Question

Principle problemas- Ischemic disease of the gut

active problems - ARF, mesenteric venous thrombosis, Anemia, blood thrombosis, blood loss, acute respiratory failure with hypoxia

concept map?

1. Main medical diagnosis and related concept (example: Concept of Gas Exchange, a medical diagnosis of pneumonia).

2. Pathophysiology of all medical diagnoses

3. Etiology of all medical diagnosies (what causes the diagnosis)

4. Epidemiology of all medical diagnoses (how common is it, who has it or who does it happen to, what is the prevalence, etc)

5. Treatments and therapies (relevant to the three medical diagnoses; must include nursing interventions)

Answer 1

1) Intestinal ischemia occurs when the blood flow through the major arteries that supply blood to your intestines slows or stops. The condition has many potential causes, including a blockage in an artery caused by a blood clot, or a narrowing of an artery due to buildup of deposits, such as cholesterol.Although intestinal ischaemia is an infrequent event, early recognition and appropriate treatment can reduce the potential for a devastating outcome.Acute or chronic abdominal pain can be the result of many different pathophysiological processes. Many presentations are due to benign processes, whereas others may be life threatening if not recognised swiftly. Among the many possible causes, clinicians need to consider the possibility of intestinal ischaemic disorders. The variable vessels involved, location of bowel affected, and different levels of acuity of illness all result in multiple possible presentations. The detection of such a serious condition can be a diagnostic and therapeutic dilemma. This review aims to help clinicians to understand the features and management of acute and chronic mesenteric ischaemia, mesenteric venous thrombosis, and ischaemic colitis.The information in this review is based on results of a Medline search for reviews and evidence based studies in major journals from the disciplines of gastroenterology, surgery, and radiology published between 1966 and 2003. The key words used included “intestinal ischemia,” “mesenteric ischemia,” “ischemic colitis,” “mesenteric venous thrombosis,” “mesenteric angiography,” “diagnosis,” “management,” and “treatment.”
Acute mesenteric ischaemia
The recognition of acute mesenteric ischaemia can be difficult, as most patients present with non-specific symptoms, particularly abdominal pain. Classically, pain is disproportionately exaggerated relative to the unremarkable physical findings and persists beyond two to three hours.However, signs of an acute abdomen with distension, guarding (rigidity), and hypotension may also occur, particularly when diagnosis has been delayed.Fever, diarrhoea, nausea, and anorexia are all commonly reported. Melena or haematochezia occurs in 15% of cases, and occult blood is detected in at least half of patients.The underlying process can involve emboli, arterial or venous thrombosis, vasoconstriction from low flow states, or vasculitis. Embolic occlusion of the superior mesenteric artery occurs in more than half of all cases.Most emboli originate in the heart and are potentiated by cardiac arrhythmias or depressed systolic function due to ischaemic heart disease.In 25% of cases, thrombosis of pre-existing atherosclerotic lesions occurs. Many of these patients report chronic symptoms consistent with previous transient mesenteric ischaemia. Non-occlusive mesenteric ischaemia, which accounts for 20-30% of all cases of acute mesenteric ischaemia, presents similarly but occurs with patent mesenteric arteries. Microvascular vasoconstriction is the underlying process and is precipitated by splanchnic hypoperfusion due to depressed cardiac output or renal or hepatic disease.

Chronic mesenteric ischaemia
Chronic mesenteric ischaemia, also known as “intestinal angina,” should be considered when a patient reports generalised abdominal pain occurring usually in the postprandial state and persisting for one to three hours. Pain may be minimal at the onset but can progress over weeks or months into an incapacitating condition. Weight loss and sitophobia, the fear of eating, are often reported.Severe stenosis or complete obstruction of at least two of the three major splanchnic arteries usually occurs before symptoms are evident, because of the formation of a rich collateral vascular supply.One of the most feared complications is acute thrombosis and the consequent development of bowel infarction.Recognition of this can be difficult, as many patients are asymptomatic owing to extensive collateral veins. When thrombosis involves the portal or splenic veins the initial presentation may be variceal bleeding, splenomegaly, or ascites.

