Intestinal ischemia resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]

Synonyms and Keywords: Mesenteric ischemia, bowel ischemia

Overview

Intestinal ischemia are a heterogeneous group of diseases characterized by hypoxia of the small bowel and/or colon, which most commonly arises from occlusion, vasospasm, and/or hypoperfusion of the mesenteric vasculature.[1]

Classification

Acute Mesenteric Ischemia

Acute mesenteric ischemia (AMI) includes superior mesenteric artery embolism (SMAE) (50%); nonocclusive mesenteric ischemia (NOMI) (20% to 30%); superior mesenteric artery thrombosis (SMAT) (15% to 25%); and superior mesenteric vein (SMV) thrombosis (5%). It is most commonly associated with compromise of the blood flow in the superior mesenteric artery (SMA) distribution affecting all, or portions of, the small bowel and right colon.[2][3]

Chronic Mesenteric Ischemia

Chronic mesenteric ischemia (CMI) is usually referred to intestinal angina, where the splanchnic circulation is insufficient in meeting the functional demands of the gut, but there is no loss of tissue viability.

Colonic Ischemia

Colonic ischemia (CI) is the most common vascular disorder of the gut that includes reversible ischemic colopathy, transient ulcerating ischemic colitis, chronic ulcerating ischemic colitis, colonic stricture, colonic gangrene, and fulminant universal ischemic colitis.

Causes

Life Threatening Causes

Intestinal ischemia can be a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Management

The algorithm is based on the American Gastrointestinal Association guidelines for management of intestinal ischemia in adults.[4][5]

Management of Acute Mesenteric Ischemia

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:

Abdominal pain:

❑ Onset (sudden or insidious)
❑ Duration (persistent for more than 2-3 hours)
❑ Location (localized or generalized)
❑ Severity (often out of proportion to findings on physical examination)

Nausea and vomiting
Abdominal distention
❑ Bloody stools
❑ Mental status change


Inquire about risk factors for AMI:


❑ Cardiovascular:

Congestive heart failure
Cardiac arrhythmias
❑ Recent myocardial infarction
Valvular heart disease
❑ Previous H/O DVT, PVD, PE, vasculitis
❑ Recent hypovolemia
❑ Recent hypotension
Cardiac surgery and dialysis

Hypercoagulable states:

Protein C deficiency and Protein S deficiency
Antithrombin III deficiency
Activated protein C resistance (APC)
Paroxysmal nocturnal hemoglobinuria
Myeloproliferative disease

Intestinal angina:

❑ Chronic postprandial pain
❑ Aversion to eating
Weight loss

Sepsis, abdominal infections
Blunt abdominal trauma
Pancreatitis, splenectomy, and malignancy in the portal region
❑ Familial history of atheroembolism

❑ Smoking history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess volume status:

❑ General condition
❑ Thirst
Pulse
Blood pressure
❑ Eyes
❑ Mucosa


Examine the patient:


❑ Abdomen:

Abdominal distension
❑ Occult blood in the stool
❑ Signs of peritoneal inflammation (rebound tenderness and guarding)
❑ Bowel sounds (absent in bowel infarction)

❑ Cardiovascular system (murmur)
❑ Respiratory system
❑ Anorectal (bleeding)

Signs of vasculitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High clinical suspicion with known risk factors

Resuscitate the patient:


❑ NPO
Intravenous fluids
❑ Avoid vasoconstrictors and digitalis

❑ If required, use dobutamine, low-dose dopamine, or milrinone

❑ Correct predisposing or precipitating factors:

❑ Relieving acute congestive heart failure and hypotension
❑ Correction of hypovolemia
❑ Correction of cardiac arrhythmias
❑ Antibiotics for sepsis

❑ Monitor vitals every 1/2 to 1 hour


Order tests (urgent):


