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  • • No embolic or thrombotic cause of vascular obstruction

    • Associated low flow state (sepsis, cardiac dysrhythmia)

    • Severe, diffuse abdominal pain

    • Gross or occult intestinal bleeding

    • Minimal physical findings

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Epidemiology

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  • • In about 25% of patients with intestinal ischemia, vascular occlusion does not involve a major artery or vein (although arterial stenosis is usually present)

    • In the presence of some other acute disease such as a cardiac dysrhythmia or sepsis, splanchnic vasoconstriction occurs, and the intestine becomes ischemic because of low perfusion pressure and flow

    • -Arterial blood is shunted away from the villi in these circumstances, and the ischemic villi are destroyed if the condition persists

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Symptoms and Signs

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  • • Severe, poorly localized abdominal pain that is often out of proportion to physical findings

    • Nausea and vomiting

    • Diarrhea

    • Shock

    • GI bleeding

    • Abdominal distention

    • Abdominal tenderness

    • Peritonitis

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Laboratory Findings

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  • • Leukocytosis

    • Serum amylase is elevated

    • Significant base deficits

    • Increased serum phosphate

    • Anemia

    • Increased serum lactate

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Imaging Findings

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  • Abdominal x-ray

    • -Nonspecific

      -Absence of intestinal gas

      -Diffuse distention with air-fluid levels

    Specific findings occur late: Intramural gas and gas in the portal venous system

    GI contrast radiography: May reveal "thumbprinting" and disordered motility

    CT scan

    • -Diffuse distention with air-fluid levels

      -Intestinal wall thickening

      -Intramural gas and gas in the portal venous system

    Arteriography: Documents the absence of major vascular occlusion but is not otherwise diagnostic in most cases

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  • • The diagnosis is suspected when acute abdominal pain develops in a potentially susceptible patient

    • -Clinical picture is similar to that of arterial thrombosis, but the onset is less often sudden

    • Ischemia is most pronounced on the antimesenteric border, and the mucosa may be extensively involved before abnormalities are visible on the serosal surface

    • -There are often ischemic areas in other organs such as liver and spleen

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Rule Out

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  • • Intestinal ischemia due to embolic or thrombotic processes

    • Acute pancreatitis

    • Intestinal obstruction

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  • • CBC

    • Serum electrolytes

    • Serum amylase

    • Serum lactate

    • ABG measurements

    • Abdominal x-ray

    • CT scan

    • Arteriography

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When to Admit

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  • • All cases

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  • • Resection of all involved gut

    • -A second-look operation is performed 12-24 hours later if marginally viable bowel was left

    • Vascular reconstruction is ineffective

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Surgery

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Indications

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  • • Suspected mesenteric ischemia

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Contraindications

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  • • Necrotic bowel should be resected unless the extent of damage is so great that satisfactory life could not be expected

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Medications

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  • • Massive volume support and antibiotics

    • Intra-arterial infusion of papaverine

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Treatment Monitoring

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  • • A ...

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