Ischaemic colitis

The most common form of ischaemic injury to the gastrointestinal tract is ischaemic colitis.The blood supply to the colon and small intestine comes from branches of the superior and inferior mesenteric arteries. The rectum also receives blood from the inferior and middle haemorrhoidal arteries, which arise from the internal iliac artery.Colonic ischaemia may be precipitated by several conditions, although the cause is not clearly identified in most cases.

The clinical spectrum of intestinal ischaemic disease is quite extensive. Timely recognition is essential for a favourable outcome. Compromise of the mesenteric blood flow, both arterial and venous disease, can result in acute ischaemia and infarction and needs an aggressive approach combining surgical and radiological expertise. Chronic mesenteric ischaemia should be considered as a source for abdominal pain after other more common causes are excluded. The outcome of ischaemic colitis can range from complete resolution to fulminant colitis.

2) Active Problems -

1. ARF :- As a result of acute renal failure (ARF), the kidneys do not filter and dispose of waste products as they should, and a person’s urine output often falls.
Ideally, a doctor will identify ARF immediately, and treatment can begin to reverse the underlying causes.Often, a person will experience ARF when they have another serious illness, such as pneumonia or sepsis.

As a result, they may not observe the symptoms of ARF immediately.

Some symptoms of ARF causes include:

urine that is very dark
confusion
lower urine output
itching skin or skin rashes from waste buildup
pressure or pain in the chest
shortness of breath
swelling in the lower extremities
unexplained nausea
Some people may experience severe side effects, including seizures and loss of consciousness.

Stages

Doctors will usually classify ARF in one of three stages, depending on test results and a person’s urine output. Stage 1 is the least severe while stage 3 is the most severe.A research

paper in the journal American Family Physician outlines the stages, as follows:

Stage 1
A person in stage 1 ARF experiences a sudden increase in their serum creatinine, a kidney waste product, by 0.3 milligrams per deciliter (mg/dl), or an increase of 1.5 to two times from their baseline.The person will also produce fewer than 0.5 milliliters per kilogram (ml/kg) of their body weight per hour for 6 hours or more.

Stage 2
A person in stage 2 ARF will have an increase in their creatinine level that is two to three times their baseline. They will also have a urine output of fewer than 0.5 ml/kg of their body weight for 12 hours or more.

Stage 3
A person will have a creatinine level that is three times their baseline, or that is greater than 4.0 mg/dl. They will produce no urine for 12 hours or fewer than 0.3 ml/kg for 24 hours.Due to its severity, this stage will require immediate renal replacement therapy, a continual form of dialysis.Typically, a doctor will start prescribing interventions before a person’s ARF progresses to stage 3.

Causes

People who are ill and receiving medical treatment in a hospital are particularly at risk of ARF. This is especially true of those in an intensive care unit (ICU) setting.

Research has estimated that as many as 7 percent of all patients in the hospital and 66 percent of those in an ICU will experience ARF.

Doctors also use three categories to classify the causes of ARF:

Pre-renal: Something is affecting blood flow to the kidneys, and these organs are unable to work correctly. Examples of these causes include low blood pressure, excess blood loss, and dehydration.
Post-renal: Something is blocking the ureters where urine leaves the kidneys, which is affecting how the organs work. Underlying causes of this include kidney stones, cancer, and an enlarged prostate in men.
Intrinsic renal: A medical condition damages the kidneys, or something inside is not working as well as it once did. Common causes of this include kidney infections, blood clots in the kidneys, or other medical conditions. Taking medications known to damage the kidneys can also be a cause.

Medications that can damage the kidneys include:

rifampin
phenytoin (Dilantin)
proton pump inhibitors
nonsteroidal anti-inflammatory drugs (NSAIDs)
Ideally, a doctor will be able to identify the underlying cause of a person’s ARF quickly. This means they can recommend treatment to prevent an acute condition from becoming chronic renal failure.

