Acute presentation of Mesenteric Ischaemia A practical approach - - PowerPoint PPT Presentation

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Acute presentation of Mesenteric Ischaemia A practical approach - - PowerPoint PPT Presentation

Nov 30, 2022 606 likes •1.18k views

Acute presentation of Mesenteric Ischaemia A practical approach Wesley Stuart Queen Elizabeth University Hospital Glasgow AMI: Background Always mentioned in standard surgical texts Bottom of any list of causes of abdominal pain

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Acute presentation of Mesenteric Ischaemia

A practical approach

Wesley Stuart Queen Elizabeth University Hospital Glasgow

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AMI: Background

  • Always mentioned in standard surgical texts

– Bottom of any list of causes of abdominal pain

  • Commonly held misconceptions

– Rare – Difficult to diagnose – Near impossible to treat

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Other Forms Of Mesenteric Ischaemia

  • NOMI: Non-occlusive mesenteric ischaemia

– Prob most common in ITU esp. after cardiac surgery – Pump failure and/or high dose inotropes

  • Venous infarction

– Acute venous (portal vein or SMV) – Associated with acquired thrombophilia

  • Colonic ischaemia

– Usually managed conservatively – Resection not revascularisation

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Key questions

  • How common is acute mesenteric ischaemia?
  • What are the reported outcomes for

treatment?

  • How is a diagnosis made?
  • Is a laparotomy needed?
  • Is there a superior method of restoring

perfusion?

  • Is a relook laparotomy needed?
  • Other issues
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SLIDE 5

Terminology

  • Acute symptoms

< 2 weeks

  • Chronic symptoms > 2 weeks
  • Acute-on-chronic

Both features

(EJVES Guidelines use 6 weeks to denote chronic symptoms)

  • Abdominal pain: acute, chronic and change (to

rest pain)

  • Food-related symptoms
  • Mesenteric angina
  • Food aversion/anorexia
  • Weight loss
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Normal Gut Arterial Supply

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Normal Gut Arterial Supply

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Normal Gut Arterial Supply

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Normal Gut Arterial Supply

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Normal Gut Arterial Supply

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Epidemiology

  • Probably not that rare
  • Swedish autopsy data from 80’s (acute cases)

– 87% autopsy rates – AMI: 8.6/100,000 population per year (mostly SMA) – Only a third suspected by pre-mortem

Acosta 2010

– RAAA: 5.6/100,000 (pre-screening era) – 8.6 /100 000 person years ≡ 103 per year GG&C

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Reported Outcomes Mortality quoted:

–48.3% for treated* embolic AMI –80% for treated* thrombotic AMI

Schoots (2004 review)

*Resection/revasc/both

–73.9% overall† (all AMI)

  • 60% mort for 2002-2014

Adaba (2015 review)

† These data are for those with a “firm diagnosis” of mesenteric infarction: hist, lap, CT, angiography

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Changes since the eighties

  • Rising recognition of acute-on-chronic disease
  • Acosta: numbers largely centred on SMA disease
  • Rise of anticoagulation

– AF, post-MI

  • Rise of statins and antiplatelet agents
  • Fewer smokers, more diabetes
  • Imaging
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SLIDE 14

Rise of emergency cross-sectional (CT) imaging

Annual number of abdominal imaging studies per modality per 1,000 ED

  • visits. (Raja, Int J Em Med, 2011.)
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CT Activity Scotland

200 400 600 800 1000 1200 1400 1600 1800 2000

CT per 10,000 population

2014-15 2016-17

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Scotland GG&C HB Mes Isch Distribution of deprivation by SIMD Quintile

SIMD 1 SIMD 2 SIMD 3 SIMD 4 SIMD 5

Mesenteric Ischaemia Association With Poverty

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Scotland GG&C HB Mes Isch Distribution of deprivation by SIMD Quintile

SIMD 1 SIMD 2 SIMD 3 SIMD 4 SIMD 5

Mesenteric Ischaemia Association With Poverty

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Scotland GG&C HB Mes Isch Distribution of deprivation by SIMD Quintile

