Surgery: Mesenteric Ischaemia
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Questions and Answers

What is the most important clue to an early diagnosis of acute mesenteric ischaemia?

  • Passage of altered blood
  • Sudden onset of severe abdominal pain in a patient with atrial fibrillation or atherosclerosis (correct)
  • Abdominal tenderness
  • Persistent vomiting and defaecation

What is often revealed in investigation of acute mesenteric ischaemia?

  • Lymphocytosis with presence of gas in the lumen of the small intestine
  • Eosinophilic reaction with presence of gas in the mesenteric and portal veins
  • Monocytosis with absence of gas in the intestinal wall
  • Neutrophil leukocytosis with an absence of gas in the lumen of the thickened small intestine (correct)

What is a possible treatment option for acute mesenteric ischaemia?

  • Laparotomy with embolectomy via the femoral artery
  • Resuscitation with pain management
  • Laparotomy with embolectomy via the ileocolic artery (correct)
  • Conservative management with antibiotics

What is a characteristic of the pain in acute mesenteric ischaemia?

<p>Sudden and severe, out of proportion to the physical findings (A)</p> Signup and view all the answers

What is a common feature of the abdominal examination in acute mesenteric ischaemia?

<p>Rigidity as a late feature (D)</p> Signup and view all the answers

What is a possible complication of acute mesenteric ischaemia?

<p>Hypovolaemia and sepsis (B)</p> Signup and view all the answers

What is the usual treatment for fistula?

<p>Selective visceral angiography with stenting/angioplasty (A)</p> Signup and view all the answers

What is the common risk factor for developing an enterocutaneous fistula?

<p>Surgery (D)</p> Signup and view all the answers

What is the definition of high fistula output?

<p>More than 500 effluent/day (A)</p> Signup and view all the answers

What is the reason for failure of spontaneous healing of fistula?

<p>Epithelial continuity between the gut and the skin (B)</p> Signup and view all the answers

What is the percentage of small bowel enterocutaneous fistulae that develop after surgery with no small bowel resection?

<p>At least 50% (C)</p> Signup and view all the answers

What is the eventual outcome of most fistulae?

<p>They heal spontaneously (D)</p> Signup and view all the answers

What is the recommended timing for implementing anticoagulation in the postoperative period?

<p>Early (C)</p> Signup and view all the answers

What is the usual outcome for elderly patients with chronic small intestinal ischaemia?

<p>Incurable (C)</p> Signup and view all the answers

What is a common symptom of chronic small intestinal ischaemia?

<p>Severe central abdominal pain after eating (A)</p> Signup and view all the answers

Why may abdominal symptoms be overlooked initially in patients with chronic small intestinal ischaemia?

<p>Mistaken for other conditions (B)</p> Signup and view all the answers

What is a possible treatment option for selected cases of chronic small intestinal ischaemia?

<p>Small bowel transplantation (B)</p> Signup and view all the answers

What is the underlying cause of chronic small intestinal ischaemia in most cases?

<p>Atherosclerosis (C)</p> Signup and view all the answers

Why is an early return to theatre to treat the problem unlikely to succeed in a septic, malnourished patient?

<p>The patient's condition is doomed to failure (C)</p> Signup and view all the answers

What is the best way to identify infected collections in patients with enterocutaneous fistulae?

<p>CT scan (A)</p> Signup and view all the answers

Why is skin protection important in patients with enterocutaneous fistulae?

<p>Because small bowel effluent is caustic (B)</p> Signup and view all the answers

What is a key consideration when deciding between enteral and parenteral feeding in patients with enterocutaneous fistulae?

<p>The location of the fistula (B)</p> Signup and view all the answers

What is the goal of a sequence of contrast studies in patients with enterocutaneous fistulae?

<p>To plan a surgical strategy (C)</p> Signup and view all the answers

When should an anastomosis be avoided in patients with enterocutaneous fistulae?

<p>When the patient has continuing intra-abdominal sepsis or is hypoalbuminaemic (B)</p> Signup and view all the answers

Flashcards

Mesenteric Ischemia

A condition where a patient's small intestine doesn't receive enough blood flow, causing severe abdominal pain.

Acute Intestinal Ischemia

A sudden, intense abdominal pain that comes on quickly, often occurring in patients with atrial fibrillation or hardened arteries.

Chronic Mesenteric Vascular Disease

A type of mesenteric ischemia where blood flow is gradually restricted over time, often caused by hardening of the arteries.

Abdominal Pain Out of Proportion

Abdominal pain that is disproportionately intense compared to the physical exam findings, often indicating a serious underlying issue.

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Early Signs of Mesenteric Ischemia

Early signs of mesenteric ischemia, including persistent vomiting and blood in the stool, often accompanied by mild abdominal tenderness.

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Shock in Mesenteric Ischemia

A dangerous condition where the body's blood pressure drops significantly, often a sign of severe mesenteric ischemia.

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Profound Neutrophil Leukocytosis

High levels of white blood cells in the blood, particularly neutrophils, indicating a serious infection or inflammation.

