Skip to content

Acute Mesenteric Ischemia, Bowel Infarction, uye Sudden Gut Clot Emergency

Nhamba dze emergency dzinosiyana nenyika. Iri peji rinoshandisa 911, nhamba yeUnited States neCanada. Dzimwe nyika dzakawanda dzinoshandisa 112, 999, kana imwe nhamba. Tsvaga nhamba yenyika yako.

Acute mesenteric ischemia (AMI) injodzi yekuvhiyiwa kwevascular uye abdominal emergency apo ropa rinoyerera nemutsinga mikuru kana tsinga dzinopa matumbu madiki nemahombe (kazhinji superior mesenteric artery [SMA]) inogurwa kamwe kamwe ne arterial blood clot (klzzwxh:000) yakanyanya kuderera kweropa (embolism) (** non-occlusivmesenteric ischemia **), kanauti venous clot (**mesenteric venous thrombosis **). Sezvinongoita tsinga yeuropi yakavharika inokonzera sitiroko uye yakavharika yegumbo artery inokonzera acuteimb ischemia, yakavharika gut artery inokonzera"intestinal stroke / heart attack of the bowel"* umo mukati memukati wakatetepamucosa) wemudumbu mudikunotanga kufa mukati me**30 kusvika 60 mamitsi** uye mudumbu wese usingapindiki. necrosis (** transmural bowel infarction **) mukati ** maawa matanhatu kusvika gumi nemaviri **. Kana munhu mukuru (kunyanya ani zvake ane atrial fibrillation, chirwere chemwoyo chichangobva kuitika, kukundikana kwemwoyo, kana chirwere chevascular) akatanga kamwe kamwe, kurwadziwa kwepakati pemudumbu kunoperekedzwa nekukurumidzira kurutsa kana manyoka, fonera munharaunda yako. nhamba dze emergency pakarepo. Paunenge wakamirira vanobatsira varwere, ongorora zvine chekuita nevascular uye abdominal emergency dhairekitori pane aortic dissection uye kuputika abdominal aortic aneurysm, kuvharika kwebowel, strangulated hernia, uye volvulus,uye acute pancreatitis uye gallbladder emergency.

Nekuti isina kurapwa bowel infarction inotakura **60 kusvika 80 muzana yekufa kwehuwandu **, kupona kunoenderana nekubata emergency panguva yayo hwindo rekutanga kudzoreredzwa (maawa matanhatu ekutanga) nekuziva chiratidzo chayo chekiriniki chinonyanyozivikanwa: *kurwadza 10/10 kurwadziwa kwemudumbu kusiri mucherechedzo wakapfava, zvisingaenzaniswi

Ita izvi ikozvino

  1. Fonera nhamba yako ye emergency nekukasika wokumbira kutakurwa kuenda kuchipatara chine Vascular and General Surgery. Dial 911 muUnited States neCanada, 112 mhiri kweEuropean Union, 999 kuUnited Kingdom, 000 kuAustralia, kana kutarisa mazita edu nhamba dze emergency. Taura zvakajeka: "Inofungidzirwa acute mesenteric ischemia / gut blood clot: kamwe-kamwe kurwadziwa mudumbu kunorwadza zvisingaenzaniswi nekuongorora mumurwere ane atrial fibrillation (kana vascular/heart disease).
  2. ** Ziva "Soft Belly Trap" (Pain Out of Proportion to Physical Exam).** Mukutanga 1 kusvika kumaawa 6 mushure mekunge ropa ravharwa richivhara mesenteric artery yepamusoro, murwere anogunun'una uye anogomera mu10 / 10 pakati pemarwadzo emimba, asi iwe kana mubatsiri wepachipatara zvinyoronyoro akatsikirira padumbu ravo uye kusununguka ** hunyoro**. Usambofa wakafunga kuti kurwadziwa "kungori gasi, kusadya, kana hutachiona hwemudumbu" nekuti dumbu rinonzwa rakapfava; panguva iyo dumbu rinenge raoma dombo uye rakaomarara, ura hunenge hwatofa uye hwabuda.
  3. Chengetedza murwere pasina nomuromo (NPO: zero mvura, zero food, zero antacids, zero pain pills). Usape mvura, ginger ale, bismuth/antacids, kana mushonga wemuromo. Chekutanga, kugaya chikafu kana mvura kunomanikidza dumbu rine nzara yeokisijeni kuti rishande nesimba uye richida okisijeni yakawanda, ichikurumidza kufa mucosal. Chechipiri, murwere anoda kukurumidza kukurumidza ** CT Angiography (CTA) ** inoteverwa necatheter thrombectomy kana kushanda-kamuri laparotomy pasi peanesthesia yakawanda.
  4. Rarisai murwere akazvambarara kana kuti akazorora zvakanaka (mabvi akakotama zvishoma) uye arambe achidziya. Hypotension uye kutonhora kwevasoconstriction kunowedzera kudzipa kuvharirwa kweropa kuyerera nemutsinga dzeceliac uye dzakaderera mesenteric.
  5. Nhan'ara chero nhoroondo yeAtrial Fibrillation (kunyanya kupotsa ropa rakatetepa dosi), hosha yemoyo nguva pfupi yadarika, kana "kutya chikafu" (kurwara kwepashure kwepandial) kune vanobatsira varwere nekukurumidza. Inopfuura 50 muzana yeacute mesenteric artery emboli inobva mugwamba riri kuruboshwe rweatrium yemurwere ane atrial fibrillation yeabixavagaban, aropitraban akarega kana kupotsa doses. kana warfarin. Udza vanobatsira varwere zita chairo uye nguva yekupedzisira yedosi yemwoyo yese nemishonga inoderedza ropa.
  6. Usambofa wakazora pedhi yekudziisa mudumbu kana kuisa mushonga wekusveta kana kuti enema. Kupisa kwekunze kunokwidza kudiwa kweokisijeni ye ischemic gut wall, ukuwo malaxative kana kuti enemas zvinokuchidzira peristalsis nechisimba uye zvinogona kuparira ischemic colon kana ura mudiki.

