Acute Mesenteric Ischemia

A selective anticoagulation policy for splanchnic vein thrombosis in acute pancreatitis is associated with favourable outcomes: experience from a UK tertiary referral centre

INTRODUCTION

There is a paucity of data on the incidence, risk factors, and treatment of splanchnic vein thrombosis (SVT) in acute pancreatitis (AP).

METHODS

All AP admissions between 2018 and 2021 across North East of England were included. Anticoagulation was considered in the presence of superior mesenteric vein/portal vein (SMV/PV) thrombus or progressive splenic vein thrombus (SpVT). The impact of such a selective anticoagulation policy, on vein recanalisation rates and bleeding complications were explored.

RESULTS

401 patients (median age 58) were admitted with AP. 109 patients (27.2%) developed SVT. The splenic vein in isolation was the most common site (n = 46) followed by SMV/PV (n = 36) and combined SMV/PV and SpVT (n = 27). On multivariate logistic regression alcohol aetiology (OR 2.64, 95% CI [1.43-5.01]) and >50% necrosis of the pancreas (OR 14.6, 95% CI [1.43-383.9]) increased the risk of developing SVT. The rate of recanalization with anticoagulation was higher for PVT (66.7%; 42/63) than in SpVT (2/11; p = 0.003). 5/74 of anticoagulated patients developed bleeding complications while 0/35 patients not anticoagulated had bleeding complications (p = 0.4).

CONCLUSION

The risk of SVT increases with AP severity and with extent of pancreatic necrosis. A selective anticoagulation policy for PVT and progressive SpVT in AP is associated with favourable outcomes with no increased risk of bleeding complications.

Splanchnic Vein Thrombosis in Acute Pancreatitis and Its Consequences

Splanchnic vein thrombosis (SVT) is a serious vascular complication that can occur in patients with acute pancreatitis. We assessed the incidence of SVT and its relationship with acute pancreatitis (AP) and associated complications. We carried out a retrospective analysis of medical histories from patients hospitalized with AP in a single surgical center. Histories were acquired from patients with abdominal and pelvic computed tomography scans performed between the 2nd and 3rd day of hospitalization. We assessed the impact and extent of thrombosis over the disease course. We found a strong positive correlation (Cramer’s V coefficient = 0.34) between SVT and disease severity. Mortality in the study group was 7.2% (8 patients) of which 5 patients (62.5%) were diagnosed with SVT. We observed an increased incidence of death among patients with thrombosis, with results approaching significance (P = 0.056). In our study, we found that SVT has a negative effect on the course of AP and is associated with more severe disease and increased mortality.

Anticoagulant therapy in the treatment of splanchnic vein thrombosis associated to acute pancreatitis: a 3-year single-centre experience

Splanchnic vein thrombosis (SVT) is a possible complication of acute pancreatitis (AP). There are no precise guidelines on the use of anticoagulant therapy (AT) in these patients. The aim of the study was to determine the safety and the efficacy of AT in AP-associated SVT. Two hundred twenty-one patients were retrospectively and consecutively enrolled from the Pancreatic Outpatient Clinic of the "A. Gemelli" hospital. Patients had a diagnosis of AP and a diagnostic imaging to evaluate whether they had or not SVT. Twenty-seven out of 221 AP patients had SVT (12.21%) and AT therapy was administered to 16 patients (59.3%), for 5.2 ± 2.2 months. A therapeutic dose of low molecular weight heparin was administered (100 UI/kg b.i.d.) at the diagnosis, with fondaparinux 7.5 mg/day, or vitamin K antagonist, or the novel direct oral anti-coagulants, upon discharge. The presence of SVT resulted significantly associated to male sex (p = 0.002). The recanalization rates were 11/16 (68.7%) in patients who received AT, and 3/11 (27.3%) in patients who did not receive it. There was a significant difference between the recanalization rates with and without AT (p = 0.03, OR 5.87). No SVT recurrence was registered during follow-up. No treated patient developed haemorrhagic complications after AT. No deaths were recorded, either in the group undergoing AT or in the one that was not. In conclusion, AT in AP-associated SVT appears to be safe and effective; yet prospective clinical trials are needed to confirm our results.

Vascular Calcifications are Associated with Increased Mortality in Patients with Acute Mesenteric Ischemia

BACKGROUND

Vascular calcifications have been identified as predictors of mortality in several cardiovascular diseases but have not been investigated in context of acute mesenteric ischemia. The aim of this study was to investigate the impact of vascular calcifications in patients with acute mesenteric ischemia.

