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64 ♀ E/A worsening abdo pain

64 ♀ E/A worsening abdo pain. 6/12 post-prandial epigastric pain. Weight loss BMI 44 Moderate COPD, hypertension Persistently elevated WCC 14.9 U/S no gallstones, OGD gastritis MRA requested ?mesenteric ischaemia. MRA. Coeliac occlusion SMA 95% stenosis IMA occlusion 5.2cm AAA

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64 ♀ E/A worsening abdo pain

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  1. 64♀ E/A worsening abdo pain • 6/12 post-prandial epigastric pain. Weight loss • BMI 44 • Moderate COPD, hypertension • Persistently elevated WCC 14.9 • U/S no gallstones, OGD gastritis • MRA requested ?mesenteric ischaemia

  2. MRA • Coeliac occlusion • SMA 95% stenosis • IMA occlusion • 5.2cm AAA • LCIA stenosis 75% • RCIA stenosis 85%

  3. Atrophic right kidney Stenosis origin left renal artery CT

  4. Options? • Percutaneous stent SMA • Access? • Back up plan/ bail out? • Need for subsequent AAA repair • Open repair and mesenteric, renal revascularisation • Iliac angioplasty, hybrid AAA repair with revascularisation

  5. Emergency! • Hypotension • Worsening abdominal pain • Rising WCC 31 • Renal impairment • No peritoneal signs • CT- no rupture AAA, no perforation/free fluid • ITU sepsis ?source • resuscitation. Would not survive major open procedure • Transbrachial angioplasty & stent

  6. Post SMA stent • Abdominal pain improved • Improved gases and WCC halved • No peritonism • Acutely ischaemic arm! • Brachial thrombectomy and patch

  7. Day 3 • Diarrhoea • Rise in WCC, abdominal tenderness • Gases normalised BE -0.6, lactate normal • CT performed • still deemed high anaesthetic risk for laparoscopy/laparotomy

  8. 3 days

  9. Day 8 • Vomiting overnight, increasing pain • Rise in inflammatory markers • BE -6.3 • ?occluded stent • Duplex- stent patent, dilated SB loops • CT

  10. Day 8

  11. Day 8

  12. Laparotomy • Multiple small areas infarction terminal ileum. Remainder very well perfused • Infarcted segment left lobe liver • Ischaemic GB • Ileal resection, cholecystectomy

  13. Discussion • Awareness of possible diagnosis essential • Definitive diagnosis often only made when advanced complications and clear clinical signs • Revascularisation often possible with angioplasty/stent/surgery • Need for vigilance post reperfusion to detect non viable bowel • CT/ relook laparotomy • Stormy post operative course normal • Mucosal sloughing/ loss of gut barrier/ need for parenteral nutrition

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