Joseph M Reardon, HMS3 Gillian Lieberman, MD

Mesenteric Ischemia: Silent Killer Joseph M Reardon, HMS3 Gillian Lieberman, MD Beth Israel Deaconess Medical Center Harvard Medical School

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Agenda • • • • • • • • •

Patient Presentation Differential Diagnosis Available Imaging Modalities Relevant Anatomy Radiologic Findings Pathophysiology Related Cases Patient Management & Disposition Take-Home Points 2

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Agenda • • • • • • • • •

Patient Presentation Differential Diagnosis Available Imaging Modalities Relevant Anatomy Radiologic Findings Pathophysiology Related Cases Patient Management & Disposition Take-Home Points 3

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Patient Presentation Hx: 83yo F with 4d of nausea, vomiting, diarrhea. No abdominal pain or fever/chills. Found by EMS unable to get out of bed or take POs PMH: HTN, CKD (baseline Cr 1.7-2), HLD, hypothyroidism, osteoporosis, non-Hodgkin lymphoma s/p radiation therapy in remission since 2001, Hx endometrial cancer Meds: atenolol, levothyroxine, pravastatin SH: Retired radiation researcher; lives with disabled relative for whom she is primary caretaker Exam: Hypotensive to 70s, A&Ox3, conversant, lungs CTAB, RRR, abd soft, NT/ND, no CVA tenderness Labs: WBC 14.1 with L shift, INR 1.5, BUN 26, Cr 2.0, LFTs, Trop 0.08, nl CK-MB, TSH 6.2, Lactate 5.0, ABG 65/27/7.4 4

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Agenda • • • • • • • • •

Patient Presentation Differential Diagnosis Available Imaging Modalities Relevant Anatomy Radiologic Findings Pathophysiology Related Cases Patient Management & Disposition Take-Home Points 5

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Clinical DDx: N/V/D, Hypotension

“V I T A M I N C D”

Vascular Mesenteric ischemia Hypovolemia Autoimmune Embolism IBD MI Allergy Infection/Inflammation Sepsis Metabolic Gastritis DKA Gastroenteritis Pancreatitis Acute Hepatitis Acute Renal Cholecystitis Failure Abscess UTI Perforated ulcer

Trauma Fall

Iatrogenic Congenital Ventral hernia Intestinal volvulus Partial obstruction Adrenocortical / Adhesions insufficiency Neoplastic Recurrent lymphoma Gastric cancer Drugs Colon cancer Pancreatic cancer B-blocker overdose Thyroid storm Hepatic cancer EtOH Carcinoid TSS, Food poisoning (Staph Toxin A) 6

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Agenda • • • • • • • • •

Patient Presentation Differential Diagnosis Available Imaging Modalities Relevant Anatomy Radiologic Findings Pathophysiology Related Cases Patient Management & Disposition Take-Home Points 7

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Imaging Modalities For our patient with N/V/D, BP • CT- abdomen & pelvis with contrast to evaluate for bowel inflammation, perforation, looping, vascular supply (Rating 8) • Ultrasound – RUQ U/S for biliary pathology (Rating 6) • MRI – T1 to assess abnormal fat distribution; T2 to assess for edema, 1st line in pregnant patient (Rating 6) • XR – KUB to evaluate for free air or dilated loops (Rating 5) • Nuclear Medicine – Ga-67 scan to evaluate for sites of metabolic activity (Rating 4) • Invasive – ultrasound-guided fluid drainage, ostomy placement via Seldinger technique Based on: “Acute Abdominal Pain and Fever or Suspected Abdominal Abscess.” ACR Appropriateness Criteria. American College of Radiology, 2008.

