acute mesenteric ischaemia -...

ACUTE MESENTERIC

ISCHAEMIA

MAMIEK DWI PUTRO

DEPARTEMEN – SMF BEDAH

FK UNAIR -RSU Dr SUTOMO – SURABAYA

SURABAYA , 11 – 12 MARET 2017

INTRODUCTION

• Acute mesenteric ischaemia ( AMI ) is defined :

- As sudden acute arterial or venous occlusion or

- Drop in circulating pressure resulting in insufficient blood flow within the

mesenteric circulation

• Isolated colonic ischaemia , focal segmental ischaemia secondary to adhesions,

hernia or other form of extrinsic compression are excluded

• AMI account for about 1 : 1000 acute hospital admissions, in Sutomo hospital

only 2 cases in 1 year

Eur J Trauma Emerg Surg ( 2016 ) 42:253 – 270

Laporan mingguan jaga II Dep /SMF Bedah RSDS

ETIOLOGY

Four different aetiological of AMI :

o Arterial embolism mesenteric ischaemia ( EAMI )

o Arterial thrombosis mesenteric ischaemia ( TAMI )

o Venous thrombosis mesenteric ischaemia ( VAMI ) or

Mesenteric venous thrombosis ( MVT )

o Non – occlusive mesenteric ischaemia ( NOMI )

Eur J Trauma Emerg Surg ( 2016 ) 42:253 – 270World J Gastrointest pathophysiol 2016 February 15; 7 (1 ): 125 -130

….....ETIOLOGY

– 70 – 80 % cases of AMI are caused by an arterial emboli or

thrombosis ( EAMI, TAMI , VAMI ) within the ( superior ) mesenteric

artery

– NOMI for about 20 % , usually occurs in patients critically ill,

artificially ventilated, who have undergone the stress of a surgical

procedure , large doses of vasopressor

– AMI will caused mesenteric infarction , intestinal necrosis ,

perforation an overwhelming inflammatory response and death

World J gastroenterol 2013, March 7; 19 ( 9 ) : 1338- 1341

RISK FACTORS

* Eur J Trauma Emerg Surg ( 2016 ) 42:253 - 270

CLINICAL PRESENTATION

– AMI most typical symptom is abdominal pain that is disproportionate to physical examination

finding.

– The pain initially is visceral , diffused, non – localized and moderate to severe, constant

sometimes colicky and occasionally unresponsive to opioid analgesic.

– Examination finding early in the course of disease are limited and non- specific, including

minimal abdominal tenderness

– If ischaemia is attributed to arterial emboli , the pain is severe and abrupt; but if arterial

thrombosis more gradual progression.

– If the ischaemia has progressed transmurally, sign of peritonitis and septicemia are

encountered

– Bowel necrosis, septic shock and death are common complication

World J Gastrointest pathophysiol 2016 February 15; 7 (1 ): 125 -130

DIAGNOSTIC MODALITIES

▪ CLINICAL PRESENTATION :

AMI is rare condition in early stage, symptom and sign are non- specific

▪ LABORATORY FINDING ( are non specific ) :

- complete blood count (leucocytosis )

- metabolic acidosis is a common but non specific disorder

- an elevated D-Dimer, PPT,APTT when MVT occurs

- should be evaluated protein C and S, antithrombin III , anticardiopilin

antibody

- an elevated serum L- lactate


Laboratory finding cannot be used as a marker for AMI because of their insufficient likelihood ratiosL – lactate is associated with late stage mesenteric ishaemiawith extensive transmural infarction,tissue –hypoperfusion,anaerobic metabolism

*World J gastroenterol 2013, March 7; 19 ( 9 ) : 1338- 1341

…....DIAGNOSTIC MODALITIES

▪ IMAGING TECHNIQUES :

- CT Scan , in order to exclude other causes with similar clinical

features,

- CT finding include intra mural ( penumatosis intestinalis), portal vein

gas, focal edematous bowel wall, mesentery edema, abnormal gas

pattern, arterial occlusion may present lack of enhancement of the vessel,

- In MVT ,CT scan demonstrate an enlargement mesenteric or portal vein

with sharp definition of the venous wall and low density within the vessel


…....DIAGNOSTIC MODALITIES

▪ IMAGING TECHNIQUES :….......