METHODS

Patients admitted for an acute mesenteric ischemia were retrospectively included. The presence of calcifications in the visceral aorta, the celiac trunk, the superior mesenteric artery, and the renal arteries was assessed on computed tomography scan images at the arterial phase. The calcification volumes were measured using the software Aquarius iNtuition Edition®.

RESULTS

The all-cause mortality was 55 out of 86 patients (63.9%) for a median follow-up of 3.5 days (1-243). The survival rate of patients with calcification in the superior mesenteric artery was significantly lower than that of those without calcification (22% vs. 55.6%, P = 0.019). Patients who died had significantly a higher frequency of calcifications in the superior mesenteric artery, the visceral aorta, the celiac trunk, and the renal arteries.

CONCLUSIONS

The presence of vascular calcifications in the superior mesenteric artery is associated with increased mortality in patients diagnosed with acute mesenteric ischemia. Further studies are required to identify the mechanisms underlying this association.

Colon Perfusion Patterns During Colorectal Resection Using Visible Light Spectroscopy

BACKGROUND

The impact of blood supply to the anastomosis on development of anastomotic leakage is still a matter of debate. Considering that bowel perfusion may be affected by manipulation during surgery, perfusion assessment of the anastomosis alone may be of limited value. We propose perfusion assessment at different time points during surgery to explore the dynamics of bowel perfusion during colorectal resection and its impact on outcome.

METHODS

In this prospective cohort study, patients undergoing elective colorectal resection were eligible. Colon perfusion was evaluated using visible light spectroscopy. Main outcome was the difference in colon perfusion, quantified by measuring tissue oxygen saturation (StO₂) in the colonic serosa, before and after anastomosis during surgery.

RESULTS

We included 58 patients between July 2013 and November 2015. Colon perfusion increased by an average of 5.9% StO₂ during surgery (95% confidence interval 3.1, 8.8; P < 0.001). The number of patients with abnormal perfusion (defined as StO₂ < 65%) decreased from 50% at the beginning to 24% by the end of surgery. Six patients (10%) developed anastomotic leaks (AL), of which five patients had abnormal perfusion at the beginning of surgery, whereas four patients had normal StO₂ at the anastomosis.

CONCLUSION

Colon perfusion significantly increased during colorectal surgery. Considering that one quarter of patients had suboptimal anastomotic perfusion without developing AL, impaired blood flow at the anastomosis alone does not seem to be critical. Further investigations including more patients are necessary to evaluate the impact of perioperative parameters on colon perfusion, anastomotic healing and surgical outcome.

Paralytic Ileus due to Superior Mesenteric Venous Thrombosis after Transarterial Injection for Hepatocellular Carcinoma

A 69-year-old man was admitted to hospital with abdominal pain. In the four years prior to his presentation, he had undergone repeated transarterial chemoembolizations and injections for hepatocellular carcinoma. He underwent his 8th transcatheter arterial therapy one month prior to admission. Abdominal X-rays and contrast-enhanced computed tomography showed large amounts of small intestinal gas and venous thrombosis from the portal vein to the superior mesenteric vein, respectively. The thrombosis was reduced after anticoagulation therapy (heparin, antithrombin III, danaparoid sodium and warfarin). This is the first case report of paralytic ileus due to superior mesenteric venous thrombosis after transcatheter arterial therapy for hepatocellular carcinoma with an arterioportal shunt.

Surgery for ischemic colitis: outcome and risk factors for in-hospital mortality

PURPOSE

Surgery for ischemic colitis is associated with high perioperative morbidity and mortality, but the risk factors for mortality and major surgical complications are unclear.

METHODS

In this retrospective single institution cohort study of all patients undergoing colorectal surgery for histologically proven ischemic colitis between 2004 and 2010, we evaluated surgical outcomes and risk factors for in-hospital mortality and major surgical complications.

RESULTS

For the 100 patients included in the study, in-hospital mortality was 54 %; major surgical complications, defined as anastomotic leakage or rectal stump and stoma complications, occurred in 16 %. In the multivariable analysis, hospital death was more likely in patients with right-sided (odds ratio [OR] 3.8; 95 % confidence interval [CI] 1.2, 12; P = 0.022) or pan-colonic ischemia (OR 11; 95 % CI 2.8, 39; P < 0.001), both relative to left-sided ischemia. Decreased preoperative pH level (OR 2.5 per 0.1 decrease; 95 % CI 1.5, 4.1; P < 0.001) and prior cardiac or aortic surgery (OR 2.4; 95 % CI 0.82, 6.8; P = 0.109) were further important risk factors for in-hospital mortality. Major postoperative surgical complications were more likely in patients with ischemic alterations at the resection margin of the histological specimen (OR 3.7; 95 % CI 1.2, 11; P = 0.022).

