QuestionSBA
QuestionChoice
Endovascular intervention, including thrombolysis, may be indicated in this patient; however, a diagnosis of acute mesenteric ischaemia should first be confirmed by CT angiography
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d
Endovascular thrombolysis
QuestionChoice
Steroids are not used in the management of acute mesenteric ischaemia
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c
IV methylprednisolone
QuestionChoice
An erect abdominal X-Ray is important to look for signs of perforation. However, a CT has higher sensitivity and has already been reported as normal in this scenario
32477
e
Erect abdominal X-Ray
QuestionChoice
Acute, severe abdominal pain, atrial fibrillation and pain out of proportion to findings on an examination suggest acute mesenteric ischaemia. The high lactate level is also highly suggestive. Although CTAP is normal, the most sensitive imaging modality is a CT angiogram, which would be indicated in this scenario given the high index of suspicion
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a
CT angiography
QuestionChoice
A laparotomy is not indicated as there are no signs of peritonitis, perforation or infraction at this stage. We are also not sure if this woman would be a candidate for surgery given her co-morbidities
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b
Laparotomy
QuestionComment
"Management" 
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QuestionComment
i think here by 'management' they mean how best to manage the case, though I can see why it can be interpreted as asking for a treatment modality 
25808
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Kinin Polyps
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Passmed>
QuestionComment
I thought: 

"Management:
immediate laparotomy is usually required, particularly if signs of advanced ischemia e.g. peritonitis or sepsis
poor prognosis, especially if surgery delayed"
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Axillary Stasis
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Chapter
# Summary

Acute mesenteric ischemia (AMI) is a serious and potentially fatal condition characterized by sudden onset intestinal hypoperfusion, typically involving the superior mesenteric artery. It presents with severe abdominal pain, often disproportionate to physical findings, nausea, vomiting, and signs of shock. Diagnostic confirmation is generally made through CT angiography. Key risk factors include atrial fibrillation, atherosclerosis, and any condition causing coagulopathy. Management primarily involves rapid diagnosis, stabilization of the patient, and both surgical and non-surgical interventions to restore perfusion.

# Definition

Acute mesenteric ischemia (AMI) is a life-threatening surgical emergency characterized by the abrupt onset of blood flow restriction (hypoperfusion) to a portion of the small intestine. This disruption may be either occlusive or non-occlusive, affecting primarily the superior mesenteric artery.

# Epidemiology

Acute mesenteric ischemia is a relatively rare but serious condition, representing approximately 0.1% of all hospital admissions. However, it's associated with high morbidity and mortality rates, with the mortality rate ranging from 60-80%. Age is a significant factor, with the majority of cases occurring in individuals over 60 years old.

# Aetiology

The causes of AMI can broadly be categorized as follows:

-   **Arterial Embolism**: The most common cause, often resulting from atrial fibrillation or other embolic sources such as infective endocarditis or aortic aneurysm.
-   **Arterial Thrombosis**: Usually associated with atherosclerosis, especially in patients with a history of ischemic heart disease or peripheral vascular disease.
-   **Venous Thrombosis**: Occurs less commonly and is often linked to hypercoagulable states.
-   **Non-Occlusive Mesenteric Ischemia**: Typically associated with low-flow states such as heart failure, shock, or during major surgery.

# Signs and Symptoms

Clinical presentation often includes:

-   Sudden severe abdominal pain and guarding, often out of proportion to the physical examination
-   Nausea and vomiting
-   Signs of shock, such as hypotension, tachycardia, altered mental status
-   Metabolic acidosis on arterial blood gas (ABG) analysis
-   Rectal bleeding can occasionally be seen in advanced ischemia

# Differential Diagnosis

Other conditions to consider that may present similarly include:

-   **Peptic Ulcer Disease**: Presents with epigastric pain, nausea, vomiting, and potential melena or hematemesis.
-   **Acute Pancreatitis**: Epigastric pain radiating to the back, nausea, vomiting, and increased serum lipase or amylase.
-   **Acute Cholecystitis**: Right upper quadrant abdominal pain, fever, nausea, vomiting, and positive Murphy's sign.
-   **Acute Appendicitis**: Right lower quadrant pain, nausea, vomiting, fever, and positive McBurney's point tenderness.
-   **Diverticulitis**: Left lower quadrant pain, altered bowel habits, and possible rectal bleeding.

# Investigations

The initial work-up should include:

-   **Blood tests**: Full blood count, liver function tests, renal function, coagulation profile, and lactate levels
-   **Arterial blood gas (ABG)**: To identify metabolic acidosis
-   **Imaging**: CT angiography is the diagnostic modality of choice due to its ability to visualize the occlusion and surrounding bowel.

# Management

The primary objectives in managing AMI are rapid diagnosis, stabilization of the patient, and restoration of bowel perfusion. This can be achieved through:

-   **Resuscitation**: Including fluid management and correction of metabolic abnormalities
-   **Anticoagulation**: Typically with intravenous heparin to limit progression of thrombosis or embolism
-   **Surgical intervention**: Including embolectomy, arterial bypass, or bowel resection if necrosis is present
-   **Non-surgical intervention**: Such as intra-arterial vasodilators or thrombolytic therapy
-   **Supportive care**: Including analgesia, antibiotics if needed, and nutritional support.
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Acute mesenteric ischaemia
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General Surgery
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Acute mesenteric ischaemia
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Acute mesenteric ischaemia
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Quesmed Tutorial: Acute Abdomen
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A 78-year-old lady with a background of atrial fibrillation and hypertension presents with a two-hour history of severe abdominal pain. She reports no other symptoms, and abdominal examination is unremarkable apart from some generalised abdominal tenderness.


A venous blood gas reveals a lactate of 7mmol/L (normal range 0.6-1.4 mmol/L), and an urgent CT abdomen and pelvis (CTAP) shows no acute pathology.


Which of the following is the next best step in management?
a