Vascular Disease of the GI Tract

superior, inferior

Arterial Supply

• ____________ mesenteric artery

  • All small intestine (except proximal duodenum)

  • Part of the colon

• __________ mesenteric artery

  • Part of the colon and rectum

sepsis, small, arterial, venous, large

Intestinal Ischemia

• Can be caused by any process that reduces intestinal blood flow

• Rapid diagnosis necessary because it can lead to ________, bowel infarction, and _______

• Classification

  • Mesenteric Ischemia (______ intestine)

    • Acute

      • __________ → occlusive vs nonocclusive

      • ___________ → thrombosis

    • Chronic

  • Colonic ischemia/ischemic colitis (_________ intestine)

hypoperfusion, thrombus, superior, jejunum, atherosclerosis, infection

Acute Mesenteric Ischemia (Arterial-Occlusive)

• Sudden, small intestine ______________

• Etiology

  • Embolism (50%)

    • Dislodged _____________ from left atrium, left ventricle, cardiac valves, proximal aorta

    • _____________ mesenteric artery; middle segment of ___________ most affected

  • Thrombosis (15-25%)

    • _______________ most common

    • Abdominal trauma or ___________

arrhythmias, valvular, endocarditis, MI, atherosclerosis, age, cardiac, trauma, smoking, DM

Acute Mesenteric Ischemia (Arterial-Occlusive)

• Risk Factors for Embolism

  • Cardiac _________________

  • Cardiac ____________ disease

  • Infective _____________

  • Recent __

  • Ventricular aneurysm

  • Aortic ______________

  • Aortic aneurysm

• Risk Factors for Thrombotic Occlusion

  • PAD

  • Advanced ___

  • Low _________ output states

  • Abdominal _________

• Hx of _________, HTN, hyperlipidemia, __

pain, proportion, evacuation, bloody, shock, bacteria

Acute Mesenteric Ischemia (Arterial-Occlusive) Symptoms

• Severe abdominal ____ out of ____________ to the PE

• ± N/V

• Urgent bowel _____________ (initially)

• ________ stools, fever, ______ (if advanced ischemia)

• __________ invasion of necrotic tissue

CT, CT angiography, Plain, perforated, laparotomy

Acute Mesenteric Ischemia (Arterial-Occlusive) Diagnosis

• __ with IV contrast

  • R/o other causes of abd pain

  • Can show mesenteric ischemia

• __ ____________ (study of choice)

  • Gives definitive dx

  • Differentiates between embolic vs thrombotic

• _______ films

  • usually done first if pt is unstable

  • Look for free air (__________ bowel) or signs of advanced ischemia

• ____________

  • If pt is unstable or plain films/H&P indicate a complication

NPO, unfractionated heparin, antibiotics, pain, embolectomy, bypass, antiplatelet

Acute Mesenteric Ischemia (Arterial-Occlusive) Treatment

• Initial

  • Make ___

  • Oxygen

  • Fluids

  • Anticoagulation (_____________ __________)

  • Empiric _________

  • _____ control

• Embolism

  • Surgical ____________ (1st line)

  • Endovascular techniques (alternatives)

    • Mechanical thrombectomy and catheter directed thrombolytic therapy

• Thrombus

  • Mesenteric __________ (1st line)

  • Endovascular techniques (alternative)

    • Balloon angioplasty with stent placement

• Anticoagulation with or w/o __________ therapy will resolve the thrombus and surgical intervention not needed

arterial, heart, aortic, shock, arrhythmias, vasoconstrictive

Acute Mesenteric Ischemia (Arterial-Nonocclusive)

• Nonocclusive reduction of __________ blood flow

• Risk Factors

  • ________ failure

  • PAD

  • _________ insufficiency

  • ______ (hypovolemic, cardiogenic, septic)

  • Cardiac _____________

  • ______________ meds (digoxin, alpha-adrenergic agonists)

  • Cocaine/methamphetamine abuse

  • Dialysis

gradually, bloating, ill, CV, perfusion, arteriography, angiography

Acute Mesenteric Ischemia (Arterial-Nonocclusive)

• Symptoms

  • Mild abdominal pain that __________ progresses

  • ___________ sensation

  • N/V

  • Usually very ___ with severe __ disease and receiving drugs know to reduce intestinal______________

• Diagnosis

  • Mesenteric _____________ and/or CT/MR _____________

    • Narrowing or spasm of mesenteric arteries

vasoconstrictive, sepsis, hemodynamic, vasodilators,exploration

Acute Mesenteric Ischemia (Arterial-Nonocclusive) Treatment

• Remove inciting factors (____________ meds)

• Treat underlying causes (HF, ________, etc)

• _______________ support/monitoring

• Intra-arterial infusion of ____________ (rarely done)

  • Papaverine, prostaglandins, nitroglycerin

• If peritoneal signs: abdominal ______________ and possible surgery

superior, small, compression, inflammation, portal, thrombophilia, inherited, bowel

Acute Mesenteric Ischemia (Venous Thrombosis)