Nei iyo 6-awa yekuongorora hwindo inosarudza hupenyu kana kufa

Zvidzidzo zveEpidemiological zvakaongororwa neWorld Society of Emergency Surgery (WSES) uye European Society for Vascular Surgery (ESVS) inoratidza kuti kana acute mesenteric ischemia ichionekwa uye yakagadziriswa ** mukati memaawa ekutanga e6 ekutanga kwechiratidzo chekutanga **, pamusoro pe ** 80 kusvika 90 muzana ** yevarwere vanorarama muhutano hwavo. Kana kuongororwa kwakanonoka kupfuura ** 12 kusvika kumaawa 24 ** (kumirira kusvika lactic acidosis, zvigwere zvine ropa, uye peritonitis yakaoma), transmural gangrene yemukati mese mudiki kubva muduodenum kuenda kune inochinjika colon yakatoitika, uye kufa kunokwira kusvika ku ** 70 kusvika 90 muzana *, zvichisiya vanorarama hupenyu hurefu Syndrome **).

Muti wesarudzo: kamwe kamwe kurwadziwa kwakanyanya mudumbu uye acute mesenteric ischemia triage

flowchart TD
    Start["Kamwe-kamwe Yakakomba Pakati / Periumbilical Abdominal Pain muMurwere Ane Atrial Fibrillation, Ichangobva Kurwiswa Kwemoyo, Kutadza Kwemoyo, PAD, kana Kuvhara Disorder."] --> ClassicTriad{"Danho 1: Tarisa Classic Embolic Triad: Agonizing 10/10 kurwadziwa OUT OF PROPORTION kusvika panyoro bvunzo yedumbu, zvine simba kubuda ura (kurutsira/manyoka), kana inozivikanwa AFib / kudya kwekutanga kutya?"}

    ClassicTriad -->|"EHE Kurwadziwa Kunze Kwechikamu kana Triad"| Emergency["SUSPECTED ACUTE MESENTERIC ISCHEMIA (6-HOUR SALVAGE WINDOW): Fonera Emergency Services (911 / 112 / 999) Pakarepo"]

    ClassicTriad -->|"Atova nebhodhi rakaomarara sedumbu, chituru chine ropa chakasviba, kuvhiringika, kufema nekukurumidza, kana kuderera kweropa"| Infarction["LATE TRANSMURAL BOWEL INFARCTION & PERITONITIS: Hyperacute Hupenyu-Kutyisa Kuvhiya Dambudziko; Fonera 911 Pakarepo"]

    Emergency --> Prehospital["1. Prehospital First Aid: Strict NPO (hapana mvura, chikafu, maantacids, kana mishonga yemuromo), rara wakatambarara wakagadzikana, gara uchidziya, uye taura AFib kana kuti ropa rakapfava."]
    Infarction --> Prehospital

    Prehospital --> HospitalCTA["2. Immediate Hospital Diagnostic & Resuscitation Bundle: STAT Biphasic CT Angiography (CTA) yeAbdomen/Pelvis pasina kumirira lactate, IV crystalloids, IV Heparin drip, uye Broad-spectrum IV mishonga inorwisa mabhakitiriya."]

    HospitalCTA --> Revasc["3. Hybrid OR Endovascular & Surgical Bowel Salvage: Endovascular Aspiration Thrombectomy / Stenting kana Surgical Embolectomy, rect frankly necrotic bowel, uye Planned Second-Look Laparotomy mumaawa 24 kusvika ku48"]

Anatomy uye pathophysiology: nei iyo Superior Mesenteric Artery (SMA) iri "bullseye" yekuvhara kwemoyo.

Hunde nhatu dzisina kupetwa dzinobva kumberi kweaorta yemudumbu kuti dzipe turakiti rose redumbu remunhu:

  1. The Celiac Hunde: Inopa dumbu, chiropa, gallbladder, spleen, pancreas, uye upper duodenum (embryonic foregut).
  2. The Superior Mesenteric Artery (SMA): Inopahura hudiki hwese (yezasi duodenum, jejunum, uye ileum) pamwe nehafu yese yekurudyi yeura hombe (cecum, inokwira colon, uye zvikamu zviviri muzvitatu zvemukati memukati, embryonic midgut).
  3. The Inferior Mesenteric Artery (IMA): Inopa colon inodzika, sigmoid colon, uye rectum yepamusoro (embryonic hindgut).

