ISCHEMIC BOWEL

SYNDROME
SN KRYSS
SN CHERYL
SN MARJORIE
AN CHIARA
OBJECTIVES

• Define ischemic bowel disease

• Describe the classic presentation of
ischemic bowel disease
• Identify causes of ischemic bowel disease
• Discuss diagnostic and treatment options
• Nursing Interventions
INTRODUCTION

DEFINITION
Ischemic Bowel Disease refers to ischemia of
the large or small intestine and can be caused
by a number of distinct etiologies which share in
common reduced mesenteric blood supply to the
bowel.
INTRODUCTION

TYPES
• Ischemic colitis (colonic ischemia): hypoperfusion
of the large bowel, which is mostly transient and
self-limiting (non-gangrenous form), but can also lead
to severe acute ischemia with bowel infarction
(gangrenous form)
• Acute mesenteric ischemia: acute inadequate
blood flow to the small intestine (arterial or venous)
that can result in bowel infarction
• Chronic mesenteric ischemia: constant or
episodic hypoperfusion of the small intestine,
ANATOMY AND PHYSIOLOGY,
PATHOPHYSIOLOGY

• INTESTINES
• Main function: digest food and enable the nutrients released
from the food to enter the blood stream
• Connected to the posterior wall of the abdomen by the
mesentery, a thin vascular membrane
• Blood supply to the intestines involves three major arteries:
– Celiac trunk
– Superior mesenteric artery
– Inferior mesenteric artery
ANATOMY AND PHYSIOLOGY,
PATHOPHYSIOLOGY
ANATOMY AND PHYSIOLOGY,
PATHOPHYSIOLOGY
Intestinal Blood Supply
ETIOLOGY
OTHER RISK FACTORS

• Age
• Smoking
• COPD
• Heart problems
• Medications
• Illegal drug use
PATHOPHYSIOLOGY
CLINICAL PRESENTATION

• Cramping and abdominal pain - initially severe and

diffuse without any localization
• Diarrhea
• Nausea or vomiting
• Abdominal distension
• Bloody stools
• Hypoactive bowel sounds
DIAGNOSTIC PROCEDURES
• Blood tests
• Abdominal CT scan
• Angiography—an x-ray test used to view the
arteries supplying the bowel
MANAGEMENT
TREATMENTS
• Supportive Care
• Optimize perfusion of the ischemic region: use of IV
fluid resuscitation, optimizing cardiac output, and use of
supplemental oxygen.
• Bowel rest is given in mild cases without significant
progressed damage to the bowel. NGT insertion for
patients with sign of ileus. Parenteral nutrition should
be considered in patients with prolonged bowel rest.

• Antibiotics
• Antibiotics are administered to minimize infection, which
can quickly complicate an ischemic bowel.

• Surgery
• In more severe cases, surgery is required to remove the
ischemic colon.
CASE STUDY
PATIENT DETAILS
Name: Mr. N. H. T
Age 59
Gender: Male
ADL-independent; NKDA
Past Medical History:
– Smoker
– Hypertension
– Hyperlipidemia
– Hyperthyroidism
– Rectosigmoid Colon CA s/p LAP assisted loop sig
moid colostomy creation on 17/07/2018
• on neoadjuvant chemotherapy (last dose 03/08
/2018)
SIGNS AND SYMPTOMS

• Severe central abdominal pain radiating to back

• Writhing in pain
• No Fever chills or rigors
• No nausea and vomiting
• Passing some urine, denies dysuria
• Had chemo yesterday at NCC but has been well till
present admission
MEDICAL and SURGICAL
MANAGEMENT
•ECG- SR, Prolonged PR interval, ST Elevation
consider anterior injury
•Blood tests
• FBC (wbc 27.51, Hgb 12.6, Plt 444)
• RP ( Na 131, K 5.6, HCO3 14, Crea 145)
• CE (Trop T 71.8)
• CRP 37.7
• ABG (pH 7.36, PCO2 37.3, PO2 119.4, BE -10.1, HCO3 16.4)
• Lactate 7.1
•Abdominal Xray - NAD
MEDICAL and SURGICAL
MANAGEMENT
• CTAP 9/8/18
• showed possible closed loop obstruction with ischemic bowel.
• known sigmoid malignancy status post sigmoid colostomy
• Closed loop obstruction of the jejunum. Suboptimal mucosal
enhancement is worrisome for bowel ischemia due to strangulati
on.
MEDICAL and SURGICAL
MANAGEMENT
• Exploratory Laparotomy and Bowel Resection 9/8/18
• Moderate amount of dark hemoserous fluid on entry
• Loop of jejunum herniated through and between the defect from
the distal and proximal limbs of sigmoid colostomy
• 2m of herniated segment appears ischemic and non viable
• Involved small bowel mesentery also congested and ischemic
MEDICAL and SURGICAL
MANAGEMENT
Sent to Surgical ICU 9/8/18
– Intubated
– Hemodynamic Monitoring
– VAC on continous suction at 50 mmHg
– Blood Glucose Monitoring
– Meds:
• Fluids
• Noradrenaline
• Augmentin
• Fentanyl
• Propofol
• Piptazo
• Esomeprazole
• Paracetamol
• Albumin 5%
• Hydrocortisone
• Ciprofloxacin
MEDICAL and SURGICAL
MANAGEMENT
• s/p relook lap small bowel anastomoses and abdomial
closure 10/8/18
• Small bowel healthy with good peristalsis
• On IV noradrenaline preoperative and was weaned off
noradrenaline post-op
• Transfused 2PCT and given 400ml Albumin 5% intra-operatively
NURSING INTERVENTION

• Parameters monitoring
• HOB 30 degrees
• 2 hourly turning
• NG to LIS, 4 hourly aspiration
• telemetry monitoring
• Pain control
• Early mobilization – SOOB and ambulation
• Diet - low residual diet and ng ensure
• Ted and calf compressors
PROGNOSIS

• Transferred to General Ward on 13/August 2018

• Discharged Home on 17/August 2018
REFERENCES

• https://www.mc.vanderbilt.edu/documents/vascularsurgery/files/mesent
eric1%5B1%5D.pdf
• https://www.mc.vanderbilt.edu/documents/vascularsurgery/files/mesent
eric1%5B1%5D.pdf
• https://vascularsurgeryassociates.net/mesenteric-ischemia/
• https://www.cag-acg.org/images/publications/EN_GAST_07B.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5114213/