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Fu and Imaging Use of Contrast

• Use of IV Contrast in CT: – Contraindicated in chronic renal insufficiency – Contraindicated in acute kidney injury – Weigh risks and benefits

• Concern for renal damage: – Use Visipaque (iodixanol) rather than Optiray (ioversol) – Ensure adequate pre-hydration 9

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Balance of Benefits & Burdens • Renal Damage • Radiation Risk • Cost

• Speed • Information

CT 10

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Agenda • • • • • • • • •

Patient Presentation Differential Diagnosis Available Imaging Modalities Relevant Anatomy Radiologic Findings Pathophysiology Related Cases Patient Management & Disposition Take-Home Points 11

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Anatomy Review Celiac artery

From Gray’s Anatomy http://commons.wikim edia.org/wiki/File:Gray 532.png 12

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Anatomy Review, continued Superior Mesenteric Artery

Inferior Mesenteric Artery

Most tenuous blood supply – Marginal artery of Drummond

From Gray’s Anatomy 13 http://en.wikibooks.org/wiki/File:Gray534.png http://en.wikibooks.org/wiki/File:Gray537.png

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Agenda • • • • • • • • •

Patient Presentation Differential Diagnosis Available Imaging Modalities Relevant Anatomy Radiologic Findings Pathophysiology Related Cases Patient Management & Disposition Take-Home Points 14

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Axial CT (Portal Venous Phase)

*

Axial C+ CT; PACS, BIDMC

NG Tube Fat Stranding Fluid tracking along portal vein Anterior Right Portal Vein obliteration Posterior Right Portal Vein thrombosis Left hydronephrosis Note margin of liver hypoattenuation

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Mesenteric Ischemia on Axial CT

*

Axial C+ CT; PACS, BIDMC

Gallbladder wall edema Bowel wall edema & hyperenhancing mucosa Hydronephrosis * Fat Stranding

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Pelvic Free Fluid on Axial CT

Bowel wall edema Free fluid in pelvis Axial C+ CT; PACS, BIDMC

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Arterial Extravasation on Axial CT

Extravasation from attempted femoral line insertion Axial C+ CT; PACS, BIDMC

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

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• How can

How can we link the patient’s presentation with disease processes?

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Putting Together the Findings Elevated Cardiac Enzymes

? MI Aggressive Resuscitation

Mesenteric Ischemia Underlying Liver Disease

Hypotension Coagulopathy ? Sepsis

? Acalculous Cholecystitis Clinical Findings Contributing Factors

History of Nausea, Vomiting, Diarrhea

? UTI 20

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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• How can

How do the disease processes manifest radiologically?

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Putting Together the Findings (2) Mesenteric Ischemia

Bowel Wall Edema

Contributing Factors Radiologic Findings

Fat Stranding

Bowel Wall Mucosal Enhancement

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Putting Together the Findings (3)

Aggressive Resuscitation

Periportal edema

Contributing Factors Radiologic Findings

? Acalculous Cholecystitis

Gallbladder Wall Edema

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Putting Together the Findings (4)

Hypotension

? Underlying Liver Disease

Coagulopathy

Portal Vein Thrombosis

Clinical Findings Radiologic Findings Contributing Factors

Arterial Extravasation

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Agenda • • • • • • • • •

Patient Presentation Differential Diagnosis Available Imaging Modalities Relevant Anatomy Radiologic Findings Pathophysiology Related Cases Patient Management & Disposition Take-Home Points 25

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

What is Mesenteric Ischemia? • Development – Lack of perfusion to bowel mesentery – Causes: • Infarction – arterial or venous • Embolism • Low-Flow State

• Pathophysiology: – Anoxia  Buildup of metabolites (H+, K+)  Cell death  Necrosis

From Al-Shraim MM, Zafer MH, Rahman GA. Acute occlusive mesenteric ischemia in high altitude of southwestern region of Saudi Arabia. Ann26 Afr Med 2011;1:5-10.

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Presentation of Mesenteric Ischemia • S/Sx: – – – – –

Abdominal pain Vomiting Abdominal distension Fever Melena

• Hx: May have Afib, hypercoagulability • DDx: thromboembolic disease, digitalis toxicity, drug reaction, small bowel obstruction, cecal volvulus, gastroenteritis, compression from tumor, complicated diverticulitis, inflammatory bowel disease, cholecystitis, appendicitis, peptic ulcer disease 27

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Why is Mesenteric Ischemia a Silent Killer?

Mortality Rate (%)

Mortality Rates of Comparable Conditions

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Radiologic Diagnostic Signs • Mucosal hyperenhancement • Bowel wall hypoattenuation (edema) • Bowel wall thickening >3mm

From Macari M, Balthazar, EJ. “CT of Bowel Wall Thickening: Significance and Pitfalls of Interpretation.” Am J Roentgenology. 2001;5:1105-1116.