There are five different types of kidney failure:
Acute prerenal kidney failure. Insufficient blood flow to the kidneys can cause acuteprerenal kidney failure.
Acute intrinsic kidney failure.
Chronic prerenal kidney failure.
Chronic intrinsic kidney failure.
Chronic post-renal kidney failure.

Causes of acute kidney failure :-
acute tubular necrosis (ATN)
severe or sudden dehydration.
toxic kidney injury from poisons or certain medications.
autoimmune kidney diseases, such as acute nephritic syndrome and interstitial nephritis.
urinary tract obstruction.

2. Mesenteric venous thrombosis occurs when a blood clot forms in one or more of the major veins that drain blood from your intestines. This condition is rare, but it can lead to life-threatening complications without prompt treatment.Mesenteric vein thrombosis is increasingly recognized as a cause of mesenteric ischemia. Acute thrombosis commonly presents with abdominal pain and chronic type with features of portal hypertension. Contrast enhanced CT scan of abdomen is quite accurate for diagnosing and differentiating two types of mesenteric venous thrombosis. Prothrombotic state, hematological malignancy, and local abdominal inflammatory conditions are common predisposing conditions. Over the last decade, JAK-2 (janus kinase 2) mutation has emerged as an accurate biomarker for diagnosis of myeloproliferative neoplasm, an important cause for mesenteric venous thrombosis. Anticoagulation is the treatment of choice for acute mesenteric venous thrombosis. Thrombolysis using systemic or transcatheter route is another option. Patients with peritoneal signs or refractory to initial measures require surgical exploration. Increasing recognition of mesenteric venous thrombosis and use of anticoagulation for treatment has resulted in reduction in the need for surgery with improvement in survival.
Keywords: mesenteric venous thrombosis, portal hypertension, thrombosis
Abbreviations: MVT, mesenteric venous thrombosis; TIPS, transjugular intrahepatic portosystemic shunt; PVT, portal vein thrombosis; JAK2, janus kinase 2.Mesenteric venous thrombosis (MVT) is an uncommon cause of mesenteric ischemia accounting for 5–15% of the cases.It was first described as a distinct cause of mesenteric ischemia by Warren and Eberhard. It can be either acute presenting commonly with abdominal pain or chronic presenting with features of portal hypertension. Rarely, it can be diagnosed as an incidental finding on abdominal CT scan. Causes of MVT include prothrombotic states, trauma and intra-abdominal infections. Advances in the radiology techniques and anticoagulation have led to improved diagnosis and outcomes.
Mesenteric circulation
Blood flow to the intestines starts from the superior mesenteric artery which arises from the abdominal aorta. It provides branches to the pancreas and duodenum; three branches to the proximal colon, and terminates in the arteriae rectae supplying the jejunum and ilium. Venous blood first drains into the venae rectae which then forms the ileocolic, middle colic and right colic veins which come together to form the superior mesenteric vein that in turn meets the splenic vein to form the portal vein. The lower part of the esophagus and the upper part of the lesser curvature drains through the left gastric vein directly into the portal vein at the point of its formation while blood from the fundus of the stomach drains through short veins into the splenic vein. The left colon venous return comes through the inferior mesenteric vein which joins the splenic vein.

