Mesenteric circulation disorders
1. Mesenteric ischemia & infarction
* acute intestinal ischemia
+- occlusive(75%) : arterial thrombus(1/3) - low C.O, extensive atherosclerosis
| embolus(2/3) - chronic AF, artificial heart valve, valvular heart
| disease 환자에서
| venous occlusion(<5%) - oral contraceptive복용여성에서
|
+- non-occlusive(25%) : 원인은 잘 모르지만 systemic a. hypotension, cardiac
arrhythmia, prolonged heart failure, digitalis therapy, dehydration,
endotoxemia가 contributing factors로 생각됨.
(1) Acute mesenteric ischemia
① major clinical feature
severe abdominal pain(colicky)
periumbilical -> diffuse & constant
심한 경우에도 bowel sound는 normal
mild GI bleeding: occult blood(+)
* groos hemorrhage는 ischemic colitis를 제외하고는 드물다.
leukocytosis
24-72시간후 gangrene with diffuse peritonitis, sepsis, shock발생
simple abdomen : air-fluid level & distention
B.E : "thumbprinting"
② high morbility & mortality
acute arterial embolus의심되면 즉시 celiac & mesenteric angiography를 시행하여
embolus위치를 찾아 embolectomy하여야 한다.
(2) Chronic arterial insufficiency(=abdominal angina)
식후 15-30분후 intermittent dull or cramping midabdominal pain
식후 수시간지속
significant weight loss(+) i) food intake↓
ii) mucosal damage & malabsorption
Tx> vascular surgery or balloon angioplasty
(3) Vasculitis
PAN, LE, Dermatomyositis, HSP(allergic vasculitis), Rheumatoid vascultitis
+-- PAN : large a 침범
+-- 나머지: small vs침범 -> intramural hemorrhage & edema
-> abdominal pain, intestinal obstruction, bleeding
B.E : thumbprinting
2. Ischemic colitis
거의 항상 nonocclusive
1) Acute fulminant ischemic colitis
lower abdominal pain, rectal bleeding, hypotension
colon dilatation, peritonitis sign
abdomen film : thumbprinting
B.E : perforation risk↑
Sigmoid & colonoscopy : ulceration, friability& buldging fold
Angiography : not helpful
경도의 환자는 보존적 치료로 회복된다.
2) Subacute ischemic colitis
rectum sparing(∵ collateral) - UC와 구별되는 소견
B.E : edema, cobble stoning, thrumprinting, superficial ulceration
Angiography : not indicated
3) Stricture formation
대부분의 nonocclusive ischemic colitis는 2-4주내 회복되고 재발하지 않는다.
수술은 postischemic stricture에 의한 obstruction을 제외하고는 필요치 않다.