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?

Sudden and severe, out of proportion to the physical findings Signup and view all the answers

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

Rigidity as a late feature Signup and view all the answers

What is a possible complication of acute mesenteric ischaemia?

Hypovolaemia and sepsis Signup and view all the answers

What is the usual treatment for fistula?

Selective visceral angiography with stenting/angioplasty Signup and view all the answers

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

Surgery Signup and view all the answers

What is the definition of high fistula output?

More than 500 effluent/day Signup and view all the answers

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

Epithelial continuity between the gut and the skin Signup and view all the answers

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

At least 50% Signup and view all the answers

What is the eventual outcome of most fistulae?

They heal spontaneously Signup and view all the answers

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

Early Signup and view all the answers

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

Incurable Signup and view all the answers

What is a common symptom of chronic small intestinal ischaemia?

Severe central abdominal pain after eating Signup and view all the answers

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

Mistaken for other conditions Signup and view all the answers

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

Small bowel transplantation Signup and view all the answers

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

Atherosclerosis 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?

The patient's condition is doomed to failure Signup and view all the answers

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

CT scan Signup and view all the answers

Why is skin protection important in patients with enterocutaneous fistulae?

Because small bowel effluent is caustic Signup and view all the answers

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

The location of the fistula Signup and view all the answers

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

To plan a surgical strategy Signup and view all the answers

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

When the patient has continuing intra-abdominal sepsis or is hypoalbuminaemic Signup and view all the answers

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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Description

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