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.