CBC: Leukocytosis
Serum electrolytes
ESR: Elevated
D dimer: Elevated
Serum lactate: Elevated
Serum amylase
ABG: Metabolic acidosis or metabolic alkalosis
❑ Serum alpha-glutathione S-transferase (alpha-GST): Elevated
❑ Urinary and plasma intestinal fatty acid-binding protein (I-FABP): Elevated
❑ Total serum protein and albumin
Urinalysis
BUN
Creatinine
Serum glucose

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Plain abdominal X-ray (urgent)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History of DVT or familial hypercoagulable state
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat accordingly
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dynamic CT scan

Portal venous gas
Pneumatosis intestinalis
❑ Bowel wall thickening
Patient #1: CT images of patient with ischemic bowel demonstrates pneumatosis and portal venous gas


 
 
 
Peritoneal signs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mesenteric venous thrombosis
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mesenteric angiography
 
Laprotomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal findings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No persistent peritoneal findings
 
Persistent peritoneal findings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Observe
 
Laprotomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mesenteric venous thrombosis
 
Major arterial occlusion (non-embolic)
 
Minor arterial occlusion or embolic
 
Major embolus
 
Splanchnic vasoconstriction (no occlusion)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Management of Mesentric Venous Thrombosis

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mesentric venous thrombosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptomatic acute mesentric venous thrombosis
 
 
 
 
 
 
 
Asymptomatic mesentric venous thrombosis
❑ Diagnosis made on a CT scan obtained for reasons other than abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No persistent peritoneal findings
 
Persistent peritoneal findings
 
 
 
 
 
❑ No therapy
Or
Anticoagulation for 3-6 months
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immediate institution of anticoagulant therapy

Low molecular weight heparin:

❑ 7-10 days
❑ Bolus of 80 U/kg, not to exceed 5000 U
❑ Infusion at 18 U/kg/h until full conversion to oral warfarin
❑ Monitor anticoagulation using activated partial thromboplastin time (aPTT)

Oral warfarin:

❑ 3-6 months or for life in permanent hypercoagulable states
❑ Tailor the dose to maintain INR in the 2-3 range

With or without thrombolytic therapy


❑ IV tissue plasminogen activator
Or
❑ IV streptokinase
Or

❑ IV urokinase
 
Laprotomy

❑ Initiate heparin preoperatively
❑ Resection for short ischemic segment and non-viable extensive ischemic segment
❑ Consider second-look procedure (re-exploration within 12-24 hours)
❑ Long term parental nutrition after resection
Thrombectomy, heparin and papaverine for viable extensive ischemic segment with main vessel occlusion
❑ Heparin and papaverine for viable extensive ischemic segment with open or reconstituted main

Warfarin prophylaxis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Laprotomy if peritoneal signs develop in due course
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Management of Major and Minor Embolus

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Major embolus
 
 
 
 
 
 
 
 
 
 
 
Minor arterial occlusion or embolus
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No persistent peritoneal findings
 
 
 
 
 
Persistent peritoneal findings
 
 
 
No persistent peritoneal findings
 
 
 
 
 
Persistent peritoneal findings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Selected cases

❑ Contraindications to surgery
❑ Good perfusion of the vascular bed distal to the embolus after a vasodilator (tolazoline)

 
 
 
 
 
Continous papaverine infusion preopratively
 
 
 
 
 
 
 
 
Continous papaverine infusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
Exploratory laprotomy

❑ Embolectomy
❑ Resection of the infarcted bowel

 
 
 
Observe and repeat angiogram
 
 
 
 
 
Laprotomy

❑ Embolectomy
❑ Local resection

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continous papaverine infusion
 
Surgical embolectomy

Or


Thrombolytic therapy


❑ If presentation is within 12 hours of the onset of symptoms
❑ If thrombus is partially occluding
or
❑ If thrombus is in one of the branches of the SMA
or
❑ If thrombus is in the main SMA distal to the origin of the ileocolic artery

 
 
 
Continous papaverine infusion postoperatively
 
 
 
Angiogram normal
 
 
 
 
 
Stop the infusion and remove the catheter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat angiogram
 
 
 
 
 
 
 
Repeat angiogram and possibly a second look operation in 24-48 hours
 
 
 
