Mesenteric ischemia medical therapy: Difference between revisions

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VisualWikitext

Latest revision as of 19:14, 15 January 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Overview

Mesenteric ischemia is a medical emergency that requires prompt treatment. The mainstay of treatment is surgery if bowel necrosis or gangrene has occurred, whereas medical therapy is considered initially for hemodynamically stable patients.

Medical Therapy

The treatment of choice, medical versus surgical in mesenteric ischemia depends on the following key elements:

Duration and severity of ischemia of the intestine
Nature of the occlusive lesion
Availability of the immediate surgical or interventional radiology facility in the emergency room
Hemodyanamic stability of the patient

(A)Conservative management:

Mesenteric ischemia is an acute emergency condition that requires prompt intervention. The outline of initial medical management of all types of mesenteric ischemia includes:^[1]^[2]^[3]^[4]^[3]

Supplemental oxygen

Pain control
Fluid resuscitation
Hemodynamic support and monitoring

Correction of electrolyte abnormalities
Anticoagulation with heparin, to limit thrombus propagation^[5]^[1]

Broad sprectrum antibiotics^[4]^[6]
Gastrointestinal decompression
Avoidance of vasopressors, which can exacerbate ischemia
Proton pump inhibitors
Measurement of electrolytes and acid base status
Nutritional assessment and support

1.Pain control:

Parenteral opioids are used to control the pain.

2.Fluid resuscitation:

Patients suspected of having mesenteric ischemia should be resuscitated with crystalloids and blood products to prevent cardiovascular collapse.

3.Hemodynamic support and monitoring:

In order to guide effective resuscitation, effective hemodyanamic support and monitoring should be implemented.

4.Anticoagulation with heparin:^[7]^[8]

Early use of heparin is asscociated with improved survival especially in cases of mesenteric venous thrombosis.

5.Broad sprectrum antibiotics:

Broad spectrum antibiotics should be administered early in the course of treatment of mesenteric ischemia to prevent the risk of infection.

6.Avoidance of vasopressors:

Vasopressors should be used with caution. Dobutamine, low dose dopamine and milrinone can be used to improve cardiac function as they have less effect on mesenteric blood flow.

7.Measurement of electrolytes and acid base status:

8.Nutritional assessment and support:^[9]^[2]

For patients presenting with chronic mesenteric ischemia, nutritional assessment and support is an important factor as they usually present with malnutrition (BMI<20 and albumin <3).

(B)Management according to the severity of presentation

History, symptoms and signs suggest mesenteric ischemia(abdominal pain out of proportion to physical exmaination findings)

Hemodyanamically unstable, signs of sepsis

No

Yes

Resuscitate, Intravenous fluid therapy, empiric antibiotic therapy,consider systemic antibiotic therapy

Plain abdominal films

Free air, signs of advanced ischemia (infarcted bowel)

No

Yes

Improved and hemodyanamically stable, but persistent signs and symptoms

Laprotomy

CT abdomen (without intravenous contrast)

Multimodal management of mesenteric ischemia
Early management					Late management
Pathophysiological events	Vascular occlusion	Splanchnic hypoperfusion	Intestinal hypoxia	Intestinal barrier injury Translocation Local inflammatory pathway	Systemic inflammatory pathways	Necrosis Organ failure
Treatment strategy	Heparin Aspirin Revascularization	Oxygen Blood volume resuscitation Transfusion		Oral antibiotics	Intravenous antibiotics	Intestinal resection