CONCLUSIONS

Colonic resection for ischemic colitis is associated with high in-hospital mortality, especially in patients with right-sided or pan-colonic ischemia. In patients developing acidosis, early laparotomy is essential. Since resection margins' affection seems to be underestimated upon surgery, resections should be performed wide enough within healthy tissue.

Risk factors effecting mortality in acute mesenteric ischemia and mortality rates: a single center experience

The objective of this study is to discuss the effective factors on morbidity and mortality in patients who were operated on for acute mesenteric ischemia. Between 2006 and 2011, 95 patients, who underwent emergent surgery for acute mesenteric ischemia, were analyzed retrospectively. The study group consisted of 56 men (58.9%) and 39 women (41.1%), with an average age of 68.4 ± 14.4 years. Elapsed time between the onset of the symptoms and the surgical operation was less than 24 hours in 47 (49.5%) cases, and more than 24 hours in 48 cases (50.5%) (P < 0.001). Although all of the patients had intestinal necroses, colon involvement was seen in 38 patients, and mortality was higher in this group of patients (P < 0.001). Mortality rate was 42.1%. This was higher in older patients, those with increased leukocyte levels, increased elapsed time to laparotomy, and when the colon was involved.

Ischemic bowel syndromes

Atherosclerotic vascular disease involving the mesenteric arteries occurs frequently in the elderly population. Although the prevalence of ischemic bowel disease is difficult to determine, acute mesenteric ischemia (AMI) has been reported to cause in 1 in 1000 hospital admissions, whereas chronic mesenteric ischemia (CMI) is estimated to affect 1 in 100,000 individuals. Mesenteric ischemia generally manifests in its chronic form as postprandial abdominal pain resulting in significant weight loss, and in its acute form as an abrupt development of abdominal pain, lower gastrointestinal bleeding, and subsequent intestinal necrosis. This article discusses the cause, clinical manifestations, diagnosis, and management of AMI and CMI.

Splanchnic vein thrombosis in severe acute pancreatitis: a 2-year, single-institution experience

OBJECTIVES

This study aimed to determine current practice in the management and outcome of splanchnic vein thrombosis complicating acute pancreatitis (AP).

METHODS

An audit of prospectively collected data for all patients presenting with AP was conducted. Patients with splanchnic vein thrombosis were grouped according to vessel involvement and whether or not systemic anticoagulation was administered.

RESULTS

Of 127 consecutive patients admitted with AP, 20 had splanchnic venous thrombosis; in all cases the thrombosis was associated with a severe attack of AP. Involvement of the splenic vein (SV), portal vein (PV) and superior mesenteric vein (SMV) was observed in 14, 10 and three patients, respectively. Involvement of more than one vessel was observed in six patients (SV and PV in four patients; SMV and SV in one patient; all three veins in one patient). Thromboses were colocalized with collections in 19 patients. Only four patients received systemic anticoagulation. Resolution of thrombosis was observed in six patients over a median of 77 days. No significant differences were observed in recanalization rates following anticoagulation (P= 0.076). No complications associated with systemic anticoagulation occurred. One patient developed liver failure associated with progressive PV thrombosis and one patient died.

CONCLUSIONS

Splanchnic vein thrombosis is a relatively common observation in severe AP and is associated with pancreatic necrosis and peripancreatic collections. Recanalization is observed in almost a third of patients, irrespective of whether or not they receive systemic anticoagulation.

Chronic superior mesenteric venous thrombosis revealed by diabetic ketonuria and bacteremia

We report a patient with superior mesenteric venous thrombosis presenting as diabetic ketonuria and bacteremia. The patient was a 65-year-old man with a history of diabetes mellitus, and was admitted to our hospital due to high fever. Tests revealed diabetic ketonuria and Bacteroides fragilis bacteremia. Abdominal computed tomographic scan and Doppler sonography revealed an old thrombus in the superior mesenteric vein with good flow through collateral vessels, causing the patient to have an absence of abdominal symptoms. There was no evidence of hereditary thrombophilia. The thrombus was secondary to a combination of comorbidities, including dehydration, hyperosmolarity, and diabetes mellitus.