Nei 85% ye visceral arterial clots ichigara muSuperior Mesenteric Artery

Kana ropa richiputika kubva pamwoyo (somuenzaniso, kubva kuruboshwe rweatrial appendage panguva yeatrial fibrillation kana kubva kumadziro e-ventricular yekuruboshwe mushure mekurwiswa kwemoyo wepamberi) uye inodonhedza pasi muota yedumbu, inenge nguva dzose ichibhururuka yakananga mu Superior Mesenteric Artery (SMA) kwete pane celiac artrior metric orta. Sei? - Hunde yeceliac inoita matavi kubva paaorta painopinza, ingangoita ** 90-degree perpendicular angle **, uye yakaderera mesenteric artery yakamanikana mucaliber. - Kusiyana neizvi, Superior Mesenteric Artery ine muromo wakapamhama uye matavi ari kumberi kweaorta pakapfava, yakadzika-inotsvedza 45-degree oblique angle, inoda kufambirana nehova huru yeaortic. Ropa rakagwamba riri kurwadza kuzasi kweaorta rinotevera nzira yekushomeka yakananga pasi ne 45-degree ramp ichipinda muSMA, kazhinji inogadzika 3 kusvika 8 masendimita kupfuura kwayakatangira kungopfuura kubviswa kwepakati colic artery.

Sei dumbu richinzwa rakapfava murwere achiridza mhere nekurwadziwa (Visceral vs. Somatic Pain)

Kunzwisisa maviri-layer nerve inopa mudumbu inotsanangura imwe yakakosha yekiriniki clue mumushonga wekukurumidzira, "kurwadziwa kusingaenderane nekuongororwa kwemuviri":

  1. ** Maawa 0 kusvika 6 (Mucosal Ischemia uye Visceral Nerve Agony - THE SOFT BELLY STAGE):**
  2. Iyo yemukati-kati yemukati (iyo ** mucosa uye submucosa **, yakarongwa nemamiriyoni e microscopic nutrient-absorbing villi) inodya ** 70 muzana yeropa rose rinoyerera ** yegut wall uye ndiyo inonyanya kushandiswa kwemagetsi mudumbu.
  3. Mukati 15 kusvika 30 maminetsi ekuvharika kweSMA, mucosal villi inotanga kudzipwa uye kutsvedza, ukuwo tsandanyama yakatsetseka yemadziro emukati inopinda muchisimba, tetanic ischemic spasm (zvichiita kuti murwere arutse zvine simba uye apfuure manyoka kuti abudise ura).
  4. Iyi ischemic spasm inopisa zviratidzo zvinorwadza zvakanyanya kuburikidza ne ** autonomic visceral C-fibers ** inofamba ne mesenteric nerve kusvika kumusana wemusana (T8-T11), zvichikonzera kurwadza, kushaikwa kwenzvimbo, kurwadziwa kwakadzika kwepakati pedumbu.
  5. **Zvisinei, kunze kwemukati (serosa) ichiri mhenyu **, saka haiti ** kwete ** inopisa kunze kwegumbo remadziro emadziro (**parietal peritoneum **). Naizvozvo, apo chiremba kana kuti paramedic akatsikirira kunze kwedumbu remurwere, tsandanyama dzemadziro emudumbu hadzirinde kana kuzungunuka zvachose: murwere ari mu10/10 kurwadziwa, asi dumbu rinonzwa rakapfava chose.
  6. ** Maawa 6 kusvika 12+ (Transmural Necrosis uye Somatic Peritonitis - THE RIGID BELLY STAGE):**
  7. Mushure memaawa matanhatu kusvika gumi nemaviri ekuyerera kweropa, kufa kwemasero kunopisa nzira yese nemuscular wall kusvika kunze ** serosal surface ** yebowel (** transmural infarction / gangrene **).
  8. Utachiona, endotoxin, uye necrotic fluid inodonhedza nemumadziro emukati akafa uye inobata **parietal peritoneum ** inonamira mukati memadziro edumbu, iyo ine waya yakapinza **somatic nerves **.
  9. Ikozvino chete dumbu rinotendeuka ** bhodhi-rakaoma, rakasimba, uye rakanyanya kunyorova kune kudiki kubatwa kana kuputika kwedanda (rebound kunyorova uye peritonitis) **, inoperekedzwa netsvina-inonhuwa yakasviba ine ropa stool ("currant-jelly" stool), septic shock, uye multi-organ kutadza.

Iwo mana akasiyana ekiriniki marudzi eacute mesenteric ischemia

Maererano ne **WSES uye ESVS mirayiridzo **, acute mesenteric ischemia inokonzerwa nemaitiro mana akasiyana, imwe neimwe iine chimiro chemurwere, kukurumidza kwekutanga, uye kurapwa kwechipatara:

