Thread by @AnandJag1

Super proud of Dan Corbally, PGY2 @ucsdim. Stellar work writing this @hdx case!

1/
Spoiler alert:
This case forced me to re-think my schema for mesenteric ischemia.

Read on:

@ucsdim @hdx 2/
I used to think of mesenteric ischemia as a diagnosis, but now think of it as a syndrome resulting from an underlying disease process.

So, what processes can result in occlusion/ischemia of mesenteric vessels?

(Disclaimer: focusing on arterial ischemia)

@ucsdim @hdx 3/
Schema/disease categories for mesenteric ischemia:

- Thromboembolism (things that block arteries)
- Hypoperfusion (things that reduce blood flow without occlusion)
- Inflammation (things that can result in the above two)

@ucsdim @hdx 4/
Thromboemboli can result from:

- cardiac emboli
- ASCVD
- arterial hypercoagulable states
- vascular/endovascular instrumentation and/or prostheses

@ucsdim @hdx 5/
Mesenteric hypoperfusion resulting from:

- cardiac dysfunction (acute or chronic)
- true hypovolemia (ischemia/spasm)
- ASCVD
- bowel strangulation
- hemodialysis

@ucsdim @hdx 6/
Inflammation secondary to vasculitides (esp young people). While any vasculitis can cause mesenteric ischemia, some of the more common ones include:

- PAN
- IgA vasculitis
- Bechet’s (50% in Japanese cohort)

ncbi.nlm.nih.gov/books/NBK54661…

@ucsdim @hdx 7/
Elevated serum lactic acid is often expected by clinicians, however initial levels at presentation can be normal in acute ischemia (esp in pts with healthy liver) with elevation occurring after ischemia progresses to necrosis!

ncbi.nlm.nih.gov/pmc/articles/P…

@ucsdim @hdx 8/
In sum:
- Mesenteric ischemia is a syndrome! Look for the underlying cause
- Broad disease categories: thromboembolism, hypoperfusion, inflammation/vasculitis
- Serum lactic acid often doesn’t rise until there’s bowel necrosis. Don’t wait!

@ucsdim @hdx 9/

#medtwitter, would love any feedback to improve upon this first-stab schema. Will plan to use your input to make a formal diagram.

@CPSolvers @rabihmgeha @DxRxEdu @sargsyanz @ArsalanMedEd @Sharminzi @HannahRAbrams @LizzyHastie @ucsdim @drlessing

Fin.