NMS. Casos Clínicos

226

Part II ♦ Specific Disorders

Q: What long-term management plan is appropriate? A: Most surgeons would place the patient on antiplatelet therapy. In addition, evaluation for the presence of cardiac and peripheral vascular disease is warranted because it is probably present and will affect survival.

Case 8.7 Abdominal Pain with Suspected Mesenteric Ischemia A 75-year-old similar to the patient in Case 8.6 presents to the emergency depart- ment. Based on the history and physical examination, mesenteric ischemia is a pos- sibility. Q: How would the following findings influence your evaluation? Case Variation 8.7.1. Significantly worsening pain over the next hour ◆ ◆ Concern that the patient has necrotic bowel should prompt you to proceed to the oper- ating room. A vascular surgeon should be consulted and ideally the patient placed on an operating room table where angiography and stenting can be done. Thus, evaluation of the mesenteric vessels and revascularization can be performed if indicated. Case Variation 8.7.2. WBC count of 24,000/mm 3 ◆ ◆ Ischemia, necrosis, or perforation with infection should be suspected. Most surgeons would view this as an indication to proceed to the operating room. Case Variation 8.7.3. WBC count of 2,500/mm 3 ◆ ◆ Your concerns should be similar to those in Case Variation 8.7.2. Older individuals, in par- ticular, sometimes respond to overwhelming sepsis with leukopenia, often with a marked left shift. Case Variation 8.7.4. Moderate to severe metabolic acidosis ◆ ◆ Your concerns should be similar to those of a patient who has a WBC count of 24,000/mm 3 (see Case Variation 8.7.2). Case Variation 8.7.5. Atrial fibrillation ◆ ◆ Embolization to the bowel from a thrombus in the left atrium associated with atrial fibril- lation should be suspected. Depending on the patient’s overall status, an angiogram of the mesenteric circulation before exploration is a possibility; exploration is most likely neces- sary. The embolus can be removed and arterial flow reestablished if indicated. Case Variation 8.7.6. History of abdominal bruit ◆ ◆ A bruit is an audible vascular sound associated with turbulent blood flow heard on aus- cultation. A bruit may suggest stenosis of the celiac and mesenteric vessels among other diagnosis such as an aortic aneurysm . An evaluation including an ultrasound or CT angiogram should be performed. Most patients with bowel ischemia do not have bruits. SAMPLE