AMI Subtype (% yeNyaya) Typical Patient Risk Factors Kukurumidza kweKutanga & Clinical Presentation Specific Hospital Treatment
**1. Arterial Embolism (40% kusvika 50% - Yakanyanya Kuzivikanwa) ** Atrial fibrillation (AFib) (kunyanya kana ichibva anticoagulants kana subtherapeutic INR), ichangoburwa myocardial infarction (left ventricular mural thrombus), endocarditis, cardioversion, kana aortic catheterization. ** Pakarepo ("Bolt kubva kublue"):** Kamwe kamwe, njodzi 10/10 pakati pedumbu kurwadziwa + **kumanikidza ura kubuda ** (kukurumidzira kurutsa uye manyoka ane mvura mukati me30 mins yekurwadziwa kutanga). Pakarepo IV heparin + endovascular aspiration embolectomy kana kuvhura kuvhiya Fogarty balloon embolectomy yeSMA + bowel viability check.
**2. Acute Arterial Thrombosis-in-Situ (20% kusvika 35%) ** Yakanyanya generalized ** atherosclerosis** (kuputa, chirwere cheshuga, hypertension, peripheral artery disease, coronary artery disease). Vanopfuura makumi manomwe muzana vakamboita Chronic Mesenteric Ischemia ("intestinal angina"): marwadzo asina kusimba maminetsi gumi nemashanu kusvika makumi matanhatu mushure mekudya kwega kwega, zvichiita kuti "kutya chikafu" (sitophobia) uye kudzikira uremu ne5 kusvika ku15 kg mumwedzi yapfuura. Subacute kana kamwe-kamwe: Chikwangwani chiri pamavambo chaiwo (ostium) cheSMA chinoputika uye chivharo chinovharika, chinowanzokonzerwa nekushaya mvura nemvura kana kuderera kweropa; inopinza ura hwese kubva ku duodenum kuenda ku transverse colon. Endovascular **angioplasty uye stenting ** yeSMA yakabva (retrograde open mesenteric stenting [ROMS]) kana kuvhiya **aorto-mesenteric bypass graft **.
3. Non-Occlusive Mesenteric Ischemia (NOMI - 15% kusvika 20%) Kurwara kwakanyanya ICU kana varwere vakwegura mu ** cardiogenic shock, septic shock, post-cardiac surgery, yakanyanya kupera mvura, hemodialysis fluid kubviswa , kana kugamuchira high-dose vasoconstrictors ( norepinephrine, vasopressin, phenylephrine, digoxin **) kana ** cocaine / methamphetamine ** kushungurudzwa. Hapana kuvharika kweropa mutsinga: Pane kudaro, kunzwira tsitsi/zvinodhaka-kunyanyisa splanchnic arterial vasospasm kunosunga matavi eSMA kuvharika kwemaawa akawanda kusvika ura hwafa. Misa vasoconstrictors, dzorera kubudiswa kwemwoyo uye uwandu hwemvura, shandisa intra-arterial vasodilators (**papaverine kana prostacyclin **), uye resect necrotic bowel.
**4. Mesenteric Venous Thrombosis (MVT - 5% kusvika 15%) ** Varwere vechidiki kana vepakati-kati vane ** nhaka kana kuti vakawana matambudziko ekuvhara (thrombophilia: Factor V Leiden, prothrombin mutation, kushayikwa kweprotein C / S, JAK2 myeloproliferative disorder) **, ** chiropa cirrhosis / portal hypertension **, intra-abdominal kuzvimba (pancreatitis, diverticuldobdominal), osralceptive, IBD. Kutanga zvishoma nezvishoma kwemazuva maviri kusvika ku7: Kuwedzera kuenderera mberi kwemarwadzo emudumbu emudumbu, kusvotwa, anorexia, uye kuzvimba segwanda riri mu Superior Mesenteric Vein (SMV) rinovharira kubuda kwetsinga, zvichikonzera kuzvimba kukuru kwemadziro emudumbu uye kubuda ropa. Immediate high-dose systemic anticoagulation (IV Heparin) ndiyo inonyanya kurapa (85%+ inopora pasina kuvhiyiwa kunze kwekunge peritonitis ichikura).

Kusiyanisa acute mesenteric ischemia kubva kune ischemic colitis uye mamwe matambudziko emudumbu

Mhando mbiri dzakasiyana dzegut ischemia dziripo, uye kuvavhiringidza kunotungamirira kunonoka kune ngozi: Acute Mesenteric Ischemia (AMI) inokanganisa small intestine (SMA) uye inokurumidza kuuraya pasina emergency revascularization, nepo Ischemic Colitis inokanganisa **nzvimbo dzakadirwa mvura yedumbu guru (inogadzirisa chipatara chemukati uye chigadziro chekuchengetedza).