Refernces

↑ ^1.0 ^1.1 Klempnauer J, Grothues F, Bektas H, Pichlmayr R (1997). "Long-term results after surgery for acute mesenteric ischemia". Surgery. 121 (3): 239–43. PMID 9068664.
↑ ^2.0 ^2.1 Corcos O, Castier Y, Sibert A, Gaujoux S, Ronot M, Joly F; et al. (2013). "Effects of a multimodal management strategy for acute mesenteric ischemia on survival and intestinal failure". Clin Gastroenterol Hepatol. 11 (2): 158–65.e2. doi:10.1016/j.cgh.2012.10.027. PMID 23103820.
↑ ^3.0 ^3.1 Wyers MC (2010). "Acute mesenteric ischemia: diagnostic approach and surgical treatment". Semin Vasc Surg. 23 (1): 9–20. doi:10.1053/j.semvascsurg.2009.12.002. PMID 20298945.
↑ ^4.0 ^4.1 Silvestri L, van Saene HK, Zandstra DF, Marshall JC, Gregori D, Gullo A (2010). "Impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome: systematic review of randomized controlled trials". Crit Care Med. 38 (5): 1370–6. doi:10.1097/CCM.0b013e3181d9db8c. PMID 20308882.
↑ Reinus JF, Brandt LJ, Boley SJ (1990). "Ischemic diseases of the bowel". Gastroenterol Clin North Am. 19 (2): 319–43. PMID 2194948.
↑ Petros A, Silvestri L, Booth R, Taylor N, van Saene H (2013). "Selective decontamination of the digestive tract in critically ill children: systematic review and meta-analysis". Pediatr Crit Care Med. 14 (1): 89–97. doi:10.1097/PCC.0b013e3182417871. PMID 22805154.
↑ Hmoud B, Singal AK, Kamath PS (2014). "Mesenteric venous thrombosis". J Clin Exp Hepatol. 4 (3): 257–63. doi:10.1016/j.jceh.2014.03.052. PMC 4284291. PMID 25755568.
↑ al Karawi MA, Quaiz M, Clark D, Hilali A, Mohamed AE, Jawdat M (1990). "Mesenteric vein thrombosis, non-invasive diagnosis and follow-up (US + MRI), and non-invasive therapy by streptokinase and anticoagulants". Hepatogastroenterology. 37 (5): 507–9. PMID 2253928.
↑ Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F; et al. (2009). "ESPEN Guidelines on Parenteral Nutrition: surgery". Clin Nutr. 28 (4): 378–86. doi:10.1016/j.clnu.2009.04.002. PMID 19464088.

[pmid9068664-1] 1.0 ^1.1 Klempnauer J, Grothues F, Bektas H, Pichlmayr R (1997). "Long-term results after surgery for acute mesenteric ischemia". Surgery. 121 (3): 239–43. PMID 9068664.

[pmid23103820-2] 2.0 ^2.1 Corcos O, Castier Y, Sibert A, Gaujoux S, Ronot M, Joly F; et al. (2013). "Effects of a multimodal management strategy for acute mesenteric ischemia on survival and intestinal failure". Clin Gastroenterol Hepatol. 11 (2): 158–65.e2. doi:10.1016/j.cgh.2012.10.027. PMID 23103820.

[pmid20298945-3] 3.0 ^3.1 Wyers MC (2010). "Acute mesenteric ischemia: diagnostic approach and surgical treatment". Semin Vasc Surg. 23 (1): 9–20. doi:10.1053/j.semvascsurg.2009.12.002. PMID 20298945.

[pmid20308882-4] 4.0 ^4.1 Silvestri L, van Saene HK, Zandstra DF, Marshall JC, Gregori D, Gullo A (2010). "Impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome: systematic review of randomized controlled trials". Crit Care Med. 38 (5): 1370–6. doi:10.1097/CCM.0b013e3181d9db8c. PMID 20308882.

[pmid2194948-5] Reinus JF, Brandt LJ, Boley SJ (1990). "Ischemic diseases of the bowel". Gastroenterol Clin North Am. 19 (2): 319–43. PMID 2194948.

[pmid22805154-6] Petros A, Silvestri L, Booth R, Taylor N, van Saene H (2013). "Selective decontamination of the digestive tract in critically ill children: systematic review and meta-analysis". Pediatr Crit Care Med. 14 (1): 89–97. doi:10.1097/PCC.0b013e3182417871. PMID 22805154.

[pmid25755568-7] Hmoud B, Singal AK, Kamath PS (2014). "Mesenteric venous thrombosis". J Clin Exp Hepatol. 4 (3): 257–63. doi:10.1016/j.jceh.2014.03.052. PMC 4284291. PMID 25755568.

