In 28% of cases, in the case of abdominal pain it is necessary to think about
intestinal obstruction;
in 22.5% of cases the cause is unknown, in 8.9% to
cholelithiasis, 8.5% to diverticulosis, 5.5% to tumor, appendicitis in 4.2% of
cases, peptic ulcer in 4.2%, pancreatitis 3.8%, urology 3.2%, aortic aneurysm
3%, and 1.5% at occlusion of a.mesenterica.
So, as you can see, in a percentage
of 8% of cases it is necessary to think of acute vascular abdomen.
- Abdominal aortic aneurysm / iliac axis during dissection or breaking
- intestinal infarction
- Kidney infarction
- Splenic infarct
- Evolution of thoracic aortic dissection
- Racing aneurysms visceral arteries
The intestinal infarction or intestinal throttling is the necrosis of a tract of
intestine caused by a vasomotor disorder or by the occlusion of the mesenteric
arteriovenous circulation.
In practice, an abrupt interruption of the bloodstream occurs (thrombo-embolic
occlusion, or ischemic without occlusion, especially in the course of shock) at
the level of the mesenteric network by arterial or venous obstruction, which
evolves towards the necrosis of a more or less extended part bowel.
The causes of circulatory obstruction can be:
- the formation of thrombi (due to more frequent finding) on atherotic plaques
that realize primitive obstructions of the superior mesenteric vessels, arterial
and venous. There are no secondary obstructions (such as volutes, bottlenecks,
etc.);
- the arrival of emboli from the general circulation (typically in carriers of
atrial fibrillation);
- pressure drops, shocks (non-occlusive ischemies due to functional causes).
Ischemia can affect both the arterial and venous districts.
The acute vascular abdomen is:
- the 13th cause of death in the USA with 15,000 deaths / year of these patients
- about 50% decline before arriving at the hospital
- approximately 25% decline before entering the Operating Room
- Acute ischemia of the lower limbs: embolization of thrombotic material from
the aneurysmal sac
- Fixation: progression towards breaking
-Rotation: hemorrhagic hemorrhage or hemoperitoneum shock
- Break with perforation:
- Inferior vena cava with high-flow A-V fistula with high-throw heart failure
- Intestinal segment (75% III porz duodenale) with hematemesis, melena
The intestinal ischemia are divided into:
- intestinal infarction due to occlusion of mesenteric vessels from thrombosis
or embolism of the superior mesenteric artery. There is an intensely violent
pain in the epigastric, mesogastric or hypogastric, which soon spreads to the
whole abdomen and often irradiates to the loins; the pain after a few hours can
give way to resume after a few hours. Frequently diarrhea arises, sometimes with
blood feces, but soon the alvo closes. The abdomen is meteoric; the intestinal
loops are extended, but do not have hydro-avaible levels and are not
hyperperistaltic
Thrombosis and embolism of the inferior mesenteric artery is somewhat rare and
may even start asymptomatic (given the existence of an efficient anastomotic
network); the pain, when it is present, is localized to the lower quadrant of
the left and the emission of blood faeces is very frequent.
- Incidence is not high: less than 1/1000 admissions
- Represents approximately 1-1.5% of all acute abusers
- Generally it manifests itself with an acute onset
- 3/4 of patients aged over 60 years
- Often the infarct represents the complication of other morbid states:
- cardiac emboligene affections
- cardiac affections with low range
- polydistrictal arteriosclerosis
- abdominal infectious processes
- hypercoagulability conditions
- previous abdominal surgery
Symptoms are characterized by:
- Abdominal pain (100% of cases) with sudden intense and continuous onset
- Abdomen tendentially treatable and relaxed (no signs of peritoneal irritation)
- Vomiting (50%)
- Alvo alterations: diarrhea and / or constipation (30%)
- Occult bleeding (25%)
- acute portal thrombosis: it can be observed in cirrhosis of the liver,
polycythemia, after splenectomy. It manifests itself with hematemesis, melena,
abdominal pain, rapid formation ascites, paralytic ileus. The clinical picture
closely resembles that of mesenteric thrombosis. A sub-diver is frequent.
The gradual occlusion of the portal circuit, on the other hand, is well tolerated,
since the development of the collateral circulation prevents the establishment
of a portal stasis.
- rupture of aneurysmal formations: sudden and violent pain in the
epigastric-mesogastric or dorso-lumbar, continuous character, which follows more
or less precociously a very severe hemorrhagic shock.
- dissecting aortic aneurysm: the collapse of the aortic tunics, which starts in
the chest, can go up to the abdomen. Pain with a lacerating and extremely
intense character, is accompanied by pressure elevation; initially it has a
thoracic seat (anteriorly and more often posteriorly), with irradiation to the
upper limbs, then it extends to the loins and the lower limbs. Characteristic is
the decrease and inequality of radial and femoral wrists. Rupture of splenic
artery aneurysms, hepatic artery, superior mesenteric artery rupture.
When an acute abdomen is suspected, it is always necessary to investigate
whether the patient has been treated with narcotics or analgesics in general, as
they can release the abdominal contracture by masking the picture of the acute
abdomen. In the case of acute abdomen rectal exploration should not be
overlooked. The recognition of an acute abdominal syndrome, ultimately, hinges
on a detailed clinical-anamnestic examination, whose essential elements are the
evaluation of the characters of the pain, the behavior of the abdominal wall,
the behavior of intestinal canalization, the existence of disorders reflexes or
a state of shock. These are situations in which the diagnosis must be formulated
quickly because surgery must be taken immediately. However, other conditions
that go under the name of false abdomen must be taken into account.
cf >> Red infarction and white infarction
Characteristics: - rare indication of splenectomy
- triangular ischemic area
Etiology:
- embolizing heart disease (endocarditis, mitral stenosis, IMA)
- compression and local vascular infiltration
- pancreatitis, neoplastic splenomegalies (leukemia, lymphomas)
Clinic: - variable (paucisintomatic, acute abdomen)
- hypochondrium pain / sin flank, fever, splenomegaly
Diagnosis: - ECO, angioTC
Therapy: - cardiological medical
- splenectomy (severe forms, ascissualization, pseudocyst evolution)
After the medical history and the patient's visit, the blood tests, immediately perform instrumental investigations.
They are:
- direct radiography of the abdomen to try to appreciate air fluid levels and
/ or free air in the abdominal cavity
- CT of the abdomen with contrast medium and Angio tomography of the abdomen.