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Radiologic Diagnostic Signs, Contd • Mesenteric vessel occlusion (+/-) From Johnson PT, Horton KM, Fishman EK. “Nonvascular Mesenteric Disease: Utility of Multidetector CT with 3D Volume Rendering.” RadioGraphics. 2009;29:721-740.

• Mesenteric fat stranding • Ascites

From NYPEmergency.org From meddean.luc.edu

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

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CT Hypotension Complex • “Shock Bowel” – Mucosal enhancement – Submucosal edema – Luminal distension

• Other: – Collapsed vena cava – Adrenal hyperenhancement – Peripancreatic fat stranding – Hypoenhancing spleen 31

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Agenda

• • • • • • • • •

Patient Presentation Differential Diagnosis Available Imaging Modalities Relevant Anatomy Radiologic Findings Pathophysiology Related Cases Patient Management & Disposition Take-Home Points 32

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Comparison Patient • 41yo F with Hx IBS, colitis, HLD, atherosclerosis who presented with LUQ/LLQ pain and leukocytosis • History notable for smoking, obesity, & family history of heart disease • Intermittent flare-ups of acute, diffuse abdominal pain over preceding 3 yrs, associated with loose stools and 35 lb weight loss 33

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Comparison Patient 1 1 month prior to presentation

Stenosed SMA

Occluded Celiac Artery

PACSC+ CT; PACS, BIDMC Axial

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Comparison Patient 1

Portal venous gas Axial C+ CT; PACS, BIDMC

Pneumatosis Coli 35

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Comparison Patient 2 • 78yo F transferred from OSH for 2 days of NB/NB emesis, nonbloody diarrhea, and bilateral lower abdominal pain • WBC 6.9, 77% PMNs • VS on arrival: HR 120 BP 90/52 T99 O2 95% on 1L • Abdominal distention with palpable loop of bowel 36

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Comparison Patient 2

Portal venous gas Aortic calcification Axial CT with PO Contrast; PACS, BIDMC

Bowel wall thickening 37

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Agenda

• • • • • • • • •

Patient Presentation Differential Diagnosis Available Imaging Modalities Relevant Anatomy Radiologic Findings Pathophysiology Related Cases Patient Management & Disposition Take-Home Points 38

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Agenda

• • • • • • • • •

Patient Presentation Differential Diagnosis Available Imaging Modalities Relevant Anatomy Radiologic Findings Pathophysiology Related Cases Patient Management & Disposition Take-Home Points 39

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Management of Mesenteric Ischemia Options: • Emergent Surgery – Bowel Resection

• Stenting • Thrombolysis Prognosis: • 50-90% mortality rate

Julio Murra-Saca, gastrointestinalatlas.com

– Lactate level correlates with mortality 40

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Our Patient

• ~23:00 – Patient calls EMS; hypotensive to 70s; taken to ED • ~23:30 – Patient arrives in ED; lactate of 5.0; central line placed; empiric antibiotics started • 00:10 – Anterior T-wave inversions; Cards consult • 00:30 – Bedside echo suggests decreased cardiac output and possible ischemia  heparinized 41

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Our Patient, Contd • 01:30 – Patient complains of feeling “unwell”, then becomes unresponsive, HR 40s, BP 50s, resuscitated with 1 round of CPR, atropine & Ca, intubated • 02:05 – CT chest/abdomen with contrast shows mesenteric ischemia • ~03:00 – Transfer to MICU • Immediately after transfer, patient develops PEA arrest; CPR resumed • After 10 more minutes of CPR, futility is determined and patient expires.

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Agenda

• • • • • • • • •

Patient Presentation Differential Diagnosis Available Imaging Modalities Relevant Anatomy Radiologic Findings Pathophysiology Related Cases Patient Management & Disposition Take-Home Points 43

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Joseph M Reardon, HMS3 Gillian Lieberman, MD

Pearls

• In patients such as ours, mesenteric ischemia may be a marker of other life-threatening conditions even if it is not the primary cause of death • Mesenteric ischemia can be acute (from hypotension, hypovolemia, embolism) or chronic (from atherosclerosis) • In patient with risk factors, always get abdominal CT with contrast to rule out mesenteric ischemia • Weigh the risks and benefits of IV contrast in patients at risk for renal damage • If mesenteric ischemia is on the differential  must be excluded IMMEDIATELY no matter how remote • Use radiologic findings to guide both prediction of outcome and amenability to therapy • Keep VESSELS on list of organs that could cause pain when examining films. 44