Feature Acute Mesenteric Ischemia (Small Bowel / SMA Emergency) Acute Ischemic Colitis (Matumbu Makuru / Mudumbu Mvura) Perforated Peptic Ulcer Ruptured Abdominal Aortic Aneurysm (AAA)
**Anatomical Vessel & Gut Segment ** Superior Mesenteric Artery (SMA): Hura hwese + hwekurudyi. Madiki microvascular mapazi pa colonic "watershed" bends (** Splenic Flexure [Griffith's point] ** uye ** Rectosigmoid Junction [Sudeck's point] **). Dumbu kana duodenal bulb wall perforation. Infrarenal abdominal aorta kuputika mu retroperitoneum.
Kuoma uye Hunhu hweKurwadza ** 10/10 inorwadza, isingaregi kurwadziwa kwepakati pedumbu ** kunze kwekuenzana nebvunzo yakapfava; narcotics haatomboibata. **Kurwadza kuri pakati nepakati kuruboshwe kuzasi quadrant mudumbu kurwadza ** kunoteverwa mukati memaawa gumi nemaviri-24 ne kupfuura kweropa rakatsvuka kana maroon muchigaro. Kamwe kamwe banga-kunge epigastric kurwadziwa iyo ** pakarepo inoita dumbu rose bhodhi-yakaoma uye yakaoma **. Kamwe kamwe kubvaruka pakati pedumbu, chiuno, uye ** kurwadza kwepasi kumashure ** ne ** pulsating belly mass ** uye pakarepo kuvhunduka.
Early Physical Exam ** Dumbu rakapfava, risina kunyorova kana kuti rakapfava zvishoma ** kwemaawa mana kusvika matanhatu ekutanga ("soft belly trap"). Hunyoro-ku-pakati-kunyoro kune rumwe rutivi rworuboshwe rwekoloni; hapana peritonitis mu85%. ** Pakarepo yakasimba "bhodhi remapuranga" mimba ** kubva kune asidi inopisa peritoneum; murwere anorara asingapfakanyiki. Hypotension, pallor, pulsatile mass pamusoro peguvhu.
**Kufa Kwehuwandu ** ** 60% kusvika 80% ** kana isina revascularized mukati maawa matanhatu kusvika gumi nemaviri. pasi (<5% to 10%): 80%+ inopora mukati memazuva nemvura yeIV, kuzorora ura, uye mishonga inorwisa mabhakitiriya (kunze kwekunge gangrenous). Yakakwira kana kuvhiyiwa kwakanonoka kupfuura maawa matanhatu kusvika gumi nemaviri. Kupfuura 80% pasina nekukurumidza aortic clamping / EVAR.

Nei yakajairika blood lactate level ZVISANGANISE kunze acute mesenteric ischemia

Imwe yenhema dzinouraya zvikuru mumakamuri ekukurumidzira yakamirira ropa rakakwirira ** serum lactate level (lactic acidosis)** isati yarayira CT angiogram yekufungidzira mesenteric ischemia.

Iyo yakajairika-lactate diagnostic trap (WSES Clinical Guideline Yambiro)

Kana ura hudiki hune nzara yeropa reropa, masero aro anobva achinja kune anaerobic glycolysis uye anogadzira huwandu hukuru hwe ** L-lactate uye D-lactate **. Zvisinei, kwekutanga 2 kusvika kumaawa matanhatu , zvinhu zviviri zvinochengeta ruoko rwemurwere-tsinga yeropa lactate level zvachose (<2.0 mmol/L): 1. Nekuda kwekuti ropa rinoyerera nemuura rakavharika kana kuti rakamira, lactate inoramba yakavharirwa mutsinga dzemesenteric. 2. Chero chero lactate inobuda muura inofamba ichienda neportal vein yakananga muchiropa, uko maseru echiropa ane hutano anokurumidza kujeka uye kugaya lactate kuburikidza neCori cycle isati yambosvika pahurongwa hweropa. Nekuda kweizvozvo, kukwira kweserum lactate level chiratidzo CHEKURAMBERI chekugadzika, kazhinji chisingachinjiki chetransmural bowel necrosis, apo simba rekuchenesa chiropa rinopedzisira rakurirwa. Usambofa wakabvumira mwero wakajairika weropa kunonoka biphasic CT angiogram mumurwere ane kurwadziwa kwakanyanya mudumbu zvisingaenzaniswi nebvunzo.

Chipatara chekuongorora goridhe chiyero uye yakasanganiswa yekuvhiya / endovascular salvage

Paunosvika kudhipatimendi rekukurumidzira uye wozivisa timu kuti inofungidzirwa acute mesenteric ischemia, miniti yega yega inoverengera ku 6-awa yekubvisa ura hwindo:

1. Immediate Biphasic Computed Tomography Angiography (CTA)

Plain abdominal X-rays uye standard abdominal ultrasounds haigoni kubvisa mesenteric ischemia (panguva iyo X-ray inoratidza huturu hwegasi mukati memadziro emukati, inonzi ** pneumatosis intestinalis **, kana gasi mutsinga yemukova, ura hwatofa). - Muedzo mumwe chete unosungirwa ndeye STAT Biphasic (Arterial + Portal Venous Phase) Multidetector CT Angiogram (CTA) yeAbdomen nePelvis ine intravenous mutsauko (uye **HAPANA mutsauko wemuromo **, iyo inononoka scan neawa uye inovharira tsinga dzeropa). - **Kunyange kana murwere akakwira creatinine kana chirwere cheitsvo chisingaperi, nhungamiro dzinoraira kupa IV mutsauko nekukurumidza **, nekuti kushaikwa kweacute mesenteric ischemia kunenge kwauraya pasi rose, nepo kusiyana kwenephropathy kunogona kutariswa neIV hydration.

