Ischemic colitis Shock phase

Epidemiology Acute abdomen with abdominal guarding and rebound tenderness

Most common form of intestinal ischemia Signs of septic shock
Mainly occurs in adults > 60 years A classic case of ischemic colitis is a patient who presents with bloody diarrhea and severe
In 8085% mild, non-gangrenous form abdominal pain after an abdominal aortic aneurysm repair!
Etiology Diagnostics
Usually caused by transient hypoperfusion No specific laboratory findings in mild ischemic colitis
Thromboembolism In severe ischemic colitis:
Hypotension, hypovolemia (e.g., sepsis, dehydration, hemorrhage) Lactate, LDH, creatine kinase
Cardiovascular surgery (especially aortic repairs or cardiac bypass) Leukocytosis
Vasoconstrictive drugs Metabolic acidosis
Thrombophilias (e.g., anticardiolipin syndrome) Colonoscopy
Colonic obstruction from tumors, adhesions, etc. Procedure of choice in mild to moderate cases of ischemic colitis
Pathophysiology Findings include edema, cyanosis, and/or ulceration of mucosa
Intestinal blood flow of the superior mesenteric artery (SMA) and/or inferior Plain abdominal radiograph: insensitive, unspecific (air-filled, distended bowel),
mesenteric artery (IMA) is suddenly compromised intestinal hypoxia but helps exclude other disorders
intestinal wall damage mucosal inflammation + possibly bleeding may CT scan: wall thickening, pneumatosis intestinalis (suggests
progress to infarction and necrosis(gangrenous type) disruption of mucosal transmural ischemia or infarction)
barrier and perforation release of bacteria, toxins, vasoactive substances
Exploratory laparotomy in severe cases
life-threatening sepsis
Therapy
Depending on the degree of ischemia, there may be two types:
Mild to medium-severe forms:
Non-gangrenous (8085%)
Supportive care (IV fluids, bowel rest, nasogastric tube in case of an
Gangrenous (1520%) ileus)
Sites of compromise Antiplatelet drugs
Superior mesenteric artery (SMA): supplies the distal duodenum, Reduce risk of atherosclerosis
jejunum, ileum, and the right colon from the cecum to the splenic
Severe forms (signs of peritonitis, sepsis): surgical
flexure
intervention (laparotomy and bowel resection)
Inferior mesenteric artery (IMA): supplies the left colon from the Complications
splenic flexure to the rectum
Non-gangrenous form: strictures or chronic ischemic colitis
The splenic flexure and the recto sigmoid junction are at high risk
Gangrenous form: peritonitis sepsis multi-organ failure
for colonic ischemia because they are watershed areas.
Prognosis
The intestines can tolerate a state of ischemia for approx. 6 hours!
Clinical features Non-gangrenous ischemic colitis mortality rate of approx. 6%
Typically presents with 3 clinical stages: Gangrenous ischemic colitis: mortality rate of 5075%
Hyperactive phase
Sudden onset of crampy abdominal pain (usually left lower quadrant)
Bloody, loose stools
> 80% of patients recover and do not progress beyond this phase
Paralytic phase
Pain more diffuse
Bowel sounds become absent.
Bloating
Bloody stools cease
Acute mesenteric ischemia A patient with acute arterial thrombosis typically has a known cardiovascular
Epidemiology or peripheral vascular disease and/or symptoms of chronic mesenteric ischemia in
Mainly occurs in adults > 60 years addition to acute symptoms!
Young people with A-fib, vasculitis, or hypercoagulable states can also be Diagnostics
affected Laboratory findings
Acute mesenteric ischemia: 0.1% of all hospital admissions Lactate, LDH, creatine kinase
Etiology Leukocytosis
Acute arterial embolism ( 50% of cases): generally resulting from atrial Metabolic acidosis
fibrillation, myocardial infarction, valvular heart disease, or endocarditis CT angiography (confirmatory test)
Arterial thrombosis ( 25% of cases): due to preexisting Detects disrupted flow and vascular stenosis
visceral atherosclerosis, arteritis, aortic aneurysm, or dissection Distended intestinal loops and air-fluid levels, wall
Nonocclusive mesenteric ischemia (NOMI; 20% of cases) thickening, pneumatosis intestinalis (suggests
Typically seen in critically ill people with low cardiac output transmural ischemia or infarction)
Hypotension, vasopressive drugs, digitalis, ergotamines, cocaine Alternative: MR angiography
Venous thrombosis (< 10% of cases): Predisposing factors include infection, Advantage: no radiation
malignancies, estrogen therapy, and hypercoagulability disorders. Disadvantage: less accurate evaluation of the IMA
Pathophysiology Ultrasound
Sudden interruption of blood flow to small bowel (see Etiology above for Detection of distended intestinal loops and free fluid in the abdominal
cause) intestinal hypoxia hemorrhagic infarction and necrosis disruption cavity in case of perforation
of mucosal barrier and perforation release of bacteria, toxins, vasoactive Color Doppler ultrasound to detect stenosis in arterial branches
substances life-threatening sepsis
Evaluation of underlying disease (e.g., ECG for atrial fibrillation or myocardial
Sites of interruption infarction)
SMA ( 90% of cases): supplies the distal duodenum, jejunum, ileum, If an acute mesenteric ischemia is suspected, quickly initiating imaging studies (CT
and colon to the splenic flexure angiography, color Doppler sonography) is essential. In cases with peritonitis or risk
Superior mesenteric vein ( 10% of cases): drains blood from the of shock, however, emergency surgery without prior imaging is indicated!