Acute mesenteric venous thrombosis
Incidence and Etiology:-
The incidence of MVT has increased with improvement in the diagnostic modalities resulting in increasing number of cases diagnosed incidentally. Incidence between 1970 and 1982 was estimated to be 2 per 100,000 compared to 2.7 per 100,000 between 2000 and 2006.3 MVT accounts for 6%–9% of all the cases of acute mesenteric ischemia and 1/1000 of emergency department admissions.The mean age of patients at presentation is 45–60 years with a slight male to female predominance.Prothrombotic states, surgery, inflammatory bowel disease and malignancy are common risk factors for the development of MVT. Thrombosis of the larger distal portions of the mesenteric vein is mostly secondary to local factors, such as malignancy, pancreatitis and infection, and is associated with portal vein thrombosis while thrombosis that originate from the vena rectae, leading to isolated MVT thrombosis is most commonly related to a prothrombotic state.Primary or idiopathic MVT account for 21–49% of the cases and depends on the depth of evaluation.The proportion of patients with idiopathic cases decreases with more extensive evaluation.Malignancies including myeloproliferative neoplasms are the most common form of prothrombotic disorders associated with MVT.JAK2 V617 mutation was previously studied and association between the presence of the mutation and MVT was found, 17 patients out of 99 with MVT were found to have the mutation and none of them had other prothrombotic risks, 7 of them had myeloproliferative disease; and of the remaining 10 patients, two were diagnosed with myelofibrosis, and one was diagnosed with polycythemia vera on the follow up after the study.Oral contraceptive use accounts for 9–18% of cases in young women.In a retrospective analysis, 4 out of 12 patients with no identifiable hypercoagulable state were using oral contraceptives.Antithrombin III, Protein S and Protein C deficiencies are associated with MVT. It is estimated that 4–10% of these patients will develop this disorder.In another study on patients with MVT compared to healthy people, a significantly higher thrombophilic genotype was found. Methylene tetrahydrofolate reductase TT677 genotype was present in 6 (50%), the factor V Leiden in 3 (25%), and the prothrombin transition G20210A in 3 (25%). Combined mutations were present in 4 (33%) patients. Intra-abdominal surgery, especially splenectomy is a common risk factor.

3. In most cases, anemia is usually mild or moderate. Affected individuals may develop a variety of symptoms such as fatigue, paleness of the skin (pallor), lightheadedness, shortness of breath, a fast heartbeat, irritability, chest pain and additional findings.Anemia is a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues. Having anemia can make you feel tired and weak. There are many forms of anemia, each with its own cause. Anemia can be temporary or long term, and it can range from mild to severe.

Signs & Symptoms
In most cases, anemia is usually mild or moderate. Affected individuals may develop a variety ofsymptoms such as fatigue, paleness of the skin (pallor), lightheadedness, shortness of breath, a fast heartbeat, irritability, chest pain and additional finding.

IRON DEFICIENCY ANEMIA SIGNS AND SYMPTOMS MAY INCLUDE:
Extreme fatigue.
Weakness.
Pale skin.
Chest pain, fast heartbeat or shortness of breath.
Headache, dizziness or lightheadedness.
Cold hands and feet.
Inflammation or soreness of your tongue.
Brittle nails.
If left untreated, iron-deficiency anemia can cause serious health problems. Having too little oxygen in the body can damage organs. With anemia, the heart must work harder to make up for the lack of red blood cells or hemoglobin. This extra work can harm the heart.

4. Blood clotting is a normal function that occurs when you have an injury. If you scrape your knee, blood clots at the site of the injury so you don’t lose too much blood. But sometimes blood clotting can cause complications.Sometimes a clot will form inside a blood vessel, which is either an artery or a vein. Clots can happen even when there is no injury. Clots can also fail to dissolve after an injury has healed. This can cause serious complications if not discovered and treated.Some complications could be serious and even life-threatening, especially if a clot forms in a blood vessel. It’s important to understand the symptoms of clots so you can get treatment before complications occur.

Risk for forming a blood clot if
are obese
are a smoker
are over the age of 60
take oral contraceptives
have a chronic inflammatory disease
have atrial flutter or atrial fibrillation
have congestive heart failure
have cirrhosis
have cancer
have fractures in your extremities, especially the lower extremities or pelvis
are pregnant
have a family history of clotting disorders
are unable to walk
sit for long periods of time
travel frequently

5. Blood Loss :- Anemia due to excessive bleeding results when loss of red blood cells exceeds production of new red blood cells. When blood loss is rapid,blood pressure falls, and people may be dizzy. When blood loss occurs gradually, people may be tired, short of breath, and pale.
Anemia Caused by Blood Loss
You can lose red blood cells through bleeding. This can happen slowly over a long period of time, and you might not notice. Causes can include: Gastrointestinal conditions such as ulcers, hemorrhoids, gastritis (inflammation of your stomach), and cancer.