2. Pakarepo Medical Resuscitation Bundle

Murwere asati apinda mukamuri yekuvhiya kana yekupindira suite, timu yekukurumidzira inotanga mana ekukurumidza kurapwa: 1. Aggressive Intravenous Crystalloid Resuscitation: Isotonic fluid (Ringer's lactate kana normal saline) kudzoreredza intravascular volume yakarasika mumadziro eura akazvimba. 2. Immediate Intravenous Unfractionated Heparin Bolus and Drip: Inomisa clot muSMA kana SMV kuti isapararire kuita matavi madiki eArcade. 3. Broad-Spectrum Intravenous Antibiotics: Nemhaka yokuti mucosal villi inotanga kufa mukati memaminitsi makumi matatu, mabhakitiriya emudumbu (E. coli, Klebsiella, Bacteroides) anobva angotama achipfuura nemuvhariyori weura akakuvadzwa achipinda muropa; nhungamiro inorayira pakarepo IV mishonga inorwisa mabhakitiriya inovhara Gram-negative bacilli uye anaerobes (semuenzaniso, ceftriaxone kana cefepime + metronidazole, kana piperacillin-tazobactam). 4. Kudzivisa Alpha-Adrenergic Vasoconstrictors: Kana BP ikaramba yakaderera mushure memvura, varapi vanoedza kudzivisa high-dose norepinephrine kana vasopressin (iyo clamp gut arteries tighter) uye inofarira inotropes yakafanana nedobutamine kana pasi-dose vasopressor rutsigiro kana vhoriyamu yadzokororwa.

3. Revascularization, Damage-Control Resection, uye "Second-Look Laparotomy"

Mukamuri yemazuvano Hybrid Operating Room, vevascular and general surgeons vanoshanda padivi nepadivi: 1. Dzoresa kuyerera kweropa PAKUTANGA: Pese chero ura hunogona kuponeswa, kubuda kweropa kunodzoserwa kutanga kuburikidza neendovascular catheter aspiration thrombectomy, mechanical thrombectomy, kana SMA stenting, kana kuti kuburikidza kuvhiya kwekuvhura Fogarty balloon embolectomy / aorto-mesenteric bypass. Zvishwe zvakawanda zve dusky, bluish-purple bowel zvinochinja pink uye zvinotanga kubata zvakare mukati memaminitsi gumi nemashanu ekudzorera arterial pulse. 2. Rejera ura wakafa (utema/wakaboborwa) USINA kusonanidza magumo pamwe chete (Damage-Control Surgery): Chero chikamu cheura chatova dema, bepa-mutete, kana kuti chakaboborwa chinoitwa kuvhiyiwa nekubviswa. 3. The Mandatory 24-to-48-Hour "Second-Look Laparotomy": Nekuti kazhinji hazvigoneke panguva yekutanga kuvhiyiwa kutaura kana borderline-dusky zvishwe zvemukati diki zvichapora mushure mekuyerera kweropa kana kufambira mberi kune necrosis, vanachiremba vanovhiya nemaune vanosiya iyo stapled bowel inopera mukati medumbu pasi pechipfeko chechinguvana murwere ari muICU kwe24 kusvika maawa 48, uye wodzosa murwere kukamuri rokuvhiyira kuti Second-Look Laparotomy kuti aongorore masendimita ose eura hwasara asati asona ura une utano hunopera pamwe chete. Iri zano rinochengetedza masendimita akakosha ehura mudiki uye kudzivirira hupenyu hwese Short Bowel Syndrome.

Dziviriro yekutarisa: kuziva "Intestinal Angina" uye kudzivirira kubva kuAFib clots

  • ** Usambofa wakafuratira "Intestinal Angina" (Chronic Mesenteric Ischemia):** Kana munhu mukuru ane nhoroondo yekusvuta, peripheral artery disease, kana chirwere chemwoyo anotanga kubereka kusuruvara kunorwadza mudumbu ** maminitsi 15 kusvika ku60 mushure mekudya kudya ** (inogara 1 kusvika kumaawa maviri kusvika 1 kusvika kumaawa maviri kusvika kugaya kudya kunopera, kuderera kwekudya kunopera, kuderera kwekudya kunopera) uye anorasikirwa nehuremu nekusaziva, kumbira kukurumidza kuvhiyiwa kwevascular kutumira kune mesenteric duplex ultrasound kana CTA. Kutsinhanisa yakatetepa SMA mavambo nenzira inodzivirira inouraya acute thrombotic infarction.
  • Chengeta kuomerera kwakasimba kune zvakatemerwa zvinoderedza ropa muAtrial Fibrillation: Usambofa wakambomira kana kumisa apixaban, rivaroxaban, edoxaban, dabigatran, kana warfarin pasina bhurogi rakajeka rachiremba.
  • **Ramba uine hydrated zvakanaka panguva yekupisa kwemafungu kana chirwere chemudumbu ** kana uine chirwere chakanyanya chevascular kana nhoroondo yekuvharwa kweropa.

