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PubMed1985

The intestinal tract.

In this chapter, we have considered angiographic applications for diagnosis and management of patients with gastrointestinal bleeding and intestinal ischaemia. For patients with upper gastrointestinal bleeding, diagnostic angiography should be performed only when and if endoscopy is not available or non-contributory. For therapeutic purposes, angiography is applied in patients who continue to bleed despite conservative measures and intervention becomes unavoidable. Therapeutic interventions include the intra-arterial infusion of vasopressin and/or transcatheter embolization. In patients with rectal bleeding the addition of radionuclide studies has reduced the number of negative arteriographic examinations. We currently use the radionuclide studies only as a guide to whether active bleeding is present or not. If the radionuclide test is negative, we do not perform angiography. If it is positive we proceed with angiography in order to confirm localization and control bleeding with an intervention. For patients with rapid bleeding who are haemodynamically unstable we bypass nuclear medicine and proceed directly with angiography. In patients with suspected intestinal ischaemia, angiography is the only means of deciding whether ischaemia is of the occlusive or the non-occlusive form. Mesenteric vascular occlusions are treated surgically while low flow states are managed with mesenteric artery infusions of papaverine. Angioplasty has been and can be applied in patients with mesenteric arterial stenoses and symptoms of chronic intestinal ischaemia.

Angiography↗
PubMed1991

[A prospective study for evaluating postoperative risk and long-term prognosis of mesenteric infarct].

In a prospective study on the patient material of the Surgical Clinic of the Johannes-Gutenberg-University Mainz the prognostically relevant factors in acute mesenteric vascular occlusion were investigated. From September 1, 1985 until August, 31, 1989 46 patients (24 men, 22 women) with an average age of 67.2 years were treated for an acute mesenteric vascular occlusion. Postoperatively 56.5% of the patients died. The postoperative lethality was correlated statistically significant to the period of anamnesis, the aetiology of the occlusion, the patient's age, the preoperative ASA score, and the length of the ischemically damaged bowel. The postoperative blood lactat level correlated with the outcome. Only two patients survived a second operation with a further bowel resection. One of these patients had a normal blood lactat level. The two year survival rate of the postoperative surviving patient's totalled at 70%. These results confirm the known prognostically relevant factors as well as the value of the blood lactat level in the postoperative period. They show as well, that an early second look operation depending on the intraoperative findings of the primarily operation and prior to an increase of the blood lactat level and prior to a deterioration in the patients condition is justified.

Aged↗
PubMed1976

[Clinical aspects and diagnosis of the occlusion of upper mesenteric arteries].

Acute mesenteric vascular occlusion is associated with an extremely high mortality. Only the early diagnosis may be helpful in this condition. A directed anamnesis and close observation of clinical signs and symptoms associated with metabolic acidosis, significant base deficit, elevated white blood count, and arteriography could shorten the time period between vascular occlusion and operation. This is the way, which possibly leads to more gratifying results.

Acidosis↗
PubMed1975

[Nonocclusive mesenteric vascular disease following atrio-ventricular block and pacemaker treatment. Gangrene of small and large bowel with occlusion of inferieor mesenteric artery (author's transl)].

A case of nonocclusive mesenteric vascular disease consequential to a low cardiac output syndrome in a patient with a temporary pacemaker is reported. Preexisting occlusion of the inferior mesenteric artery resulted in a total gangrene of small and large bowel. Experimental findings suggest that this occlusion could have resulted in a compensatory increase of blood flow in the superior mesenteric artery. The possibility is discussed that the preexisting necessary increase of superior mesenteric blood flow could be followed by equally increased sensitivity of regional organic systems in non-occlusive mesenteric vascular disease.

Abdomen, Acute↗
PubMed1986

Assessment of small-bowel ischemia by laser Doppler flowmetry. Some case reports.

Laser Doppler flowmetry was used for intraoperative assessment of intestinal blood flow in five patients with small-bowel ischemia. In two patients with mechanically caused ischemia, bowel resection could be limited or avoided after flowmeter recordings. In two patients with mesenteric vascular occlusion, the flowmeter recording confirmed the macroscopic impression of irreversible gangrene. In a third subject with mesenteric vascular occlusion the extent of severe ischemia was clinically underestimated compared with the results obtained with the laser Doppler flowmeter. We conclude that, with further experience and development, laser Doppler flowmetry has great potential as a useful method for objective intraoperative assessment of blood flow in patients with small-bowel ischemia of various origins.

Aged↗
PubMed1988

Gastrointestinal application of laser Doppler flowmetry. An experimental and clinical study in cat and man.