SIMD 1 SIMD 2 SIMD 3 SIMD 4 SIMD 5

Mesenteric Ischaemia Association With Poverty

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48) Female:Male

14:13 29:25 37:11

Weight loss

3 39 44

Abdominal pain

27 54 46

Eating related symptoms

  • Post-prandial pain
  • Food aversion
  • Anorexia

2 28 39

GI/abdo pain Ix in preceding year

9 42 48

Presenting Features

Eighty one cases with acute symptoms

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48) Female:Male

14:13 29:25 37:11

Weight loss

3 39 44

Abdominal pain

27 54 46

Eating related symptoms

  • Post-prandial pain
  • Food aversion
  • Anorexia

2 28 39

GI/abdo pain Ix in preceding year

9 42 48

Presenting Features

Eighty one cases with acute symptoms

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48) Female:Male

14:13 29:25 37:11

Weight loss

3 39 (72%) 44 (92%

Abdominal pain

27 54 46

Eating related symptoms

  • Post-prandial pain
  • Food aversion
  • Anorexia

2 28 (52%) 39 (81%

GI/abdo pain Ix in preceding year

9 42 48

Presenting Features

Eighty one cases with acute symptoms

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Where do our cases come from?

Acute (n=27) Acute-on- chronic (n=54) Chronic (n=48) Gastroenterology 1 4 15 Medicine Specs

  • 4

5 General Surgery 25 40 23 Other vascular 1 3 1

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Acute

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Acute-on-chronic

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Acute* (n=27) Acute-on-chronic (n=54) Chronic (n=48) SMA only 14 (52%) 7 6 Triple vessel 5 27 22 Coeliac only

  • 2

Coeliac and SMA 5 19 11 IMA and SMA or coeliac 2 1 7

Vessels Affected

*One case no with no data. Laparotomy without imaging.

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Acute* (n=27) Acute-on-chronic (n=54) Chronic (n=48) SMA only 14 7 6 Triple vessel 5 27 (50%) 22 Coeliac only

  • 2

Coeliac and SMA 5 19 (38%) 11 IMA and SMA or coeliac 2 1 7

Vessels Affected

*One case no with no data. Laparotomy without imaging.

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Making a diagnosis

  • Most likely after imaging

– Radiologist suggests considering diagnosis of AMI

  • Do images and symptoms match?
  • What are the symptoms?

– Lots of pain, background of pain and weight loss. – Food-related symptoms.

  • Biomarkers: not much help

– Perhaps a normal D-dimer makes AMI or A-on-C unlikely

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Is a laparotomy needed?

  • Abdominal signs (any tenderness or

peritonism)

  • WCC, perhaps a little
  • Resolution of all symptoms after awake

procedure

  • Ceiling of care
  • If you think it might be needed, just do it.
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Visible necrosis No evidence of necrosis White cell count <10 2 4 10-12 1 6 12.1-15 7 5 15.1-20 7 7 >20 14 7

Is a laparotomy needed?

Sixty patients with acute symptoms and a primary laparotomy.

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Visible necrosis No evidence of necrosis White cell count <10 2 4 10-12 1 6 12.1-15 7 5 15.1-20 7 7 >20 14 7

Is a laparotomy needed?

Sixty patients with acute symptoms and a primary laparotomy.

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Visible necrosis No evidence of necrosis White cell count <10 2 4 10-12 1 6 12.1-15 7 5 15.1-20 7 7 >20 14 7

Is a laparotomy needed?

Sixty patients with acute symptoms and a primary laparotomy.

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48)

Primary intervention Resection only 4 Thromboembolectomy 13 4 Radiological Intervention 3 21 33 Bypass graft 7 28 14 Necrosis at first lap 19 16 Bowel resection Cholecystectomy 16

  • 21

2 5

  • Laparotomy only
  • 1

1 Inpatient/30 day Death 10 (37%) 12 (22%) 6 (13%)

Primary Interventions

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48)

Primary intervention Resection only 4 Thromboembolectomy 13 (48%) 4 Radiological Intervention 3 21 33 Bypass graft 7 28 14 Necrosis at first lap 19 16 Bowel resection Cholecystectomy 16

  • 21

5 5

  • Laparotomy only
  • 1

1 Inpatient/30 day Death 10 (37%) 12 (22%) 6 (13%)

Primary Interventions

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48)