Observe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Management of Thrombus Occlusion and Nonocclusive Mesenteric Ischemia

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Major arterial occlusion or thrombus
 
 
 
 
 
 
 
 
 
 
 
Nonocclusive mesenteric ischemia or splanchnic vasoconstriction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No persistent peritoneal findings
 
 
 
 
 
 
 
 
No persistent peritoneal findings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Angiographic evidence of collaterals
 
 
 
 
 
 
 
 
 
 
 
 
Continous papaverine infusion
 
 
 
 
 
Continous papaverine infusion preoperatively
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
No
 
 
 
 
 
 
 
Observe
 
 
 
 
 
Laprotomy with or without resection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SMA filling
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat angiogram
 
 
 
 
 
Continous papaverine infusion postoperatively
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Good
 
Poor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stop the infusion and remove the catheter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Observe
 
 
 
 
Laprotomy

❑ Continous papaverine infusion if possible
❑ Arterial reconstruction
❑ Resection of the infarcted bowel

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat angiogram and possibly a second look operation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Management of Chronic Mesenteric Ischemia

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:

Abdominal pain:

❑ Recurrent acute episodes
❑ Dull, crampy
❑ Occurs shortly after meals and persists for 1-3 hours
❑ Variable intensity and location
❑ Increases in severity over weeks to months

❑ Fear of eating
❑ Early satiety
Weight loss
Nausea and vomiting


Inquire about all the risk factors for AMI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Examine the patient:


❑ General condition
Pulse
Blood pressure
❑ Abdomen (distension, bowel sounds)
❑ Cardiovascular system (murmur)
❑ Respiratory system

❑ Anorectal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnosis by clinical criteria

❑ Above mentioned positive history
❑ No other explanation for the abdominal pain


Order tests (urgent):


CBC: Leukocytosis
Serum electrolytes
ESR
D dimer
Serum lactate
Serum amylase
ABG
Urinalysis
BUN
Creatinine
Serum glucose

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Screening tests

❑ Precibal and postcibal doppler ultrasound
Or
MRI angiography
Or
❑ MRI oximetry
Or

❑ Provocative balloon tonometry
 
 
 
 
 
 
 
Splanchnic angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Abnormal
 
 
Abnormal
 
 
 
Normal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Observe
 
Splanchnic angiography
 
 
Specific treatment
 
 
 
Observe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Poor surgical candidates
 
Good surgical candidates
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Angioplasty with or without stent
 
Surgical revascularization
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Management of Colonic Ischemia

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:

Abdominal pain:

❑ Rapid onset
❑ Severe pain initially over the affected segment
❑ Pain usually diminishes, becomes more continuous, and diffuses

Bloody diarrhea within 24 hours of the onset of abdominal pain
Rectal bleeding within 24 hours of the onset of abdominal pain.
Nausea and vomiting
Dehydration
❑ Mental state change


Inquire about the risk factors for colonic ischemia


❑ Cardiovascular:

Cardiopulmonary bypass
❑ Aortoiliac instrumentation/surgery
Myocardial infarction
Valvular heart disease
❑ Previous H/O DVT, PVD, PE, vasculitis
Hypotension

Hypercoagulable states
❑ Obstructive lesions of the colon:

Colon cancer
❑ Adhesion
Rectal prolapse
Fecal impaction or pseudoobstruction
Strangulated hernia
Diverticulitis

Escherichia coli O157:H7
Cytomegalovirus infections

Medications

Pancreatitis
Hemodialysis
❑ Strenuous and prolonged physical exertion

❑ Major vascular occlusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Assess volume status:


❑ General condition
❑ Thirst
Pulse
Blood pressure
❑ Eyes
❑ Mucosa


Examine the patient:


❑ Abdomen (distension, bowel sounds)
❑ Anorectal (bleeding)
❑ Cardiovascular system (murmur)
❑ Respiratory system

Signs of vasculitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical suspicion of colonic ischaemia

❑ Above mentioned positive history
❑ No other explanation for the abdominal pain
❑ Other colonic pathology not responding to previous medications