• __________ mesenteric venous system most affected (involving distal _______ intestine)

• Risk Factors

  • Abdominal mass (venous ____________)

  • Abdominal _____________ (pancreatitis, diverticulitis, etc)

  • ________ HTN and cirrhosis (increases portal venous pressure)

  • Acquired _____________ (malignancy, oral contraceptives)

  • ________ thrombophilia (Factor V Leiden, etc)

  • Inflammatory _______ disease

perfusion, resistance, decreased, lumen, edema, hypovolemia, arterial, ischemia, infarction

Acute Mesenteric Ischemia (Venous Thrombosis) Pathophysiology

• Venous thrombosis → reduced ____________ pressure d/t increased venous ___________ → _____________ blood flow → efflux of fluid into the intestinal _______ and bowel wall ________ → _____________ and systemic hypotension → decreased __________ flow → exacerbated ___________ → all possibly leading to bowel ___________

colicky, distention, peritonitis, slowly, nonspecific, incidental

Acute Mesenteric Ischemia (Venous Thrombosis) Symptoms

• Acute

  • Dull, ________, periumbilical abdominal pain

  • Possible abdominal __________ and occult blood in stool

  • Signs of ___________ (advanced ischemia)

• Subacute

  • Progresses ________ (develop sx over days to weeks)

  • ____________ abd pain

• Chronic

  • Usually __________ finding (asymptomatic)

CT, screening, venography, second, heparin, LMWH, anticoagulation, bowel, surgery

Acute Mesenteric Ischemia (Venous Thrombosis) 

• Diagnosis

  • __ with and w/o oral and IV contrast (initial_______)

  • CT or MR __________ (best imaging but typically _______ line)

• Treatment

  • Typically conservative

    • Anticoagulation (mainstay)

      • Hospitalized → unfractionated ________ or ____

      • Outpatient → oral ___________

    • IV fluids, _______ rest, serial observations

  • __________ limited to those suspected to have bowel infarction

hypoperfusion, small, atherosclerotic, superior, asymptomatic, episodic, postprandial, loss, mesenteric

Chronic Mesenteric Ischemia (Intestinal Angina)

• Episodic or constant, incomplete __________ of the _____ intestine

• Etiology

  • _____________ narrowing of celiac or ___________ mesenteric arteries (majority)

  • Median arcuate ligament syndrome, fibromuscular dysplasia, aortic or mesenteric artery dissection, vasculitis

• Symptoms

  • Can be ____________

  • __________, dull, crampy, __________ abdominal pain

    • Starts within 1 hr of eating and resolves w/in 2 hrs after eating

  • Weight ____

  • Can lead to acute ___________ ischemia (acute or chronic)

angiography, duplex, preventative, atherosclerotic, revascularization

Chronic Mesenteric Ischemia (Intestinal Angina)

• Diagnosis

  • CT ____________ (1st line)

    • High grade stenosis or occlusion of >2 mesenteric vessels

  • _________ US

• Treatment

  • Asymptomatic (incidental finding)

    • _____________ measures to limit progression of _____________ disease

  • Symptomatic

    • ______________ (open or endovascular) → percutaneous transluminal angioplasty with or w/o stent placement, bypass grafting, endarterectomy

intestinal, >, AAA, bypass, hereditary, constipation, exercise

Colonic Ischemia (Ischemic Colitis)

• Most frequent form of ____________ ischemia

• Epidemiology

  • Older/elderly adults

  • Female _ Male

• Risk Factors

  • Aortoiliac instrumentation/surgery (ie repair of ___)

  • Cardiopulmonary _________

  • MI

  • Hemodialysis

  • Acquired or ___________ thrombophilia

  • Medications/drugs (___________ inducing drugs, immunomodulators, illicit drugs)

  • Extreme _________

nonocclusive, arterial, mesenteric, watershed, collateral, splenic, rectosigmoid, rapid, left, defecate

Colonic Ischemia

• Pathophysiology

  • 3 Mechanisms

    • __________ Ischemia (most common)

    • Embolic and thrombotic __________ occlusion

    • ___________ vein thrombosis

  • “_________” areas most affected

    • d/t limited ____________ blood flow

    • _________ flexure and _____________ junction

• Symptoms

  • _______ onset of mild, crampy abdominal pain and tenderness

    • Usually _____ sided

  • Hematochezia

  • Urgent desire to ___________

CT, thumbprinting, colonoscopy, supportive, antibiotics, antithrombotic, exploration, colectomy

Colonic Ischemia

• Diagnosis

  • __ with oral and IV contrast (1st line)

    • Segmental wall edema, “____________”

  • ___________ can also confirm

• Treatment

  • Mild → no risk factors, no s/s indicating exploration

    • ___________ care (bowel rest/NPO, fluids, observation)

  • Moderate → up to 3 risk factors, no s/s indicating exploration

    • Supportive care plus ___________ and possibly _____________ therapy

  • Severe → > 3 risk factors and/or indications for exploration

    • Abdominal ___________ and possible surgery (__________)