[pmid2253928-8] Karawi MA, Quaiz M, Clark D, Hilali A, Mohamed AE, Jawdat M (1990). "Mesenteric vein thrombosis, non-invasive diagnosis and follow-up (US + MRI), and non-invasive therapy by streptokinase and anticoagulants". Hepatogastroenterology. 37 (5): 507–9. PMID 2253928.

[pmid19464088-9] Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F; et al. (2009). "ESPEN Guidelines on Parenteral Nutrition: surgery". Clin Nutr. 28 (4): 378–86. doi:10.1016/j.clnu.2009.04.002. PMID 19464088.

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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Mesenteric ischemia}}
-Please help WikiDoc by adding more content here.  It's easy!  Click  [[Help:How_to_Edit_a_Page|here]]  to learn about editing.
+{{CMG}} {{AE}} {{FT}}
 ==Overview==
+[[Mesenteric ischemia]] is a [[medical emergency]] that requires prompt treatment. The mainstay of treatment is surgery if bowel necrosis or [[gangrene]] has occurred, whereas medical therapy is considered initially for hemodynamically stable patients.
 ==Medical Therapy==
-Acute mesenteric artery ischemia is an emergency. If a blood clot is causing it, you may need to take medicines to dissolve the clot (thrombolytics) and widen the mesenteric arteries (vasodilators).
+The treatment of choice, medical versus surgical in [[mesenteric ischemia]] depends on the following key elements:
+*Duration and severity of [[ischemia]] of the [[intestine]]
+*Nature of the occlusive lesion
+*Availability of the immediate surgical or [[interventional radiology]] facility in the emergency room
+*Hemodyanamic stability of the patient
+'''(A)Conservative management:'''
+[[Mesenteric ischemia|Mesenteric]] ischemia is an acute emergency condition that requires prompt intervention. The outline of initial [[Medicine|medical]] management of all types of [[mesenteric ischemia]] includes:<ref name="pmid9068664">{{cite journal| author=Klempnauer J, Grothues F, Bektas H, Pichlmayr R| title=Long-term results after surgery for acute mesenteric ischemia. | journal=Surgery | year= 1997 | volume= 121 | issue= 3 | pages= 239-43 | pmid=9068664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9068664  }} </ref><ref name="pmid23103820">{{cite journal| author=Corcos O, Castier Y, Sibert A, Gaujoux S, Ronot M, Joly F et al.| title=Effects of a multimodal management strategy for acute mesenteric ischemia on survival and intestinal failure. | journal=Clin Gastroenterol Hepatol | year= 2013 | volume= 11 | issue= 2 | pages= 158-65.e2 | pmid=23103820 | doi=10.1016/j.cgh.2012.10.027 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23103820  }} </ref><ref name="pmid20298945">{{cite journal| author=Wyers MC| title=Acute mesenteric ischemia: diagnostic approach and surgical treatment. | journal=Semin Vasc Surg | year= 2010 | volume= 23 | issue= 1 | pages= 9-20 | pmid=20298945 | doi=10.1053/j.semvascsurg.2009.12.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20298945  }} </ref><ref name="pmid20308882">{{cite journal| author=Silvestri L, van Saene HK, Zandstra DF, Marshall JC, Gregori D, Gullo A| title=Impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome: systematic review of randomized controlled trials. | journal=Crit Care Med | year= 2010 | volume= 38 | issue= 5 | pages= 1370-6 | pmid=20308882 | doi=10.1097/CCM.0b013e3181d9db8c | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20308882  }} </ref><ref name="pmid20298945">{{cite journal| author=Wyers MC| title=Acute mesenteric ischemia: diagnostic approach and surgical treatment. | journal=Semin Vasc Surg | year= 2010 | volume= 23 | issue= 1 | pages= 9-20 | pmid=20298945 | doi=10.1053/j.semvascsurg.2009.12.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20298945  }} </ref>
+* Supplemental oxygen
+*Pain control
+*[[Fluid replacement|Fluid resuscitation]]
+*[[Hemodynamically|Hemodynamic]] support and monitoring
+*Correction of [[Electrolyte disturbance|electrolyte abnormalities]]