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CT Scan for Mesenteric Ischemia

A medical imaging technique that shows the organs and structures inside the abdomen, often used to diagnose mesenteric ischemia.

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Laparotomy with Embolectomy or SMA Revascularization

Surgical procedures to remove a blockage in the blood vessels of the gut, improving blood flow and relieving ischemia.

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Anticoagulation Postoperatively

Medications that prevent blood clots, often used after surgery for mesenteric ischemia to prevent complications.

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High Mortality Rate

The likelihood of death from mesenteric ischemia, which can be high due to the severity of the condition.

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Resection of Affected Bowel

A surgical process where part of the affected intestine is removed due to severe ischemia, a more common procedure in younger patients.

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Incurable Mesenteric Ischemia

A common outcome in elderly patients with mesenteric ischemia, where the condition is too advanced for curative treatment.

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Intravenous Alimentation

Providing nutrition directly into the bloodstream, often necessary after extensive bowel resection to meet nutritional needs.

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Normal Digestive Function After Resection

The possibility for some younger patients to regain normal digestive function after bowel resection for mesenteric ischemia.

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Chronic Small Intestinal Ischemia

A condition where hardening of the arteries affects the blood vessels supplying the small intestine, causing severe central abdominal pain.

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Mesenteric Angina

Severe abdominal pain that occurs within 30-60 minutes of eating due to chronic small intestinal ischemia.

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Symptoms of Chronic Small Intestinal Ischemia

Symptoms of chronic small intestinal ischemia, including weight loss, diarrhea, and malabsorption, which can lead to misdiagnosis.

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Significant Vascular Disease

A common finding in elderly patients with chronic small intestinal ischemia, reflecting widespread vascular disease.

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Visceral Angiography

A medical imaging technique that uses X-rays to visualize the blood vessels in the abdomen, often used to diagnose chronic small intestinal ischemia.

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Treatment Options for Chronic Small Intestinal Ischemia

Treatment options for chronic small intestinal ischemia, including expanding the narrowed blood vessels or bypassing the blockage.

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Enterocutaneous Fistula

A connection between the small intestine and the skin, most commonly occurring as a complication of surgery.

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Surgical Complications

A common cause of enterocutaneous fistulae, often happening after surgical procedures involving the intestines.

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High-Output Fistulae

Enterocutaneous fistulae that produce a large amount of fluid, exceeding 500 mL per day, leading to significant electrolyte imbalances and dehydration.

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Spontaneous Healing

The possibility for enterocutaneous fistulae to heal on their own, unless hindered by other factors.

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Study Notes

Mesenteric Ischaemia

  • Classified into acute intestinal ischaemia and chronic mesenteric vascular disease.
  • Sudden onset of severe abdominal pain is a key symptom, particularly in patients with atrial fibrillation or atherosclerosis.
  • Pain typically located in the central abdomen; out of proportion to physical exam findings.
  • Persistent vomiting and altered blood in stools are early indicators; mild abdominal tenderness may initially be present.
  • Shock can rapidly develop, showing signs of hypovolaemia and sepsis.
  • Diagnosis usually reveals profound neutrophil leukocytosis; CT scans may show absence of gas in thickened small intestine.
  • Treatment options include laparotomy with embolectomy or SMA revascularization; anticoagulation postoperatively is critical.
  • High mortality rate; resection of affected bowel more common in younger patients, while elderly patients may be deemed incurable.
  • Intravenous alimentation often needed after extensive bowel resection, with some younger patients achieving normal digestive function.

Chronic Small Intestinal Ischaemia

  • Primarily caused by atherosclerosis affecting proximal superior mesenteric and coeliac vessels.
  • Patients experience severe central abdominal pain within 30-60 minutes after eating, known as mesenteric angina.
  • Symptoms can lead to weight loss and diarrhea due to malabsorption; often misdiagnosed as peptic ulcer disease or IBS.
  • Significant vascular disease is common in elderly patients; visceral angiography is used for diagnosis.
  • Treatment typically involves selective visceral angiography with potential stenting or bypass surgery.
  • Smoking cessation and anticoagulation are important components of management.

Enterocutaneous Fistula

  • An abnormal connection between the small intestine and skin; most commonly related to surgical complications.
  • Up to 50% of enterocutaneous fistulae develop post-surgery, primarily from anastomosis leaks or inadvertent enterotomy.
  • More frequent in cases involving adhesion division during abdominal surgery.
  • High-output fistulae (>500 mL effluent/day) can lead to challenging electrolyte imbalances and dehydration.
  • Spontaneous healing is anticipated unless hindered by distal obstruction or abscess formation.
  • Management focuses on nutritional support, fluid replacement, and skin protection due to caustic intestinal effluent.
  • Decisions on enteral versus parenteral feeding depend on fistula output and anatomical considerations.
  • Surgical intervention requires careful planning, especially if intra-abdominal sepsis or hypoalbuminemia is present; definitive treatment is best performed under optimal conditions.

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Diagnosing and managing mesenteric ischaemia, including symptoms, classification, and risk factors. Learn about acute and chronic mesenteric vascular disease.

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