Mesenteric Ischemia

Pt >60 y/o with h/o CAD, AFib, PAD, ESRD, hypercoagulability, and smoking presents with paroxysmal abdominal pain out of proportion to physical exam. Pain worse after eating and/or snorting cocaine. Receives outpatient dialysis three times weekly and is s/p recent vascular surgery including CABG. Fever, tachycardia, tachypnea, leukocytosis, JVD, bilateral lung crackles, irregularly irregular heart rhythm, diffuse abdominal tenderness to palpation, and LE pitting edema on exam.

• Obtain CBC, CMP, lactic acid

• FOBT negative

• Obtain magnetic resonance angiography

• Treatment

  • Consider GI decompression

  • Start normal saline at 125 cc/hr

  • Start IV morphine 3 mg q4h PRN pain control; titrate as necessary

  • Etiology specific

    • Arterial occlusion identified: Consult surgery for potential laparotomy with embolectomy

    • Non-occlusive: Eliminate vasoconstricting medications and consider starting nitroglycerin 0.4 mg sublingual for acute pain

  • Start anticoagulation with apixaban (Eliquis) 5mg BID

Notes

• Risk factors

  • Conditions that reduce peripheral circulation, e.g. sepsis, HF

  • CABG → transient hypoperfusion during procedure and increased risk for thromboemboli

  • Cocaine → vasoconstriction

  • Dialysis increases risk for non-occlusive mesenteric ischemia

• Intestinal bleeding is uncommon early in the disease process

• Start vasodilating agents if needed, but avoid vasoconstricting agents that may reduce blood supply