+*[[Anticoagulant|Anticoagulation]] with [[heparin]], to limit [[thrombus]] propagation<ref name="pmid2194948">{{cite journal| author=Reinus JF, Brandt LJ, Boley SJ| title=Ischemic diseases of the bowel. | journal=Gastroenterol Clin North Am | year= 1990 | volume= 19 | issue= 2 | pages= 319-43 | pmid=2194948 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2194948  }} </ref><ref name="pmid9068664">{{cite journal| author=Klempnauer J, Grothues F, Bektas H, Pichlmayr R| title=Long-term results after surgery for acute mesenteric ischemia. | journal=Surgery | year= 1997 | volume= 121 | issue= 3 | pages= 239-43 | pmid=9068664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9068664  }} </ref>
+*Broad sprectrum [[Antibiotic|antibiotics]]<ref name="pmid20308882">{{cite journal| author=Silvestri L, van Saene HK, Zandstra DF, Marshall JC, Gregori D, Gullo A| title=Impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome: systematic review of randomized controlled trials. | journal=Crit Care Med | year= 2010 | volume= 38 | issue= 5 | pages= 1370-6 | pmid=20308882 | doi=10.1097/CCM.0b013e3181d9db8c | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20308882  }} </ref><ref name="pmid22805154">{{cite journal| author=Petros A, Silvestri L, Booth R, Taylor N, van Saene H| title=Selective decontamination of the digestive tract in critically ill children: systematic review and meta-analysis. | journal=Pediatr Crit Care Med | year= 2013 | volume= 14 | issue= 1 | pages= 89-97 | pmid=22805154 | doi=10.1097/PCC.0b013e3182417871 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22805154  }} </ref>
+*[[Gastrointestinal tract|Gastrointestinal]] [[decompression]]
+*Avoidance of vasopressors, which can exacerbate [[ischemia]]
+*[[Proton pump inhibitor|Proton pump inhibitors]]
+*Measurement of [[Electrolyte disturbance|electrolytes]] and [[Acid-base imbalance|acid]] base status
+*[[Nutrition|Nutritional]] assessment and support
+'''1.Pain control:'''
+Parenteral [[Opioid|opioids]] are used to control the pain.
+'''2.Fluid resuscitation:'''
+Patients suspected of having [[mesenteric ischemia]] should be resuscitated with crystalloids and blood products to prevent [[Shock|cardiovascular collapse]].
+'''3.Hemodynamic support and monitoring''':
+In order to guide effective [[Cardiopulmonary resuscitation|resuscitation]], effective hemodyanamic support and monitoring should be implemented.
+'''4.[[Anticoagulant|Anticoagulation]] with [[heparin]]''':<ref name="pmid25755568">{{cite journal| author=Hmoud B, Singal AK, Kamath PS| title=Mesenteric venous thrombosis. | journal=J Clin Exp Hepatol | year= 2014 | volume= 4 | issue= 3 | pages= 257-63 | pmid=25755568 | doi=10.1016/j.jceh.2014.03.052 | pmc=4284291 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25755568  }} </ref><ref name="pmid2253928">{{cite journal| author=al Karawi MA, Quaiz M, Clark D, Hilali A, Mohamed AE, Jawdat M| title=Mesenteric vein thrombosis, non-invasive diagnosis and follow-up (US + MRI), and non-invasive therapy by streptokinase and anticoagulants. | journal=Hepatogastroenterology | year= 1990 | volume= 37 | issue= 5 | pages= 507-9 | pmid=2253928 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2253928  }} </ref>
+Early use of heparin is asscociated with improved survival  especially  in cases of [[Mesenteric ischemia|mesenteric]] venous [[thrombosis]].
+'''5.Broad sprectrum [[Antibiotic|antibiotics]]:'''
+Broad spectrum [[Antibiotic|antibiotics]] should be administered early in the course of treatment of [[mesenteric ischemia]] to prevent the risk of [[infection]].
+'''6.Avoidance of vasopressors:'''
+[[Vasoconstriction|Vasopressors]] should be used with caution. [[Dobutamine]], low dose [[dopamine]] and [[milrinone]] can be used to improve [[Heart|cardiac]] function as they have less effect on [[Mesentery|mesenteric]] [[blood]] flow.
+'''7.Measurement of electrolytes and acid base status:'''