Ruzivo rwekuunganidza kuchipatara vascular uye timu yekuvhiya

Ndichiri kumirira ambulensi, kugadzirira zvikamu zvina zvakakosha zvenhoroondo yekurapa zvinochengetedza maminetsi akakosha mudhipatimendi rekukurumidzira:

  1. Chaicho wachi nguva marwadzo emudumbu akatanga: Kungofanana nesitiroko kana kurwiswa kwemoyo, vavhiyi vevascular vanoshandisa awa chaiyo yechiratidzo chekutanga kuona kuti ura huri pedyo sei ne6-awa transmural necrosis threshold.
  2. ** Yakazara rondedzero yemwoyo rhythm uye vascular diagnosis: ** Nyora pasi kana murwere ane paroxysmal kana zvachose atrial fibrillation, prosthetic heart valve, ichangopfuura myocardial infarction, peripheral artery bypasses, kana chero nhoroondo yedeep vein thrombosis kana pulmonary embolism.
  3. Mishonga ichangoburwa inochinja kana kuroyiwa: Huya nemabhodhoro akanyorwa nechiremba, uchinyatsotarisa kune chero ipi zvayo inoderedza ropa ichangobva kuitwa kuti ishanyirwe mazino, colonoscopy, kana kuvhiyiwa, kana chero ichangotanga diuretic (piritsi remvura) kana digoxin.
  4. Ivo isati yashanda kana kusiyanisa nhoroondo yekusawirirana: Kuita kuti chiremba wekukurumidzira azive basa rekutanga reitsvo remurwere kunovabatsira kugadzirira post-scan intravenous hydration vachienderera mberi nekukasika nehupenyu hunoponesa biphasic CT angiogram.

Nhamba dzenharaunda dzechimbichimbi uye zvirongwa zveagency

Acute mesenteric ischemia inoda kukurumidza kutakura ambulensi kuenda kuchipatara chikuru ne **24-awa CT Angiography, Vascular Surgery, Interventional Radiology, uye General/Trauma Surgery **:

  • United States neCanada: Dial 911. Kumbira kutakurwa kuenda kuchipatara chepamusoro-soro kana chipatara cheLevel ½ (usambofa waenda kukiriniki yakasununguka yekukurumidzira marwadzo emudumbu kamwe kamwe).
  • United Kingdom: Dhonza 999 yeamburenzi yechimbichimbi kana kuenda nekukurumidza kuchipatara chikuru chakakomba Dhipatimendi reEmergency (A&E) ine on-site Arterial Vascular Center uye Emergency General Surgery.
  • European Union: Dial 112. Inotungamirirwa pasi pe **European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines pamusoro peKutarisira Zvirwere zveMesenteric Arteries uye Veins ** uye **WSES Guidelines **.
  • Australia neNew Zealand: Dial 000 muAustralia kana 111 muNew Zealand.
  • India neAsia-Pacific: Dial 112 (kana 108 muIndia), 995 muSingapore, 119 muJapan neSouth Korea, kana 999 muMalaysia neHong Kong. Pfuurira zvakananga kuchipatara chepamusoro ne 24-awa MDCT angiography uye kuvhiyiwa kwevascular/GI.

Mibvunzo inowanzo bvunzwa

Chii chinonzi "marwadzo kunze kwechiyero chekuongorora kwemuviri" zvinorevei mune acute mesenteric ischemia?

Muzviitiko zvakawanda zvemudumbu (se appendicitis kana chironda chakaboorwa), jira rekunze remudumbu (parietal peritoneum) rinobva razvimba ipapo ipapo, saka kudzvanya padumbu remurwere kunokonzera kurwadziwa kwakanyanya uye kuoma kwetsandanyama kusingaite (kurinda). Muacute mesenteric ischemia, ropa rakagwamba rinofa nenzara mukati memukati meura kutanga apo kunze kwekunze kunoramba kuripo kwemaawa mana kusvika matanhatu ekutanga. Izvi zvinokonzera kurwadza kwe10/10 yakadzika yevisceral iyo inoita kuti murwere anyanye mukurwadziwa, asi kana chiremba achimanikidza kunze kwedumbu, dumbu rinonzwa rakanyorova uye rakasununguka. Kuziva kusawirirana uku mumaawa matanhatu ekutanga ndiko kunoponesa hupenyu hwemurwere.

Sei vanhu vane atrial fibrillation vari panjodzi yakakura kudaro yekukasira gut ropa clot?

Muatrial fibrillation (AFib), makamuri ekumusoro emwoyo anodedera zvisina nguva pane kudzvinya zvakanaka, zvichiita kuti ropa rimire rimire rivhare uye kugwamba mukati mehomwe diki inonzi left atrial appendage. Kana murwere akapotsa madosi eropa rake rakatetepa (kana kuti asina kuongororwa AFib), chidimbu chegwamba iroro chinogona kubuda, kupomba kubva pamwoyo kupinda mutsinga, uye kutsvedzerera zvakananga pasi ne 45-degree angle yepamusoro mesenteric artery, kucheka kuyerera kweropa kusvika kudumbu duku rose mukurova kwemoyo kumwe chete.

Chii chinonzi "kutya kwekudya" (sitophobia) kana "intestinal angina," uye nei chiri chiratidzo chekunyevera?

Kungofanana netsinga dzemwoyo dzakatetepa dzinokonzera kurwadziwa kwechipfuva (angina) panguva yekurovedza muviri apo tsandanyama yemwoyo inoda ropa rakawanda, cholesterol-yakamanikana gut arteries inokonzera crampy central abdominal kurwadziwa 15 kusvika 60 maminetsi mushure mekudya chikafu, apo ura hunoda ropa rakawedzerwa kugaya chikafu. Kwemavhiki kana mwedzi, varwere vanodzidza kuti kudya kunokonzera marwadzo, saka vanotya kudya (sitophobia) uye vanorasikirwa ne10 kusvika ku30 mapaundi vasingadi. Inenge 70 muzana yevarwere vanotambura inouraya acute mesenteric artery thrombosis vaiva nezviratidzo izvi zvekunyevera zvisati zvaitika; kubata uye kupinza tsinga yakatetepa nekukurumidza kunodzivirira bowel infarction.

