The Diagnosis of Acute Mesenteric Ischemia: A Systematic Review and Meta-analysis

Cudnik, Michael T.; Darbha, Subrahmanyam; Jones, J B; Macedo, Julian; Stockton, Sherrill W.; Hiestand, Brian

doi:10.1111/acem.12254

Cited by 212 publications

(159 citation statements)

References 83 publications

(181 reference statements)

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“…The first, being that in spite of a thorough history and an abundance of clinical data, the critical piece of data for making the diagnosis of mesenteric ischemia is a contrasted CT scan. A meta-analysis examining the diagnosis of acute mesenteric ischemia found that among all of the data collected when working towards a diagnosis of acute mesenteric ischemia, the CT angiogram was the most important and definitive [3]. Accordingly, it would seem that no argument would be raised regarding the use of contrasted imaging in the evaluation of acute mesenteric ischemia.…”

Section: Discussion and Teachable Momentmentioning

confidence: 99%

A case of abdominal pain and fear of intravenous contrast

M¹,

Pandit²,

Fritz³

2017

Int Med Care

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A 66-year-old male with a past medical history of 50-pack-year tobacco smoking and atrial fibrillation presented to an outside facility with abdominal pain and hematochezia. Of note, he was not taking his home medications of Metoprolol and Coumadin for a few weeks due to lack of insurance. He was found to have lactic acidosis, acute kidney injury, and significant leukocytosis. The patient was transferred to our facility for further evaluation and management.On presentation to our ED, the patient was in atrial fibrillation with a rate of 104. He reaffirmed his story and provided additional history, including chronic symptoms suggestive of claudication. A nonenhanced CT of the abdomen and pelvis was obtained in the ED and revealed mural thickening of a jejunal loop.After evaluation by the vascular surgery service, further contrasted imaging was deferred due to acute renal failure. An ultrasound of the abdominal vessels was performed. The preliminary interpretation was deemed to be inconclusive, and the patient was followed clinically on the medicine service.Over the following 24 hours, the patient developed acute neurovascular changes in the bilateral lower extremities, with total paralysis and sensory changes. Emergent CT angiogram ( Figure 1) showed complete abrupt occlusion of the aorta just above the level of the diaphragmatic crus with non opacification of the abdominal aorta and its branches extending to the iliac arteries and evidence of renal and bowel ischemia. The patient was then taken emergently to the OR for aortic thrombectomy. The extent of his vascular insult was significant, and the patient ultimately passed away. It was only after the events of the surgery that a formal read on the ultrasound revealed that the patient had no blood flow within the aorta and branch vessels. Discussion and teachable momentAcute mesenteric ischemia has persisted as a source of mortality across several decades [1]. The etiology of mesenteric ischemia is commonly associated with cardio-embolic events and native vascular disease. However the cause of ischemia in this case was a massive occlusion of the abdominal aorta, which is unusual [2]. Occlusion of the aorta can be seen in large abdominal aortic aneurysms, and rarely from embolic events.Despite absent aortic flow on ultrasound, our patient did not exhibit symptoms of aortic occlusion for several hours, resulting in a delay of surgical intervention. It was not until CT angiography was performed that assurance of the patient's diagnosis was made and surgical intervention was enacted. We believe our patient suffered a thromboembolic event from a cardiogenic source, given his history of atrial fibrillation without anti-coagulation. However, acute thrombosis is possible, given identified atherosclerosis on imaging, smoking history, and description of chronic symptoms. While a cardiac thrombus would typically go to the brain, a large thrombus, as presumed in this case, could bypass the brachiocephalic arteries and progress through the aorta.Our case highlights several im...

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Section: Discussion and Teachable Momentmentioning

confidence: 99%

A case of abdominal pain and fear of intravenous contrast

M¹,

Pandit²,

Fritz³

2017

Int Med Care

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“…[9] Biphasic contrast CT scanning is the gold standard in the diagnosis of AMI. [10,11] Due to non-specific symptoms and clinical manifestations, accurate diagnosis may be delayed, and this delay may increase the mortality and morbidity rates. In our study, we diagnosed the AMI patients by dynamic CT angiography and we recommended it for all patients suspected for AMI.…”

Section: Discussionmentioning

confidence: 99%

Factors affecting surgical outcomes after superior mesenteric artery thromboembolism

Yüksel¹,

Güçlü²,

Yilmaz³

et al. 2017

Turk Gogus Kalp Dama

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ÖZAmaç: Bu çalışmada, akut mezenterik iskemi nedeniyle ameliyat edilen hastalarda superior mezenterik arter tromboembolisinin ameliyat sonuçları ve mortaliteyi etkileyen faktörler değerlendirildi.Ça lış ma pla nı: Ocak 2011 -Aralık 2016 tarihleri arasında akut mezenterik iskemi tanısı konan ve ameliyat edilen ardışık 28 hasta (15 erkek, 13 kadın; ort. yaş 71.2±10 yıl; dağılım 48-89 yıl) çalışmaya alındı. Açık revaskülarizasyon işlemlerinin sonuçları ve mortaliteyi etkileyen faktörler retrospektif olarak değerlendirildi. Bul gu lar:En sık şikayet karın ağrısını takiben bulantı ve kusma idi. Tanı, bilgisayarlı tomografi anjiyografi ve Dupleks ultrasonografi ile doğrulandı. Hastaların çoğunluğunda tromboembolektomi yapılırken, uygun hastalarda otolog safen ven baypas ve transpozisyon uygulandı. Revaskülarizasyon işlemleri 10 hastada bağırsak rezeksiyonunu engelledi. Solunum, böbrek ve kalp patolojilerine bağlı mortalite oranı %35.7 idi. Ameliyat sonrası solunum yetmezliği ve karın ağrısı başlangıcından sonra altı saatten daha geç hastaneye başvuru, mortaliteyi etkileyen faktörler olarak bulundu.So nuç: Çalışma sonuçlarımız ameliyat sonrası solunum yetmezliği ve karın ağrısı başlangıcından sonra geç başvurunun ameliyat sonrası mortalite ile ilişkili olduğunu gösterirken, bağırsak rezeksiyon gereksiniminin mortalite oranlarına bir etkisi gözlenmedi. Çalışma sonuçlarımıza göre, keşif amaçlı laparotomi ve tromboembolektominin, bağırsak canlılığını değerlendirmede ve mezenterik perfüzyonun devamında önemli olduğu kanısındayız.Anah tar söz cük ler: Embolektomi; mezenterik iskemi; superior mezenterik arter. ABSTRACT Background:In this study, we aimed to evaluate the operative results of superior mesenteric artery thromboembolism and influential factors for mortality in patients undergoing surgery for acute mesenteric ischemia.

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“…2 The overall operative mortality rate is roughly 50% 2 and varies depending on such factors as the extent of gangrene, length of resection and reversibility of the ischemia.…”

Section: Mortality Rates Are High Even With Appropriate Managementmentioning

confidence: 99%

“…1 In stable patients in whom clinical suspicion is high, computed tomography angiography is usually the most appropriate diagnostic test, with a sensitivity and specificity close to 95%. 2 However, in patients with peritoneal findings, the diagnosis is usually made with diagnostic laparoscopy 3 or laparotomy. 4 CMAJ invites submissions to "Five things to know about …" Submit manuscripts online at http://mc.manuscriptcentral .…”

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confidence: 99%