GASTRO/GENSURG
ISCHAEMIC BOWEL
Stem - Severe, sudden onset abdo pain in someone with AF. Tender not peritonitic. Sore but usually stable-ish
Prompt
ResponseDilated small bowel loops
Thickened bowel wall with “Thumbprint” sign (thickened oedematous mucosal folds, non specific but concerning for ischaemia)
No portal venous gas, no pneumatosis intestinalis, no foecal loading
Thickened bowel wall with “Thumbprint” sign (thickened oedematous mucosal folds, non specific but concerning for ischaemia)
No portal venous gas, no pneumatosis intestinalis, no foecal loading
Prompt
ResponsePneumatosis intestinalis (Pathognomonic of ischaemia)
Other causes
Primary - Benign idiopathic conditions, submucosal/subserosal cysts
Secondary - Infectious enteritis, COPD, coeliac disease, lukaemia, AIDS, Amyloidoosis, post chemo enteritis, connective tissue disorder
Other causes
Primary - Benign idiopathic conditions, submucosal/subserosal cysts
Secondary - Infectious enteritis, COPD, coeliac disease, lukaemia, AIDS, Amyloidoosis, post chemo enteritis, connective tissue disorder
Prompt
ResponsePortal venous gas (very bad)
Intramural gas
Mesenteric venous gas
Gastric distension
= Acute mesenteric/bowel ischaemia
Intramural gas
Mesenteric venous gas
Gastric distension
= Acute mesenteric/bowel ischaemia
PromptRisk factors for mesenteric ischaemia/bowel ischaemia
ResponseAF
Arterial embolism 50%, arterial thrombosis 15-25% - risk factors for this
Arterial embolism 50%, arterial thrombosis 15-25% - risk factors for this
- Age >60, recent MI, Valvular heart disease, aortic atherosclerosis or aneurysm, aortoiliac instrumentation or surgery
- Hypoperfusion, vasospasm
- Hypercoagulable states, dehydration, portal htn, abdominal infections, trauma, pancreatitis, splenectomy, malignancy in portal region
PromptInvestigations in ischaemic bowel
ResponseEUC - electrolyte disorders
FBC - anaemia, leukocytosis
ABG/VBG for acid base disturbance
Lactate as marker for sepsis/ischaemic gut
AXR ? obstruction
Erect CXR ? pneumoperitoneum
USS (Bedside) - dilated aorta/free fluid
CTA - vascular occlusion/ischaemia/perforation/obstruction/infarct/collection
FBC - anaemia, leukocytosis
ABG/VBG for acid base disturbance
Lactate as marker for sepsis/ischaemic gut
AXR ? obstruction
Erect CXR ? pneumoperitoneum
USS (Bedside) - dilated aorta/free fluid
CTA - vascular occlusion/ischaemia/perforation/obstruction/infarct/collection
PromptManagement of (thrombotic) mesenteric ischaemia/ischaemic bowel
ResponseSupportive care - Analgesia, NBM, IV fluids, NGT
Antibiotics - Broad spectrum
Heparin infusion - controversial - indicated in venous thrombus or cardiac embolisation
Urgent notification of surgeons for consideration of early laparotomy
Consideration of interventional procedures - Endovascular stenting, catheter directed thrombolysis, Intraarterial vasodilators
ICU bed
Antibiotics - Broad spectrum
Heparin infusion - controversial - indicated in venous thrombus or cardiac embolisation
Urgent notification of surgeons for consideration of early laparotomy
Consideration of interventional procedures - Endovascular stenting, catheter directed thrombolysis, Intraarterial vasodilators
ICU bed
PromptPoor prognostic factors in ischaemic bowel
ResponseBloody diarrhoea
Lactic acidosis
Portal venous gas
Thickening of bowel wall on imaging
Lactic acidosis
Portal venous gas
Thickening of bowel wall on imaging