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Diagnosis and Treatment of Acute Mesenteric Ischemia

Case Presentation. 81 F presents in the early evening to the emergency department with a vague abdominal pain and no additional complaintsPain is described as diffuse located primaily in the lower abdomenPMH includesCAD s/p angioplasty with stentsDiverticulosisCT scan ordered but never complete

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Diagnosis and Treatment of Acute Mesenteric Ischemia

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    1. Diagnosis and Treatment of Acute Mesenteric Ischemia

    2. 81 F presents in the early evening to the emergency department with a vague abdominal pain and no additional complaints Pain is described as diffuse located primaily in the lower abdomen PMH includes CAD s/p angioplasty with stents Diverticulosis CT scan ordered but never completed in ED

    3. At approximately midnight she is transferred to the floor without a diagnosis At 2am the on call resident called: Hypotension Shortness of breath Worsening abdominal pain ABG: 7.15/24/84/8 Transferred to MICU for vasopressor and respiratory support

    4. General surgery consulted ABG 7.05/35/100/8 on 100% positive pressure ventilation Lactate 12 Dopamine and Norepinephrine infusing Decision made to take to the operating room for an exploratory laparotomy Bowel found to be grossly necrotic form ligament of treitz to descending colon.

    5. Severe disease affecting 1/100,000 hospitalized patients Diagnosis often delayed Mortality rates high 60% – 80%

    6. Acute Mesenteric Ischemia (AMI) Chronic Mesenteric Ischemia (CMI) Intestinal Angina Colonic Ischemia (CI)

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    10. Severe abdominal pain of abrupt onset Poorly localized Classically out of proportion to physical exam Bowel evacuation with heme positive stools (50%)

    11. Age (> 65) Generally affects older individuals Highest mortality among those >80 Atherosclerotic disease Arrythmias Cardiogenic shock with pressor dependence Known hypercoaguable state Intrabdominal Malignancy

    12. No reliable test Helpful adjuncts include ABG – acidosis indicates ischemia but only develops in 50% Lactic acid Amylase Creatine phosphokinase D-Dimer (100% sensitivity in one study with 38% specificity) Leukocytosis – greater than 15K supports diagnosis

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    15. Use of preoperative angiography is still controversial With peritoneal signs exploratory laparotomy mandated Embolectomy Resection of dead bowel Laser dopler, dopler US and fluoresceine dye are usefull adjuncts to assess viability Routine second look laparotomy is recommended

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