Ko bvunzo yeropa lactic acid (lactate) inogona kubvisa tsinga yakavharika?

Kwete, hazviite. Mukati memaawa maviri kusvika matanhatu ekutanga eacute mesenteric ischemia, lactic acid inogadzirwa neoxygen-nzara ura inovharirwa mutsinga dzisina kumira mudumbu kana kupepetwa zvachose nechiropa isati yasvika mutsinga dzeruoko uko kunotorwa ropa. Panosvika mwero weropa welactate uchikwira kumusoro, madziro emuura kazhinji anenge atove neronda reronda risingadzoreki. Vanachiremba vanofanira kuraira mutsauko wekukurumidza CT angiogram zvichibva pakunyumwira kwekiriniki pasina kumirira kuti lactate isimuke.

Sei vanachiremba vanoita "Second-Look Laparotomy" maawa 24 kusvika ku48 mushure mekuvhiyiwa kwegut clot?

Apo vanovhiya vanodzorera kuyerera kweropa kune ischemic intestine uye kubvisa chero zvikamu zviri pachena zvitema uye zvakafa, kureba kwenguva refu kwemukati wakasara ura kazhinji unotarisa dusky uye wakapwanyika, zvichiita kuti zvisingakwanisi kuziva nechokwadi muawa yekutanga kana zvishwe izvozvo zvichapora kana kufa. Kana vavhiyi vakacheka ura hwese hwepamuganhu ipapo ipapo, murwere anogona kusara aine Short Bowel Syndrome (asingakwanisi kutora chikafu). Pane kudaro, vanachiremba vanosiya dumbu rakapfeka kwenguva pfupi, tsigira murwere ari muICU kwemaawa 24 kusvika ku48 kuti ura hwakadzokororwa hudzoke, uye voongororazve ura muimba yekuvhiya vasati vabatanidza zvakare magumo ane utano.

Ndeupi musiyano uripo pakati peacute mesenteric ischemia uye ischemic colitis?

Acute mesenteric ischemia kuvharika kwehupenyu kwetsinga huru (superior mesenteric artery) inopa ura hudiki hwese uye colon yekurudyi; inokonzera 10/10 kurwadziwa kwepakati uye inouraya 60 kusvika ku80 muzana yevarwere kunze kwekunge kuyerera kweropa kuchidzorerwa kuvhiyiwa mukati memaawa. Ischemic colitis inowanzoitika, kazhinji kudonha kwekanguva kweropa re microvascular kusvika ku "watershed" mabhendi ekuruboshwe ura (colon), zvichiita kuti zvinyoro-nyoro zvakasara-sided belly cramps inoteverwa mukati memaawa makumi maviri nemana nemaroon kana ropa rakatsvuka rakajeka muchitsiko; pamusoro pe80 muzana ye ischemic colitis kesi dzinoporesa mukati memazuva mashoma nemvura inopinza uye kuzorora kwebowel.

Nzvimbo uye nhungamiro yepamutemo

  • World Society of Emergency Surgery (WSES, International): Acute Mesenteric Ischemia: Updated Guidelines of the World Society of Emergency Surgery (Bala et al., World Journal of Emergency Surgery, 2022/2023 update: CTA pakarepo pasina kumirira lactate, anticoagurst-vascular fizikisi kukuvara-kudzora kwechipiri-kutarisa laparotomy).
  • European Society for Vascular Surgery (ESVS, Europe): Sarudzo yeMupepeti - Kutarisira Zvirwere zveMesenteric Arteries uye Veins: Clinical Practice Guidelines yeEuropean Society for Vascular Surgery (Björck et al., European Journal of Vascular and Endovascular Surgery).
  • American College of Gastroenterology (ACG) & American Gastroenterological Association (AGA, United States): ACG Clinical Guideline: Epidemiology, Risk Factors, Patterns of Presentation, Diagnosis, and Management of Colon Ischemia uye Acute Mesenteric Ischemia.
  • Society for Vascular Surgery (SVS, United States): Clinical Practice Guidelines for Chronic and Acute Mesenteric Ischemia.
  • National Institute for Health and Care Excellence (NICE) & Royal College of Surgeons yeEngland (United Kingdom): Emergency General Surgery uye High-Risk Acute Abdominal Pain Triage Pathways.

Tora kosi yerubatsiro rwekutanga yakasimbiswa uye bvunza nyanzvi

Gwaro iri rinopa ruzivo rwechimbichimbi uye dzidzo yerubatsiro rwekutanga uye haitsive kuongororwa kwehunyanzvi hwekurapa kana kuvhiyiwa kwevascular. Kuti udzidze kuziva matambudziko ekurapa akanyanya, kugadzirisa kuvhunduka, uye kuita CPR, tora kosi yerubatsiro rwekutanga yakasimbiswa kuburikidza neRed Cross, St John Ambulance, kana mupi wepano.

Mazano anoenderana