Primary intervention Resection only 4 Thromboembolectomy 13 4 Radiological Intervention 3 21 33 Bypass graft 7 (24%) 28 14 Necrosis at first lap 19 16 Bowel resection Cholecystectomy 16

  • 21

5 5

  • Laparotomy only
  • 1

1 Inpatient/30 day Death 10 (37%) 12 (22%) 6 (13%)

Primary Interventions

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48)

Primary intervention Resection only 4 Thromboembolectomy 13 4 Radiological Intervention 3 21 (39%) 33 Bypass graft 7 28 (52%) 14 Necrosis at first lap 19 16 Bowel resection Cholecystectomy 16

  • 21

5 5

  • Laparotomy only
  • 1

1 Inpatient/30 day Death 10 (37%) 12 (22%) 6 (13%)

Primary Interventions

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SLIDE 37

Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48)

Primary intervention Resection only 4 Thromboembolectomy 13 4 Radiological Intervention 3 21 (39%) 33 Bypass graft 7 28 (52%) 14 Necrosis at first lap 19 16 Bowel resection Cholecystectomy 16

  • 21

5 5

  • Laparotomy only
  • 1

1 Inpatient/30 day Death 10 (37%) 12 (22%) 6 (13%)

Primary Interventions

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48)

Primary intervention Resection only 4 Thromboembolectomy 13 4 Radiological Intervention 3 21 33 Bypass graft 7 28 14 Necrosis at first lap 19 16 Bowel resection Cholecystectomy 16

  • 21

5 5

  • Laparotomy only
  • 1

1 Inpatient/30 day Death 10 (37%) 12 (22%) 6 (13%)

Primary Interventions

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Best revascularisation?

  • No single answer: therefore discuss with IR
  • Appearances of lesions

– What is likely to succeed?

  • Need for laparotomy: increases options
  • Time considerations
  • Where is the patient?

– Distant site and in theatre with limited IR facilities

  • Ceilings of care

– Fit for laparotomy

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Thrombus aspiration

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Retrograde SMA stent

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Patient with intermittent rest pain on a background of food related symptoms awaiting scheduled endovasc intervention. Continuous pain overnight, WCC rose to 21 Findings: GB fundus infarction (no perforation) Good quality common hepatic artery Long occlusion of SMA (Aorta not occluded)

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Day 2 post-op second-look: well perfused bowel Day 4 post-op: WCC rose again with new abdo pain Laparotomy: all bowel clearly well perfused. SMA limb

  • ccluded, but no action taken

(CT performed 6 weeks later

  • n readmission. Abdo pain,

settled in 24 hours, cons Mx.)

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CHA-SMA vein graft

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Acute (n=27) Acute-on- chronic(n=54) Chronic (n=48) No of laparotomies 1 2 3 4 5 43 1 15 7 3 1 70 13 19 17 4 1 33 26 14 6 1 1 Vascular Re-intervention:

  • Early
  • Late

1 2 8 10 6 8

Laparotomies and re-intervention

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Ischaemic but not necrotic

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Much improved

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Dubious viability

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48)

Fistula 1 4 Stoma 8 7 4 Home TPN 3 5 2 Inpatient/30 day Death 10 (37%) 12 (22%) 6 (13%)

Outcomes

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48)

Fistula 1 4 Stoma 8 7 4 Home TPN 3 5 2 Inpatient/30 day Death 10 (37%) 12 (22%) 6 (13%)

Outcomes

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48)

Fistula 1 4 Stoma 8 7 4 Home TPN 3 5 2 Inpatient/30 day Death 10 (37%) 12 (22%) 6 (13%)

Outcomes

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Acute (n=27) Acute-on-chronic (n=54) Chronic (n=48)

Fistula 1 4 Stoma 8 7 4 Home TPN 3 5 2 Inpatient/30 day Death 10 (37%) 12 (22%) 6 (13%)

Outcomes

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Survival After Intervention

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Summary

Glasgow strategy

–Discuss with IR if at all possible –Tailor treatment to patient’s needs and what might work quickly and first time –Low threshold for laparotomy –Low threshold for second laparotomy: standard in acute –Repeat lap & salvage procedures as needed –Acceptable results are possible