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Med Clin N Am 92 (2008) 627–647

Acute Abdominal Vascular Emergencies
Charles J. Shanley, MD, FACS*, Jeffrey B. Weinberger, MD
Department of Surgery, William Beaumont Hospital, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA

Abdominal vascular emergencies are relatively uncommon, frequently catastrophic, and highly lethal. Despite improved understanding of the pathophysiology andnatural history of these disorders, delays in diagnosis and treatment remain the most important factors contributing to the observed high mortality. Although diagnostic imaging may confirm the diagnosis or help plan the surgery, it is important to remain clinically vigilant because an initially stable patient can rapidly deteriorate. Despite the complexities of clinical management, preoperativedecision making is generally straightforward. For a suspected abdominal vascular emergency, the advantage of delaying intervention to obtain confirmatory diagnostic tests and for extensive preoperative resuscitation is outweighed by the risk for fatal massive intestinal necrosis or exsanguination. When an abdominal vascular catastrophe is clinically suspected, therefore, the presence of a competentsurgeon and an available suitably equipped operating room are generally the only prerequisites to proceed with intervention. In these situations, the consequence of further delays in treatment perforce outweighs the probability of finding new, clinically useful information through additional diagnostic tests or the benefits of further emergency resuscitation. Treatment delays are also generally morecostly in patients who have multiple comorbidities and poor physiologic reserve. Any delay should be undertaken in consultation with the surgeon who is ultimately responsible for the care of the patient. More patients die of not receiving an emergency operation to stop hemorrhage or to restore intestinal perfusion, than die of a negative laparotomy. A high index of clinical suspicion together with asound understanding of the clinical presentation, natural history, and management of these disorders are critical to improving outcomes. This

* Corresponding author. E-mail address: cshanley@beaumont.edu (C.J. Shanley). 0025-7125/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.mcna.2008.01.004 medical.theclinics.com

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articlefocuses on abdominal vascular emergencies presenting with acute visceral ischemia or catastrophic intra-abdominal hemorrhage (Table 1).

Abdominal vascular emergencies: acute visceral ischemia Acute embolic mesenteric ischemia Acute embolic occlusion of the superior mesenteric artery (SMA) remains a catastrophic vascular disorder with a mortality exceeding 50% [1–6]. Delayed diagnosis and treatmentleading to intestinal necrosis and infarction is responsible for this high mortality. The classic presentation is the sudden onset of severe abdominal pain out of proportion to the physical findings and often accompanied by abrupt emptying of the gut with vomiting or diarrhea. Bloody diarrhea, peritonitis, and sepsis are late findings associated with transmural intestinal ischemia and infarction;they portend a poor outcome. Cardiogenic emboli underlie most cases. Risk factors include atrial fibrillation, recent myocardial infarction, ventricular aneurysm, prosthetic heart valve, and rheumatic heart disease. Synchronous emboli to the brain or extremities are not uncommon. A complete neurologic and peripheral vascular examination is imperative in these patients. Although many patients haveprior cardiac or atherosclerotic diseases, few patients have antecedent symptoms of chronic mesenteric ischemia, such as postprandial abdominal pain or weight loss. The differential diagnosis of the acute onset of severe abdominal pain includes perforated ulcer, intestinal obstruction, acute pancreatitis, acute cholecystitis, and nephrolithiasis. Laboratory findings are nonspecific but may include...