+'''8.[[Nutrition|Nutritional]] assessment and support:'''<ref name="pmid19464088">{{cite journal| author=Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F et al.| title=ESPEN Guidelines on Parenteral Nutrition: surgery. | journal=Clin Nutr | year= 2009 | volume= 28 | issue= 4 | pages= 378-86 | pmid=19464088 | doi=10.1016/j.clnu.2009.04.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19464088  }} </ref><ref name="pmid23103820">{{cite journal| author=Corcos O, Castier Y, Sibert A, Gaujoux S, Ronot M, Joly F et al.| title=Effects of a multimodal management strategy for acute mesenteric ischemia on survival and intestinal failure. | journal=Clin Gastroenterol Hepatol | year= 2013 | volume= 11 | issue= 2 | pages= 158-65.e2 | pmid=23103820 | doi=10.1016/j.cgh.2012.10.027 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23103820  }} </ref>
+For patients presenting with chronic mesenteric ischemia, [[Nutrition|nutritional]] assessment and support is an important factor as they usually present with [[malnutrition]] ([[Body mass index|BMI]]<20 and [[albumin]] <3).
+===(B)Management according to the severity of presentation===
+{{familytree/start}}
+{{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | |A01=History, symptoms and signs suggest mesenteric ischemia(abdominal pain out of proportion to physical exmaination findings)}}
+{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
+{{familytree | | | | | | | | | | | | | | | B01 | | | | | | | | | | | |B01=Hemodyanamically unstable, signs of sepsis}}
+{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |}}
+{{familytree | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|.| | | | | | | }}
+{{familytree | | | | | | |!| | | | | | | | | | | | | | | | |!| | | | | | | }}
+{{familytree | | | | | | C01 | | | | | | | | | | | | | | | C02 | | | | | | |C01=No|C02=Yes}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | |}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | D01 | | | | | | |D01=Resuscitate, Intravenous fluid therapy, empiric antibiotic therapy,consider systemic antibiotic therapy}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | |}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | E01 | | | | | | |E01=Plain abdominal films}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | |}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | F01 | | | | | | |F01=Free air, signs of advanced ischemia (infarcted bowel)}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | |}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | G01 | | | | | | |G01=}}
+{{familytree | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | |}}
+{{familytree | | | | | | | | | | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|.|}}
+{{familytree | | | | | | | | | | | | | | | | | H01 | | | | | | | | | | | H02 | |H01=No|H02=Yes}}
+{{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | |!| }}
+{{familytree | | | | | | | | | | | | | | | | | I01 | | | | | | | | | | | I02 | | |I01=Improved and hemodyanamically stable, but persistent signs and symptoms|I02=Laprotomy}}
+{{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | }}
+{{familytree | | | | | | | | | | | | | | | | | J01 | | | | | | | | | | | | | | |J01=CT abdomen (without intravenous contrast)}}
+{{familytree/end}}
+{| class="wikitable"
+! colspan="7" |Multimodal management of mesenteric ischemia
+|-
+| colspan="5" |Early management
+| colspan="2" |Late management
+|-
+|Pathophysiological events
+|[[Vascular]] [[occlusion]]
+|[[Splanchnic]] hypoperfusion
+|Intestinal hypoxia
+|
+* [[Intestine|Intestinal]] barrier injury
+* Translocation
+* Local [[Inflammation|inflammatory]] pathway
+|Systemic [[Inflammation|inflammatory]] pathways
+|[[Necrosis]]
+Organ failure
+|-
+|Treatment strategy
+|
+* [[Heparin]]
+* [[Aspirin]]
-==References==
+* [[Revascularization]]
+| colspan="2" |
+* Oxygen
+* Blood volume resuscitation
+* [[Blood transfusion|Transfusion]]
+|Oral [[Antibiotic|antibiotics]]
+|Intravenous [[Antibiotic|antibiotics]]
+|[[Intestine|Intestinal]] resection
+|}
+===Refernces===
 {{Reflist|2}}
-[[Category:Needs content]]
+[[Category:Gastroenterology]]
+[[Category:up-to-date]]