small intestine Therapy
IMA and the celiac artery are less commonly affected. If signs of advanced ischemia (e.g., peritonitis, sepsis) or hemodynamically
Clinical features unstable patient emergency laparotomy
Periumbilical pain that is disproportionate to physical findings Open surgical embolectomy or mesenteric artery bypass depending on
Nausea and vomiting the cause of occlusion
Diarrhea (bloody in later stages) Resection of necrotic bowel segments
Gangrenous bowel: rectal bleeding and signs Hemodynamically stable patients without signs of
of sepsis (e.g., tachycardia, hypotension) advanced ischemia endovascular approach
Clinical courses Balloon angioplasty and stenting
Acute arterial embolism: most abrupt and painful onset of all types Catheter-based pharmacologic (thrombolytics) and/or mechanical
(abdominal apoplexy) thrombectomy
Acute arterial thrombosis: presentation less severe because patients Supportive: IV fluids, nasogastric tube , analgesics and broad-
have better collateral supply spectrum antibiotics
Nonocclusive ischemia: symptoms develop over several days Infusion of a vasodilator (e.g., papaverine) during arteriography to relieve
Venous thrombosis: symptoms less dramatic, worsen gradually (e.g., occlusion and vasospasm
abdominal discomfort evolves over a week) Heparin anticoagulation in cases of venous thrombosis
A patient with acute arterial embolism typically presents with
severe abdominal pain, fever, bloody diarrhea, leukocytosis and atrial fibrillation!
 Long-term measures
Reduce risk of further atherosclerosis (antiplatelet and statin therapy)
Treat underlying cardiac disease (e.g., anticoagulation therapy in Differential diagnoses
patients with A-fib) Malignancy
Complications Chronic cholecystitis
Peritonitis sepsis multi-organ failure Chronic pancreatitis
Prognosis Peptic ulcer disease
Acute mesenteric arterial ischemia: mortality rate of 6080% Therapy
In cases of bowel infarction, mortality rate is 90100% Nutritional support (frequent, small meals; low-fiber diet)
Long-term anticoagulation for patients not healthy enough for vascular repair
Revascularization procedures to prevent bowel infarction in patients with
Chronic mesenteric ischemia abdominal pain and weight loss:
Epidemiology Angioplasty and stenting
A clinically manifested chronic mesenteric ischemia is rare Mesenteric artery bypass surgery
Generally occurs in adults > 60 years Prognosis
Etiology In chronic mesenteric ischemia, surgical revascularization and reduction of risk
See risk factors for atherosclerosis (e.g., high blood pressure, smoking, diabetes factors can lead to significant pain reduction.
mellitus, high cholesterol levels)
Pathophysiology
Slowly progressing stenosis of two or more main arteries (SMA, IMA, or celiac
artery) postprandial mismatch between splanchnic blood flow and intestinal
metabolic demand postprandial pain
If only one main artery is affected, collateral connections between the arteries
can form and compensate for the reduced flow patient may be asymptomatic
Thrombus formation in addition to progressive stenosis can lead to acute-on-
chronic mesenteric ischemia acute mesenteric ischemia
Clinical features
Some patients may be asymptomatic (see Pathophysiology)
So-called 'abdominal/intestinal angina'
Recurrent, dull, postprandial epigastric pain usually within the first
hour after eating
Can lead to a fear of eating weight 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!
Diagnostics
No specific laboratory findings in chronic mesenteric ischemia
Clinical suspicion CT scan of the abdomen (identifies atherosclerotic vascular
disease and rules out other abdominal disorders)
CT angiography or MR angiography: High-grade stenoses of at least two major
vessels must be established for diagnosis
Duplex sonography of the mesenteric vessels: best screening modality in an
office setting