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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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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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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, and systemic ...