Colonic ischemia: an under-recognized cause of lower gastrointestinal bleeding

We described signs and symptoms of patients who present to an Emergency Department (ED) with intestinal ischemia and compare clinical course and outcomes of patients with mesenteric vs. colonic ischemia. We retrospectively reviewed charts of 100 patients discharged from our hospital with an ICD-9 code for mesenteric or intestinal ischemia. Compared to patients with mesenteric ischemia, those with colonic ischemia were older (61 vs. 77 years, respectively; p = 0.002), were more likely to present with gastrointestinal (GI) bleeding (11 vs. 90%, respectively; p < 0.001), but were less likely to report abdominal pain as their primary complaint (89% vs. 10%, respectively; p < 0.001) or to receive a correct ED diagnosis (75% vs. 9%, respectively; p < 0.001). Patients with colonic ischemia frequently presented with gross GI bleeding, and were often misdiagnosed in the ED. For timely treatment of a potentially serious condition, the diagnosis of intestinal ischemia should be considered in ED patients presenting with GI bleeding and appropriate risk factors.

Acute bowel ischemia: CT findings

Acute bowel ischemia represents one of the most dramatic abdominal emergencies and, despite the fact it is more and more frequently observed in clinical practice, its mortality rate remains very high. In recent years Computed Tomography (CT) has proved to be a valid diagnostic tool in the evaluation of patients with acute abdominal syndrome and in the visualization of early signs of bowel ischemia. This paper reviews the aetiological and pathophysiological aspects as well as a broad spectrum of CT findings of this clinical condition.

Abdominal surgical emergencies in the elderly

The evaluation of abdominal pain can be considerably more challenging in elderly patients. A higher likelihood of life-threatening pathology combined with a myriad of diagnostic pitfalls in this population mandate a more cautious approach with greater use of diagnostic resources and specialist consultation.

Intensive care unit management of intra-abdominal infection

OBJECTIVE

To review the biologic characteristics of, and management approaches to, intra-abdominal infection in the critically ill patient.

DESIGN

Narrative review.

SETTING

Medline review focussed on intra-abdominal infection in the critically ill patient.

PATIENTS AND SUBJECTS

Restricted to studies involving human subjects.

INTERVENTIONS

None.

RESULTS

Intra-abdominal infections are an important cause of morbidity and mortality in the intensive care unit (ICU). Peritonitis can be classified as primary, secondary, or tertiary, the unique pathologic features reflecting the complex nature of the endogenous gut flora and the gut-associated immune system, and the alterations of these that occur in critical illness. Outcome is dependent on timely and accurate diagnosis, vigorous resuscitation and antibiotic support, and decisive implementation of optimal source control measures, specifically the drainage of abscesses and collections of infected fluid, the debridement of necrotic infected tissue, and the use of definitive measures to prevent further contamination and to restore anatomy and function.

CONCLUSIONS

Optimal management of intra-abdominal infection in the critically ill patient is based on the synthesis of evidence, an understanding of biologic principles, and clinical experience. An algorithm outlining a clinical approach to the ICU patient with complex intra-abdominal infection is presented.

Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia

Major breakthroughs in catheter, guidewire, and other angiographic equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. Similarly, the interventional radiologist can treat acute intestinal ischemia safely and effectively with selective catheterization and papaverine administration and treat chronic mesenteric ischemia by percutaneous angioplasty and stent placement. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is critical in managing GI bleeding and intestinal ischemia, particularly in patients at high risk or presenting as diagnostic dilemmas.

Mesenteric arterial occlusive and aneurysmal disease

Mesenteric arterial diseases are a heterogeneic group of clinically significant illnesses that have become recognized with increasing frequency because of the more common imaging of the intestinal circulation when studying both vascular and nonvascular diseases of the abdomen. Considerable knowledge exists regarding some of these diseases, whereas the understanding of others is anecdotal. It is important for clinicians to recognize differences among common ischemic diseases and common splanchnic aneurysms.

Acute gastrointestinal bleeding in the intensive care unit. The gastroenterologist's perspective

Although SRES-associated hemorrhage previously constituted a significant cause of bleeding in the ICU, improvements in ICU management and the institution of prophylactic measures in high-risk patients have significantly reduced SRES-associated hemorrhage since the 1980s. Antacids, H2-receptor antagonists, and sucralfate have been shown to be effective in preventing clinically significant bleeding resulting from SRES, particularly when the intragastric pH is maintained at greater than 4. A selective approach should be adopted in SRES prophylaxis: Patients on mechanical ventilation, with coagulopathy, or with two of the other known risk factors should receive prophylaxis. Although the drug of choice depends to some extent on local preferences, an H2-receptor antagonist by continuous intravenous infusion may represent the best option. No pharmacologic therapy is of proven value once hemorrhage begins, but the current interventional techniques are effective in controlling hemorrhage. Gastrointestinal bleeding from NOMV has become less common with improvements in the hemodynamic monitoring of critically ill patients, but this disease must always be considered when lower gastrointestinal bleeding occurs in the context of relative hypoperfusion. For SRES and NOMV, treatment of the underlying disease or diseases is the optimal route to prevention.

