A 68-yrs-old man is admitted to the coronary care unit

Discussion in 'MRCS Forum' started by Lona., Oct 25, 2007.

  1. Lona.

    Lona. Guest

    A 68-yrs-old man is admitted to the coronary care unit with an acute myocardial infarction. His post-infarction course is marked by congestive heart failure and intermittent hypotension. On the fourth hospital day, he develops severe mid-abdominal pain. On physical examination, blood pressure id 90/60 mmHg and pulse is 110/min and regular; the abdomen is soft with mild generalized tenderness and distension. Bowel sounds are hypoactive; stool hematest is positive. The next step in this patient’s management should of the following -
    a- Barium enema
    b- Upper gastrointestinal series
    c- Angiography
    d- Ultrasonography
    e- Celiotomy
  2. Lona.

    Lona. Guest

    Answer: c- Angiography. (Schwartz, 7/, pp 966-967) Acute mesenteric ischemia may be difficult to diagnose. The condition should be suspected in patients with either systemic manifestations of arteriosclerotic vascular disease or lo cardiac output states associated with a sudden development of abdominal pain that is out of proportion to the physical findings. Lactic acidosis and an elevated hematocrit reflecting hemoconcentration are common laboratory findings. Abdominal films show a nonspecific ileus pattern. The cause may b embolic occlusion or thrombosis of the superior mesenteric artery, primary mesenteric venous occlusion, or nonocclusive mesenteric ischemia secondary to low cardiac output states. A mortality of 65% to 100% is reported. The majority of affected patients are at high operative risk, but, since early diagnosis followed by revascularization or resectional surgery or both is the only hope for survival, celiotomy must be performed once the diagnosis of arterial occlusion or bowel infarction has been made. Initial treatment of nonocclusive mesenteric ischemia includes intraarterial infusion of vasodilators such as papaverine into the superior mesenteric system. This patient is at risk for both occlusive and nonocclusive mesenteric ischemic disease. If his clinical status permits, angiographic studies should be performed before the operation to establish the diagnosis and to determine whether embolectomy, revascularization or nonsurgical management is indicated as initial treatment.

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