6. Hypoxemic respiratory failure means that you don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal.Hypercapnic respiratory failure means that there's too much carbon dioxide in your blood, and near normal or not enough oxygen in your blood.It is caused by intrapulmonary shunting of blood resulting from airspace filling or collapse (eg, pulmonary edema due to left ventricular failure, acute respiratory distress syndrome) or by intracardiac shunting of blood from the right- to left-sided circulation .

Hypoxemic respiratory failure means that you don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal. Hypercapnic respiratory failure means that there's too much carbon dioxide in your blood, and near normal or not enough oxygen in your blood.A patient with acute respiratory failure generally should be admitted to a respiratory care unit or intensive care unit (ICU). Most patients with chronicrespiratory failure can betreated at home with oxygen supplementation and/or ventilatory assist devices along with therapy for their underlying disease.

3) 1. Impaired gas exchange a nursing diagnosis approved by the North American Nursing Diagnosis Association,defined as excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolocapillary membrane.
Etiological and contributing factors include an altered oxygen supply, changes in the alveolar-capillary membrane, altered blood flow, and altered oxygen-carrying capacity of the blood. Defining characteristics include changes in mental status such as confusion, somnolence, restlessness, and irritability; ineffective coughing and inability to move secretions from the air passages; hypercapnia; and hypoxia. For specific medical treatments and nursing interventions, see airway clearance, ineffective; breathing patterns, ineffective; chronic airflow limitation; and anemia.
2. Your doctor will start by asking about your medical history and doing a physical exam, including listening to your lungs with a stethoscope to check for abnormal bubbling or crackling sounds that suggest pneumonia.
If pneumonia is suspected, your doctor may recommend the following tests:

Blood tests. Blood tests are used to confirm an infection and to try to identify the type of organism causing the infection. However, precise identification isn't always possible.
Chest X-ray. This helps your doctor diagnose pneumonia and determine the extent and location of the infection. However, it can't tell your doctor what kind of germ is causing the pneumonia.
Pulse oximetry. This measures the oxygen level in your blood. Pneumonia can prevent your lungs from moving enough oxygen into your bloodstream.
Sputum test. A sample of fluid from your lungs (sputum) is taken after a deep cough and analyzed to help pinpoint the cause of the infection.
Your doctor might order additional tests if you're older than age 65, are in the hospital, or have serious symptoms or health conditions. These may include:

CT scan. If your pneumonia isn't clearing as quickly as expected, your doctor may recommend a chest CT scan to obtain a more detailed image of your lungs.
Pleural fluid culture. A fluid sample is taken by putting a needle between your ribs from the pleural area and analyzed to help determine the type of infection.

4) 1. Phathophysiology of :-

* ARF :- ARF is characterized by tubular dysfunction with impaired sodium and water reabsorption and is associated with the shedding and excretion of proximal tubule brush border membranes and epithelial tubule cells into the urine
* Mesenteric Venous Thrombosis :-
MVT often (ie, >80% of the time) is the result of some processes that make the patient more likely to form a clot in the mesenteric circulation (ie, secondary MVT). Primary MVT occurs in the absence of any identifiable predisposing factor. MVT may also occur after ligation of the splenic vein for a splenectomy or ligation of the portal vein or the superior mesenteric vein as part of damage control surgery for severe penetrating abdominal injuries. Other associated causes include pancreatitis, sickle cell disease, and hypercoagulability caused by malignancy.
The mechanism responsible for ischemia in this setting is a massive influx of fluid into the bowel wall and lumen, which results in systemic hypovolemia and hemoconcentration. The consequent bowel edema and decreased outflow of blood secondary to venous thrombosis impede the inflow of arterial blood, and this leads to bowel ischemia. Although bowel ischemia is itself detrimental to the patient, it is the resulting multiple organ system failure that actually accounts for the high mortality.

