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1.
Med-Challenger FM Career
Comprehensive Review and Assessment for
Practicing
Family Physicians
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Issue: January 1, 2007
Case: Mesenteric Ischemia
Taken from
Med-Challenger FM Career
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Question:
An 82-year-old man presents with the sudden onset of diffuse
abdominal pain and vomiting. He has a history of hypertension.
His blood pressure is 110/60 mmHg, pulse 100 beats/minute,
respirations 20 breaths/minute, temperature 99.3 degrees F. His
abdomen is soft and diffusely tender. There is no pulsatile
mass. His stool is hemoccult positive. He has a leukocytosis
with a left shift, and his bicarbonate is 15. Which of the
following is the best diagnostic study for the evaluation of
this patient’s condition?
Answer Options:
- Mesenteric angiography
- CT angiography
- Magnetic resonance angiography
- Plain x-rays
- Doppler flow ultrasonography
Answer:
A
Remediation:
Mesenteric
angiography remains the gold standard for the evaluation of
mesenteric ischemia. Plain x-rays are normal in 25% of patients
with mesenteric ischemia. There may be nonspecific bowel
dilation or ileus. Thickening of the bowel wall or gas in the
portal vein or bowel wall suggests mesenteric ischemia in the
correct clinical setting. CT is helpful for identification of
mesenteric vein thrombosis.
About the Image(s):
Image 1:
Bowel Ischemia and Adynamic Ileus
This extremely ill patient had abdominal pain. The
distended bowel is due to adynamic ileus secondary to bowel
ischemia. A gastrostomy tube is present. Air in portal veins --
a very grim sign -- is due to loss of mucosal integrity of the
bowel. This usually implies dead bowel. Portal vein air tends to
be in the small peripheral branches, in contrast to the
distribution of air in the bile ducts.
Unfortunately, the abdominal x-ray is usually nonspecific in the
early stages of bowel ischemia, when intervention is most likely
to be effective.
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