiology[amboss.com]
Sex distribution
Age distribution

Pathophysiology

  • This is the first report of massive bowel ischaemia and duodenal perforation with no apparent underlying common pathophysiology leading to this presentation.[ncbi.nlm.nih.gov]
  • Pathophysiology The main mechanism underlying mesenteric ischemia is decreased blood flow to the small intestine.[wikidoc.org]
  • Pathophysiology The intestinal mucosa has a high metabolic rate and, accordingly, a high blood flow requirement (normally receiving 20 to 25% of cardiac output), making it very sensitive to the effects of decreased perfusion.[merckmanuals.com]
  • Pathophysiology Intestinal blood flow of the superior mesenteric artery ( SMA ) and/or inferior mesenteric artery ( IMA ) is suddenly compromised (see “Etiology” for causes) intestinal hypoxia intestinal wall damage mucosal inflammation possibly bleeding[amboss.com]
  • I just read that wikipedia page... please refer on that same page to "non-occlusive ischemia" and "pathophysiology".[forums.studentdoctor.net]

Prevention

  • Early diagnosis and immediate anticoagulation will prevent subsequent complications and need for surgical intervention.[ncbi.nlm.nih.gov]
  • We suggest that endovascular treatment is a feasible option in patients with AMI and can prevent intestinal infarction.[ncbi.nlm.nih.gov]
  • Chronic mesenteric ischemia requires urgent detection and therapy in order to prevent irreversible intestinal ischemia.[ncbi.nlm.nih.gov]
  • RESULTS: Alleged failure to make a timely diagnosis was the basis for 5 of these claims, failure to provide anticoagulant protection for 1, and failure to prevent nonocclusive ischemic infarction for 1.[ncbi.nlm.nih.gov]
  • Prompt diagnostic evaluation and early therapeutic interventions may help to prevent the development of these fatal predictors. Copyright 2014. Published by Elsevier Taiwan.[ncbi.nlm.nih.gov]

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