[Severe digestive complications after heart surgery using extracorporeal circulation]

PURPOSE

To determine the incidence, circumstances of occurrence and evolution of gastrointestinal complications after cardiac surgery with extracorporeal circulation (ECC).

METHODS

Retrospective chart study of gastrointestinal complications in 6.281 patients undergoing ECC between january 1994 and December 1997.

RESULTS

Sixty patients developed 68 gastrointestinal complications (1%). Complications included: upper gastrointestinal bleeding (n = 23), intestinal ischemia (n = 19), cholecystitis (n = 7), pancreatitis (n = 6), and paralytic ileus (n = 16). The incidence of these complications was low after coronary artery (0.4%) or valvular surgery (0.8%) and high after cardiac transplantation (6%) and after surgery for acute aortic dissection (9%). Compared with a control population, patients with gastrointestinal complication had a higher Parsonnet score (29 +/- 15 vs 13 +/- 12 points; P = 0.002), were more frequently operated upon as an emergency (40/60, 66% vs 1120/6221, 18%; P = 0.01), underwent ECC of longer duration (114 +/- 66 vs 74 +/- 42 min; P = 0.01), and presented more frequently with low cardiac output after surgery (45/60, 75% vs 435/6221, 7%; P = 0.001). The mortality rate after gastrointestinal complications was 52%. The major factor associated with mortality was the occurrence of sepsis (OR = 38.7). Other factors were: renal failure (OR = 7.9), age > 75 yr (OR = 3.5), mechanical ventilation for more than seven days (OR = 2.7), associated cerebral damage (OR = 3.9).

CONCLUSION

Gastrointestinal complications after ECC occur in high risk surgical patients. These complications are frequently associated with other complications leading to a high mortality rate.

Intestinal (mesenteric) vasculopathy. I. Acute superior mesenteric arteriopathy and venopathy

Intestinal vasculopathy is not rare, comprising about 1 per 1000 hospital admissions. Primary mesenteric vasculopathy causes cardiovascular disease, whereas secondary mesenteric ischemia causes extrinsic vascular compression or vascular trauma. Acute superior mesenteric arteriopathy is caused by a mesenteric embolus, thrombus, or vasospasm (i.e., nonocclusive vasculopathy). Acute superior mesenteric venopathy is caused by a thrombus, which is often associated with a hypercoagulopathy. The clinical presentation of both diseases is often subtle and nonspecific at an early stage and becomes overt and specific only when advanced and severe, when ischemia progresses to necrosis. The mortality of acute superior mesenteric arteriopathy is still very high, whereas superior mesenteric venopathy is less rapidly progressive and has a lower, but still significant, mortality. Early diagnosis and aggressive therapy significantly reduces the mortality of these life-threatening diseases.

Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia

Ischemic colitis accounts for approximately half of all cases of mesenteric vasculopathy. The clinical presentation varies depending on underlying cause, extent of vascular obstruction, rapidity of ischemic insult, degree of collateral circulation, and presence of comorbidity. Ischemic colitis is usually diagnosed by colonoscopy. Only approximately 20% of patients require surgery because of signs or laboratory findings of peritonitis or because of clinical deterioration. Approximately 20% of patients develop chronic colitis from irreversible colonic ischemic injury, which manifests clinically as persistent diarrhea, rectal bleeding, or weight loss and endoscopically as a colonic stricture or mass. Chronic mesenteric ischemia is almost always caused by significant atherosclerotic stenosis involving at least two mesenteric arteries, usually the superior mesenteric artery and celiac axis. The classic symptomatic triad of postprandial pain, fear of eating, and involuntary weight loss occurs with advanced disease.

Percutaneous mesenteric venous thrombectomy and thrombolysis: successful treatment followed by liver transplantation

Mesenteric vein thrombosis (MVT) is a rare cause of intestinal ischemia. Because of its nonspecific symptoms, diagnosis is often delayed. We describe a patient with liver cirrhosis who developed acute MVT while waiting for liver transplantation. Surgical intervention carried a high risk because of her underlying cirrhosis. Mesenteric venous thrombectomy and thrombolysis were performed with an AngioJet (Possis Medical, Minneapolis, MN) thrombectomy device and streptokinase infusion through transjugular route. The patient subsequently received an orthotopic liver transplant. We also present a review of the literature about the occurrence and treatment options for MVT.