*Pathophysiology of anemia:- consequences for development, growth, birth outcomes, and work productivity.Anemia has significant consequences for human health, as well as for social and economic development. In 2010, anemia accounted for 68.4 million years of life lived with disability, or 9% of the total global disability burden from all conditions.Anemia has been associated with negative health and development outcomes, including neonatal and perinatal mortality, low birth weight,premature birth,and delayed child development.The negative effects on health and development outcomes from anemia arise from the impacts of decreased oxygen delivery to tissues (in which multiple organ systems may be affected), as well as effects related to the underlying causes of anemia, which are difficult to disentangle. For example, in iron deficiency anemia (IDA), decreased iron availability has well-established negative effects on brain development and functioning even prior to anemia development.

* Blood Thrombosis:- Abnormal (stasis) or turbulent blood flow can lead to thrombosis. Normal blood flow is laminar. Turbulent blood flow leads to endothelial injury thus promoting the formation of a thrombus.

* Blood Loss:-

Extensive blood loss of more than 20% of theblood volume leads to regional vasoconstriction, decrease in central venous pressure and in venous return, as well as to reduction of the cardiac output. The heart rate rises, the temperature in the periphery drops, and the skin is pale and moist.

* Acute Respiratory Failure With Hypoxia :-

It is caused by intrapulmonary shunting of blood resulting from airspace filling or collapse (eg, pulmonary edema due to left ventricular failure,acute respiratory distress syndrome) or by intracardiac shunting of blood from the right- to left-sided circulation . Findings include dyspnea and tachypnea.

ETIOLOGY OF :-
1. ARF :-

Blood or fluid loss.
Blood pressure medications.
Heart attack.
Heart disease.
Infection.
Liver failure.
Use of aspirin, ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, others) or related drugs.

2. Mesenteric Venous Thrombosis :-
Genetic disorders that make your blood more prone to clotting, such as Factor V Leiden thrombophilia, which is an inherited clotting disorder. abdominal infections, such as appendicitis. inflammatory bowel diseases, such as diverticulitis, ulcerative colitis, and Crohn's disease.
3. Anemia :- The most common cause of anemia is low levels of iron in the body. This type of anemia is called iron-deficiency anemia. Your body needs a certain amount of iron to make hemoglobin, the substance that moves oxygen throughout your body. However, iron-deficiency anemia is just one type.
4. Blood Thrombosis :- The blood clots of deepvein thrombosis can be caused by anything that prevents your blood from circulating or clotting normally, such as injury to a vein, surgery, certain medications and limited movement.
5. Blood Loss :- It is also caused by blood loss, such as from heavy menstrual bleeding, an ulcer, cancer and regular use of some over-the-counter pain relievers, especially aspirin, which can cause inflammation of the stomach lining resulting in blood loss. Vitamin deficiency anemia.
6.Acute respiratory failure with hypoxia :-
Acute respiratory failureoccurs when fluid builds up in the air sacs in your lungs. When that happens, your lungs can't release oxygen into your blood. In turn, your organs can't get enough oxygen-rich blood to function.

Treatment:-
-Treatment for acute renal failure (ARF) may involve vasopressor drugs to help raise the blood pressure, intravenous fluids to aid in rehydration, diuretics to increase urine output, and hemodialysis to help filter the blood while the kidneys are healing.
-Anticoagulation is the treatment of choice for acute mesenteric venous thrombosis. Thrombolysis using systemic or transcatheter route is another option. Patients with peritoneal signs or refractory to initial measures require surgical exploration.
-Treatment might include oxygen, pain relievers, and oral and intravenous fluids to reduce pain and prevent complications. Doctors might also recommend blood transfusions, folic acid supplements and antibiotics. A cancer drug called hydroxyurea (Droxia, Hydrea, Siklos) also is used to treat sickle cell anemia.