Laser Doppler flowmetry (LDF) was evaluated as a method for study of gastrointestinal blood flow with emphasis on clinical applicability in man. Measuring depth of LDF in the gastrointestinal tract was studied in cat and man. The LD-signal was attenuated in an exponential manner by unperfused intestinal tissue between the probe and the perfused organ. With a probe with optical fibre diameter of 0.7 mm, the measuring depth was approximately 6 mm i.e. transmural in most parts of the gastrointestinal tract. In experimental mesenteric vascular occlusion on feline small intestine, it was possible to discriminate arterial and venous occlusion by simultaneous recording of the total amount of backscattered light. The effect of epidural anaesthesia on intestinal blood flow was studied in 15 patients during large bowel resections. A significant increase of total blood flow was found in the colon (p less than 0.01) and the small intestine (p less than 0.05), with an average increase of 41% and 15% respectively. LDF was used intraoperatively for assessment of the extent and degree of disturbed microcirculation in 8 patients with late radiation injury of the gastrointestinal tract. The flow values obtained were compared with reference values earlier obtained in unaffected tissue from corresponding gastrointestinal sites. Severe reduction of blood flow was demonstrated in segments with visible fibrosis. Five segments also showed varying degrees of disturbed blood flow in adjacent macroscopically normal bowel with histological radiation injury. In patients with radiation injury of the rectum, it was possible to assess the extent of vascular damage in the rectum prior to surgery by endoscopic flowmeter recording. The post-operative course was uneventful in all patients. In 23 patients with small bowel ischemia of different origins, LDF proved valuable for assessment of blood flow and tissue viability. In patients with mechanical strangulation, bowel resection was avoided in 9 out of 10 segments of clinically uncertain viability following flowmeter recording. In 6 patients with mesenteric vascular occlusion, the extent of severe ischemia seemed underestimated by clinical judgement compared to the results obtained with LDF. The ability of LDF to detect small ischemic areas and to select the proper level of resection was demonstrated. It is concluded that LDF is a suitable method for study of gastrointestinal blood flow in experimental and clinical work. LDF provides substantial information in the intraoperative management of small bowel ischemia and late radiation injury of the gastrointestinal tract.

Anesthesia, Epidural↗
PubMed1982

Mesenteric infarction in Takayasu's arteritis treated by thromboendarterectomy and intestinal resection.

A 36-year-old woman with a history of left nephrectomy for renovascular hypertension secondary to arterial occlusive lesion of Takayasu's arteritis was re-admitted to our hospital with complaints of postprandial abdominal pain in the sixth post-operative month. On the 14th hospital day, the developing abdominal distension and generalized tenderness suggested a mesenteric vascular occlusion. Following abdominal aortography, emergency surgery was performed. The entire small bowel was edematous and markedly cyanotic with spotted, dark colored areas and the mesentery was pulseless. The patient was successfully treated by thromboendarterectomy at the origin of the celiac and superior mesenteric arteries and the necrotic loop of intestine was then resected 7 days later. Takayasu's arteritis was diagnosed by histological examination of the resected specimens. Although the occurrence of mesenteric infarction secondary to Takayasu's arteritis is rare, the possibility of mesenteric vascular occlusion should be given consideration in the follow-up of patients with Takayasu's arteritis.

Adult↗
PubMed1987

The rationale for "second-look operation" in mesenteric vessel occlusion with uncertain intestinal viability at primary surgery.

In a 10-year period, 80 patients, median age 78 years, were operated on for mesenteric vascular occlusion--arterial in 50 cases, venous in 24 and of uncertain etiology in six cases. Abdominal pain out of proportion to physical findings occurred in only eight cases. Vague abdominal symptoms with increasing tenderness led to surgical exploration in most cases. Median patient delay was 34 hours and doctor's delay 15 hours. Resection was primarily nonfeasible in 28 cases. Primary resection without second-look operation was performed in 32 cases, in seven of which signs of anastomotic insufficiency appeared. In the remaining 20 cases, primary resection (18) and/or embolectomy (3/2) was followed by a planned second-look operation within 24 hours, when five resections were performed. In a patient with viable anastomosis at second look, there were late signs of anastomotic insufficiency. Although the data do not permit firm recommendations, use of second-look operation in patients with doubtful viability of the intestine may reduce the extent of resection at primary exploration and also the incidence of insufficient anastomosis.

Adult↗
PubMedDate not supplied

Computed tomography of bowel infarction.

Bowel infarction is a potentially lethal disorder that is notoriously difficult to diagnose clinically and radiographically. Computed tomography is often used in the early radiographic evaluation of patients with severe abdominal pain of unknown etiology. This study defines the CT findings in patients with bowel infarction. The findings in 22 patients with mesenteric infarction were reviewed. Seven were due to mesenteric arterial occlusion, six due to mesenteric venous occlusion, and nine were nonocclusive. The CT abnormalities were diffuse or focal bowel wall thickening (19 patients), bowel dilatation without mural thickening (three patients), intramural low attenuation zones of edema (eight patients), intramural gas (11 patients), mesenteric gas (five patients), portal or mesenteric venous gas (one patient), mesenteric vascular occlusion (eight patients), and peritoneal gas or fluid (12 patients). The diagnosis of bowel infarction must be considered when performing CT in patients with abdominal pain of unknown etiology.

Adult↗
PubMedDate not supplied

Intraoperative assessment of blood flow and tissue viability in small-bowel ischemia by laser Doppler flowmetry.

Laser Doppler flowmetry (LDF) was used for intraoperative assessment of blood flow and tissue viability in 23 patients with small-bowel ischemia, and the signal levels in ischemic bowel were compared with previously obtained reference values from normal ileum and jejunum. The average LD signal was 6.8 +/- 2.9 V in nonischemic bowel, 0.3 +/- 0.2 V in segments with macroscopically irreversible ischaemia and 2.1 +/- 1.2 V in segments with clinically uncertain viability. In 12 cases with strangulated bowel it was possible, following LDF, to avoid resecting nine of ten bowel segments with clinically uncertain viability. In four of the six patients with mesenteric vascular occlusion, LDF indicated that clinical judgement had underestimated the extent of severe ischemia. Among the five cases of iatrogenic ischemia there was one failure, with postoperative irreversible ischemia and anastomotic leakage. LDF is concluded to be a useful method for intraoperative assessment of intestinal blood flow in patients with small-bowel ischemia and it provides substantial information on tissue viability affecting surgical strategy.

Adolescent↗