Order tests (urgent):


CBC: Leukocytosis
Serum lactate
Serum amylase
LDH
CPK
Serum electrolytes
ESR
D dimer
ABG
BUN
Creatinine
Serum glucose


Order imaging (urgent):


Barium enema:

❑ Pseudotumors
Thumbprinting: Sign of bowel wall thickening

❑ CT of the abdomen
Colonoscopy

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Confirmed diagnosis

Resuscitate the patient:


❑ NPO for 48-72 hours
Intravenous fluids
❑ Avoid vasoconstrictors and digitalis

❑ If required, use dobutamine, low-dose dopamine, or milrinone

❑ Broad spectrum antibiotics
❑ Medications that can promote ischemia should be promptly discontinued
❑ Monitor vitals every 1/2 to 1 hour

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evolving peritoneal signs or clinical deterioration
 
 
 
Continued diarrhea, bleeding, protein losing colopathy for > 2-3 weeks
 
 
 
Stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Laprotomy
 
 
 
Resection of the involved bowel
 
 
 
Repeat barium enema or colonoscopy in 1-2 weeks
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Resection of the involved bowel
 
 
 
 
 
 
Segmental colitis
 
 
 
Normal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptomatic

or
Stricture formation or
Recurrent fever or sepsis

 
Asymptomatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Resection of the involved segment
 
Observe

or


Treat for inflammatory bowel disease

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • A high index of suspicion in elderly patients with risk factors for intestinal ischemia is imperative for making a prompt diagnosis.
  • Rapid diagnosis is essential to prevent the catastrophic events associated with delay in immédiate treatment leading to intestinal infarction.
  • Aggressive hemodynamic support, monitoring in intensive care unit, correction of metabolic acidosis, initiation of broad spectrum antibiotics, and placement of a nasogastric tube for gastric decompression take priority over specific treatment.
  • Hemodynamic stabilization should be achieved prior to arteriography.
  • Stool cultures for Salmonella, Shigella, Campylobacter, Yersinia, E-coli O157:H7, and assay for stool toxins of Clostridium difficile should be considered in the appropriate clinical situation.
  • Do aim at the prevention of future embolic events, typically with the long term use of warfarin.

Dont's

  • Don't treat patients with severe diarrheal dehydration using 5% dextrose with 1/4 normal saline, as using solutions with lower amounts of sodium (such as 38.5 mmol/L in 1/4 saline with 5% dextrose ) would lead to sudden and severe hyponatremia with a high risk of death.[6]
  • Dont administer systemic anticoagulants to prevent thrombus formation or propagation in patients who are actively bleeding.
  • Dont use opioids, anticholinergic and antidiarrheal agents in patients with severe colitis because of the potential to precipitate further complications.

References

  1. Gore RM, Thakrar KH, Mehta UK, Berlin J, Yaghmai V, Newmark GM (2008). "Imaging in intestinal ischemic disorders". Clin Gastroenterol Hepatol. 6 (8): 849–58. doi:10.1016/j.cgh.2008.05.007. PMID 18674733.
  2. Greenwald DA, Brandt LJ, Reinus JF (2001). "Ischemic bowel disease in the elderly". Gastroenterol Clin North Am. 30 (2): 445–73. PMID 11432300.
  3. Lock G (2001). "Acute intestinal ischaemia". Best Pract Res Clin Gastroenterol. 15 (1): 83–98. doi:10.1053/bega.2000.0157. PMID 11355902.
  4. Brandt LJ, Boley SJ (2000). "AGA technical review on intestinal ischemia. American Gastrointestinal Association". Gastroenterology. 118 (5): 954–68. PMID 10784596.
  5. "American Gastroenterological Association Medical Position Statement: guidelines on intestinal ischemia". Gastroenterology. 118 (5): 951–3. 2000. PMID 10784595.
  6. "http://www.worldgastroenterology.org/assets/export/userfiles/Acute%20Diarrhea_long_FINAL_120604.pdf" (PDF). Retrieved 2 January 2014. External link in |title= (help)


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