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Management of acute mesenteric ischaemia
- Andrew L Tambyraja (21 June 2003)
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Ischaemic bowel and cardiac surgery
- Ian Ramnarine (24 June 2003)
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An important cause of intestinal ischaemia
- Vadamalai Vivek, Richard Kingston, Azad Ghuran, Tarek F.Antonios (18 July 2003)
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Andrew L Tambyraja, Lecturer Department of Clinical & Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, EH 16 4SA
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Editor – Sreenarasimhaiah has produced a comprehensive review of the clinical features and diagnosis of intestinal ischaemia1. However, the recommended management strategy for acute mesenteric ischaemia is misleading and flawed. Contrary to Sreenarasimhaiah’s report, surgical embolectomy should only be considered the standard of care in cases of embolic arterial occlusion. In up to 50% of cases of acute mesenteric ischaemia, arterial occlusion occurs due to thrombosis at a superior mesenteric artery (SMA) atherosclerotic stenosis2. In these instances SMA reconstruction is indicated either through aorto – SMA bypass grafting or reimplantation of the SMA to the aorta. Furthermore, despite Sreenarasimhaiah’s support for interventional radiology, the evidence base for the use of thrombolytic agents in mesenteric ischaemia remains largely anecdotal. Savassi-Rocha and colleagues’ review of the use of lysis in SMA embolism identified only 18 other reported cases in the literature3. Though thrombolysis may be a viable therapeutic option in the management of mesenteric ischaemia, its efficacy and indications for use are by no means clear at present. 1. Sreenarasimhaiah J. Diagnosis and management of intestinal ischaemic disorders. BMJ 2003; 326:1372-6 2. Bradbury AW, Brittenden J, McBride K, Ruckley CV. Mesenteric ischaemia: a multidisciplinary approach. Br J Surg 1995; 82: 1446-59 3. Savassi-Rocha PR, Veloso LF. Treatment of superior mesenteric artery embolism with a fibrinolytic agent: case report and literature review. Hepatogastroenterology 2002; 49: 1307-10 Competing interests: None declared |
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Ian Ramnarine, Cardiothoracic Surgical Registrar CArdiothoracic Center, Liverpool, L14 3PE
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I must congratulate the author on a comprehensive and thorough review and would like to make some suggestions based on my own practice. Bowel ischaemia is a rare (incidence <1%) but highly fatal (mortality >50%) complication of cardiac surgery1. Most cardiac surgical patients have multiple risk factors for developing the problem. Ghosh, et al identified use of significant vasopressor support, intra- aortic balloon counterpulsation for low cardiac output, need for blood transfusions, duration of cross-clamp, triple vessel disease and peripheral vascular disease as six possible predictors of the development of intestinal ischaemia in the cardiac surgical patient. The first three all go together with the management of low cardiac output. The diagnosis of bowel ischaemia in the post-operative cardiac surgical patient on the Intensive Care Unit is difficult2 and complicated by multiple factors. I would like to highlight some common pitfalls and suggest remedies: 1) The development of lactic acidosis is a common feature that should be identified early in the disease process. Some units do not have the emergency facility to process serum lactate levels. 2) Beware of ‘normal’ serum pH as this may represent a temporary correction of a metabolic acidosis. A serum base excess level that suddenly drops (despite still being in the ‘normal’ range) and all infusions of alkaline solutions (e.g. solutions of bicarbonate) should be identified. 3) Have an established protocol for management. Far too much time is often spent ‘phoning around’ in an emergency to find out who the covering surgeon is. 4) The diagnosis is often made on clinical grounds and the importance of serial abdominal examinations that illicit changes in abdominal signs cannot be stressed enough. Imaging may not be easily available and may not be as helpful as surgical exploration. Finally, in some cases the extent of ischaemia may render further active management futile. It is always a difficult decision to commence palliative care only3. I hope that you find my comments helpful, Sincerely, Ian Ramnarine 1) Ohri SK, Desai JB, Gaer JA, Roussak JB, Hashemi M, Smith PL, et al. Intraabdominal complications after cardiopulmonary bypass. Ann Thorac Surg 1991;52(4):826-31. 2) Ghosh S, Roberts N, Firmin RK, Jameson J, Spyt TJ. Risk factors for intestinal ischaemia in cardiac surgical patients. Eur J Cardiothorac Surg 2002;21(3):411-6. 3) Withholding and Withdrawing Life-prolonging Treatments: Good Practice in Decision-making. General Medical Council, Guidelines. August 2002 Competing interests: None declared |
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Vadamalai Vivek, Specialist Registrar, General Medicine St George's Hospital, Blackshaw Road, Tooting, London, SW17 0QT, Richard Kingston, Azad Ghuran, Tarek F.Antonios
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Editor, We read with interest Sreenarasimhaiah’s extensive review on the diagnosis and management of intestinal ischaemia (1). He appears to have overlooked an important but less common cause of intestinal ischaemia. Radiation-induced occlusive arterial disease has been previously well described (2-4). We recently treated a 54 year old Caucasian male patient who presented with severe epigastric pain, anorexia and vomiting. Twenty five years earlier he was diagnosed with a testicular teratoma for which he underwent orchidectomy followed by radiotherapy to the inguinal and para- aortic lymph nodes. A few years later his blood pressure started to rise and proved difficult to control and he was found to have severe bilateral renal artery stenosis. Following his recent hospital admission he was initially treated as a possible case of cholecystitis and he was managed conservatively with antibiotics and IV fluids. However, he failed to respond to treatment and continued to have abdominal pain and anorexia. Because of his previous history of radiotherapy we suspected bowel ischaemia and a subsequent aortogram showed severe coeliac and mesenteric artery occlusive disease. Of interest, there was no evidence of arterial disease outside the field of radiation, clearly, a well defined margin between the normal arteries outside the field of radiation. At laparotomy he was found to have a gangrenous gall bladder for which he underwent a cholecystectomy and a mesenteric iliac artery bypass was performed to relieve his intestinal ischaemia. Post-operatively his symptoms settled quickly. This case clearly illustrates the importance of considering radiation -induced arterial disease as a cause of bowel ischaemia. Long-term complications of radiotherapy for malignant disease are seen more frequently now because of improved survival of these patients. References- 1. Diagnosis and management of intestinal ischaemic disorders. Jayaprakash Sreenarasimhaiah BMJ 2003; 326: 1372-1376 2. Management of arterial occlusive disease following radiation therapy. Andros G. Schneider PA. Harris RW. Dulawa LB. Oblath RW. Salles- Cunha SX. Cardiovasc Surg 1996 Apr;4(2):135-42 3. Radiation-induced arterial injuries. McCready RA. Hyde GL. Bivins BA. Mattingly SS. Griffen WO Jr. Surgery 1983 Feb;93(2):306-12 4. Irradiation injury to large arteries. Butler MJ. Lane RH. Webster JH. Br. J. Surg. 1980 May;67(5):341-3 Competing interests: None declared Editorial note
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