Joseph M Reardon, HMS3 Gillian Lieberman, MD

• • • • • • •

• • • • • •

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References

“Acute Abdominal Pain and Fever or Suspected Abdominal Abscess.” ACR Appropriateness Criteria. American College of Radiology, 2008. Al-Shraim MM, Zafer MH, Rahman GA. Acute occlusive mesenteric ischemia in high altitude of southwestern region of Saudi Arabia. Annals of African Medicine 2011;1:510. Ames JT, Federle, MP. “CT Hypotension Complex (Shock Bowel) is not always due to traumatic hypovolemic shock.” Am J Roentgenology. 2009:192:W230-W235. “Ascites.” Surgery Curriculum, Loyola University-Chicago. http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/Ascites.htm Broder, JS. “Mesenteric Ischemia.” Feature Article CME. EMedHome.com. 2011, Jan 1. Donnan GA, Fisher M, Macleod M, Davis SM. “Stroke.” Lancet 2008;371:1612-1623. Furukawa A, Kansaki S, Naoaki K et al. “CT Diagnosis of Acute Mesenteric Ischemia from Various Causes.” Gastrointestinal Imaging. 2009;192:408-416. Gray’s Anatomy of the Human Body, 20th Edition. Helton WS, Fisichella PM. “Intestinal Obstruction” in ACS Surgery. WebMD. 2004. 4:10. Johnson PT, Horton KM, Fishman EK. “Nonvascular Mesenteric Disease: Utility of Multidetector CT with 3D Volume Rendering.” RadioGraphics. 2009;29:721-740. Kaewlai R, Kurup D, Singh A. “Imaging of Abdomen and Pelvis: Uncommon Acute Pathologies.” Seminars in Roentgenology. 2009;228-236. Levy AD. “Mesenteric Ischemia.” Radiologic Clin N Am. 2007;593-599. Macari M, Balthazar, EJ. “CT of Bowel Wall Thickening: Significance and Pitfalls of Interpretation.” Am J Roentgenology. 2001;5:1105-1116. 45

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References, contd • • •

• • • • •

•

“Mesenteric Panniculitis.” New York – Presbyterian Emergency Medicine. Sept 2008. http://nypemergency.org/radiology/radiology_2008/case-of-the-month-0908.html “Mesenteric Ischemia” in El Salvador Atlas of Gastrointestinal Video Endoscopy. http://www.gastrointestinalatlas.com/English/Jejuno_and_Ileum/Etc__Etc_/etc__etc_.html Mirvis SE, Shanmuganathan K, Erb R. “Diffuse Small-Bowel lschemia in Hypotensive Adults After Blunt Trauma (Shock Bowel): CT Findings and Clinical Significance.” Am J Roentgenology. 1994;163:13751379. Nishijima DK, Su M. “Mesenteric Ischemia in Emergency Medicine.” Medscape eMedicine. http://emedicine.medscape.com/article/758674-overview Oldenburg WA, Lau LL, Rodenberg TJ et al. “Acute Mesenteric Ischemia: A Clinical Review.” Arch Int Med. 2004;164:1054-1062 Reeder MM. “G-69: Mesenteric Vascular Compromise.” in Reeder & Felson’s Gamuts in Radiology. Springer, 2003. Rha SE, H HK, Lee SH, et al. “CT and MR Imaging Findings of Bowel Ischemia from Various Causes.” RadioGraphics. 2000;20:29-42. “Universal differential diagnosis.” Musculoskeletal Radiology, University of Washington. http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/onlinemusculoskeletal-radiology-book/general-principles Zafari AM. “Myocardial Infarction.” Medscape eMedicine. http://emedicine.medscape.com/article/155919-overview 46

Joseph M Reardon, HMS3 Gillian Lieberman, MD

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Acknowledgements • Gillian Lieberman, MD • Mark Masciocchi, MD, PGY1 reviewed the presentation and provided comparison cases • Elizabeth Asch, MD, PGY2 reviewed the presentation and index case • Grant Smith, HMS3; Christian Strong, HMS3; Michael Honigberg, HMS3

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