- Mesenteric angiography is the gold standard, accurate and increase

survival , however catheter angiography is invasive and time

consuming

- CT angiography (CTA ) less invasive and less time consuming, to day

CTA may be replaced angiography as the gold standard with

sensitivity specificity of 96 % and 94 % respectively


CT SCAN AND CT ANGIOGRAPHY

a. Partially occluding thrombus in the Superior mesenteric vein

b. Normal Mesenteric vein

BA

…...DIAGNOSTIC MODALITY

▪ NEW DIAGNOSTIC STRATEGIES :

❖ RADIOLOGICAL EXAMINATION

- Contrast – enhanced magnetic resonance angiography (CE-MRA), it

is non – invasive and avoids the nephrotoxicity

- A sensitivity and specificity 95 % and 100 % respectively I clinical

trial designed to diagnose severe stenosis or occlusion of the origin

of the celiac axes and superior mesenteric artery

- Non- contrast – enhanced 7 tesla magnetic resonace imaging

( 7T – MRI )allow for the identification of pathological finding of

ischemic colitis and histopathological correlation

- Further research is needed


NEW DIAGNOSTIC STRATEGIES…..

❖ BIOCHEMICAL MARKER :

- In AMI, ischaemia starts at the mucosa and extends toward the

serosa. An ideal biomarker for AMI should originate at the mucosa to

detect ischaemia at the earliest stage

- The biochemical marker are :

• I-FABP : intestinal fatty acid binding protein

• Alpha - GST : alpha – glutathione S transferase

• D- Lactate


INTESTINAL FATTY ACID BINDING PROTEIN

( I-FABP )

– It is small cytosolic protein found in tissue involved in uptake and consumption

of fatty acid

– It is highly expressed in cell on the luminal side of small intestinal villi

– I-FABP released in to circulation and renally cleared upon enterocyte membrane

integrity loss and has been reported as specific ( 90% ) and sensitive marker (

89 % ) for intestinal necrosis

– These findings suggest that further research is needed to confirm the

diagnostic value of I-FABP in case of mesenteric ischemia


ALPHA GLUTATHIONE S TRANSFERASE

( ALPHA – GST )

– A family of cytosolic enzyme in detoxification and release from variety of cell

following cell membrane damage

– It is known to be highly active both in liver and the small intestine mucosa

– It has pooled sensitivity and specificity for diagnosing AMI of 68% and 85 %,

respectively

– A Limitation of alpha – GST is hypotensive patients with multiple organ failure

and hepatic ischaemia may also elevated alpha - GST


D- LACTATE

– Which originated from bacteria such as Escherichia coli in the intestinal lumen

– Hypothesized that D- Lactate level increase during mesenteric ischaemia due to

bacterial translocation and over growth following mucosal injury

– A recent review showed sensitivity and sensitivity for D-Lactate only 0.82 and

0.48 , respectively

– D- Lactate cannot be used a marker for AMI


THERAPEUTIC APPROACH

– AMI high mortality rate indicate the importance of urgent medical treatment

– Intra venous fluid administration ,maintenance of hemodynamic stability and adequate oxygen saturation as well as correction of any electrolyte imbalance and acid / base abnormality

– Vasopressor should be avoided

– Blood product can be provided

– Administration of broad spectrum antibiotic start early

– Nasogastric tube decompression and bladder catheterization

– Pain control is mainly accomplished with opioids


…...THERAPEUTIC APPROACH

NOMI ( non- occlusive acute mesenteric ischaemia ) :

– infusion papaverine through angiography catheter

– Subsequent continuous administration of 30 – 60 mg / h after angiography with

appropriate dose adjustment in accordance with clinical response for at least 24 h

– Caution should be taken , hypotension may occur

– VEGF has been recently thoroughly proposed as a future potential therapeutic

approach


…....THERAPEUTIC APPROACH

EMBOLI – THROMBI

• Infusion of thrombolytic agents ( alteplase, tenecteplase, reteplase) within 8 h

of symptoms onset is recommended for selected patients

• Absolut contraindication for intense thrombolysis are the presence of

peritonitis sign or bowel necrosis

• More over , iv administration of anticoagulants to prevent further extension of

thrombus

• Conversion to oral warfarin with suitable dose adjustment is always indicated

for at least 6 mo


….....THERAPEUTIC APPROACH

MULTIDISCIPLINARY SURGICAL MANAGEMENT

• Surgical treatment of AMI with sign of peritonitis is exploratory laparotomy with

meticulous assessment of bowel viability

• Resection of infarcted intestine is strongly indicated, but for anastomosis

remain controversial

• In addition , intra operative doppler US, iv infusion of fluorescein and bowel

under lamp illumination can differentiate poorly perfused bowel

• A second look operation is strongly suggested


…...THERAPEUTIC APPROACH

• More specific :

