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Ischemic Bowel Disorders

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Ischemic bowel disease is the term used to describe disorders that cause insufficient blood flow to the gastrointestinal tract. (Table 412-1).1 Arteriosclerotic vascular disease is the major cause of ischemic bowel disease in adults but is extremely rare in children. Most pediatric cases of acute childhood ischemic bowel disease result from extrinsic obstruction, hypercoagulable states, or following hypovolemic shock.2

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Table 412-1. Disorders Associated with Gastrointestinal Ischemia
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Clinical findings with mesenteric vascular insufficiency consist of postprandial colicky periumbilical pain, with symptoms that are far worse than would be expected from physical examination of the abdomen. Similar symptoms can also be experienced with ischemia of the spleen or omentum. Acute vascular insufficiency results in nonspecific findings including ileus, bilious vomiting, and mucosal necrosis with hematemesis or hematochezia. Symptoms may worsen following reperfusion. Ischemic injury should be considered if symptoms persist or worsen following an acute insult such as shock or surgical obstruction. Chronic vascular insufficiency may result in protein-losing enteropathy, steatorrhea, or carbohydrate malabsorption.

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Diagnosis of ischemic bowel disease or other vascular disorders of the bowel requires a high degree of suspicion and is mainly dependent upon the history and physical examination.3 Confirmatory studies may include gastric tonometry, Doppler ultrasound, and abdominal computerized tomography (CT). In some cases, mesenteric angiography may be necessary to establish the diagnosis. Due to the rarity of ischemic disease in childhood, endoscopic findings (see eFig. 412.1) of exudate are often misinterpreted as being due to inflammatory bowel disease. Biopsy generally shows acute inflammatory changes. Chronic ischemia may be associated with fibrosis. Treatment depends upon the underlying cause and may include resection of involved bowel, anticoagulation therapies, and interventional radiographic therapies.

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eFigure 412.1.
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Colonoscopic findings with ischemia. There is a diffuse exudate. In cases of acute ischemia, the mucosa may appear cyanotic or necrotic.

(Courtesy of www.gastrolab.net. With permission.)

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Rarely, symptoms similar to ischemic bowel disease result from mesenteric venous inflammation. Mesenteric inflammatory venoocclusive disease is characterized by extended thrombophlebitis and fibrous organized thrombosis of multiple veins, not the arteries.4 Diagnosis is usually made on pathology of bowel resected for ischemia.

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Systemic vasculitic diseases (especially polyarteritis nodosa), anatomical malformations of the mesenteric artery, degas disease, and dermatomyositis are the most common chronic or recurrent causes of bowel ischemia in children.2Dermatomyositis can be associated with mesenteric vasculitis, intestinal ulcerations, and perforations. Other collagen vascular disorders, including polymyositis, polyarteritis nodosa...

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