o In case of embolic AMI an attempt of reperfusion remains of vital

importance . Embolectomy by tranverse arteriotomy proximal to

occlusion, and then by using Fogarty catheter to extract the clot

o In case of thrombotic occlusion with absence of gangrenous

bowel, revascularization is attempted by aorto - mesenteric

bypass or trans aortic - endarterectomy


ILUSTRASI KASUS

– Wanita 46 th dengan keluhan 1 minggu tidak dapat b.a.b , perut

terasa sebah, dan badan panas

– Riwayat penyakit dulu sirosis hepatis, hipertensi portal dan

splenomegali

– Pemeriksaan fisik abdomen distensi, nyeri tekan kwuadran kanan –

kiri bawah tidak teraba tumor , bising usus tidak terdengar.

– Colok dubur mukosa licin, tidak teraba tumor , tidak nyeri, tidak

terdapat feses , cairan coklat gelap ( pada sarung tangan )

…..ilustrasi kasus

– Periksaan laboratorium :

- Leukosit 24.680

- Hb 7,9 g%

- PLT 303.000

- SGOT 32 u/l dan SGPT 14,3 u/l

- S.Creat 1,08 mg / dl dan BUN 11,0 mg/dl

- Albumin 4g/dl , Glob 2,6 g/dl

- Faal hemostasis dalam batas normal

…..Ilustrasi kasus

USG abdomen

– Hepar normal

– Spleen S III

– Distensi usus kecil

– Ascites

With courtesy prof Soetamto

…...ilustrasi kasus

Foto polos abdomen

– Distensi usus

– Tak tampak gambaran colon

Colon in loop

– Gambaran colon normal

With courtesy prof Soetamto With courtesy prof Soetamto

• Dilakukan punksi ascites : cairan ascites hemorrhagis , analisa sitologis cairan

ascites tidak tampak sel ganas

• Hari ke 5 perawatan perut tambah tegang , tekanan intra abdominal 28 cm H2O

• Diputuskan untuk Explorasi – Laparotomi, didapatkan

- nekrosis ileum sepanjang 15 cm, terletak 100 cm dari ICJ

- thrombosis vena mesenterica superior, cairan ascites >>

- tidak ada perlekatan, jeratan, volvulus, maupun hernia interna

- hepar fibrosis, lien S IV

- dilakukan reseksi usus , reanastomose – stapler

• Direncanakan re-laparotomi on demand


Ileum nekrosis sepanjang 15 cmThrombosis v. mesenterica


With courtesy prof SoetamtoReseksi ileum 20 cmRe- anastomose dengan linier staplerRe- laparotomy on demand



– 4 hari paska laparotomi , perawatan dalam ICU , cairan dari NGT

ke-merahan, abdomen distensi, tekanan intra abdominal 35 cm

H2O

– Diputuskan untuk Re- open ( Re – Laparotomy )

– Didapatkan :

-nekrosis ileum meluas sampai 150 cm distal lig.Trietz

-thrombosis v.mesenterica dan ascites >> kemerahan

• Dilakukan : -Re – reseksi ileum lebih kurang 100 cm

-Ileostomi

-Bogota – bag ( planned re- laparotomy )


– Hari ke tujuh paska operasi kedua , fungsi ileostomi baik,

penderita minum tabl warfarin ( simarc )

– Dilakukan pengangkatan Bogota – bag , tutup primer luka

laparotomi

– Hasil pemeriksaan histo –PA : nekrosis usus , throbomsis

pembuluh darah vena

– Hari ke sebelas paska tutup luka laparotomi , defekasi melalui

ilestomi lancar, konsistensi faeses mulai padat

– Penderita pulang

With courtesy prof Soetamto With courtesy prof Soetamto

Re – open : - ileum nekrosis lebih kurang 100 cmre - reseksi ileum yang nekrosis- ileostomi

Hari kesebelas paska tutup laparotomiLuka operasi tidak tampak infeksidanileostomi berfungsi baik, penderita pulang

CONCLUSION

➢ AMI is rare condition with non- specific clinical presentation

➢ AMI is often diagnosed late or even missed due to low clinical

suspicion , therefore a high mortality rate results

➢ By a marker to identify patients with AMI early would be of great

importance in selecting can candidat for CT angiography

➢ Biochemical marker such as I- FABP and GST still in research

➢ Multidisciplinary team are needed for therapeutic approach

TERIMA KASIH

ATAS

PERHATIANNYA

acute mesenteric ischaemia -...

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