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Vasodilatory Drugs in the Management of Nonocclusive Bowel Ischemia
GASTROENTEROLOGY 68:146-150, 1975 Copyright © 1975 by The Williams & Wilkins Co,
Vol. 68, No.1
Printed in U.S.A.
VASODILATORY DRUGS IN THE MANAGEMENT OF NONOCCLUSIVE BOWEL ISCHEMIA CHRISTOS A. ATHANASOULlS, M.D., JACK WITTENBERG, M.D., RALPH BERNSTEIN, M.D., AND tESTER F. WILLIAMS, M.D.
Department of Radiology and the First Surgical and Third Medical Services, Boston City Hospital; and Department of Radiology, Boston University School of Medicine, Boston, Massachusetts
A patient with a clinical and angiographic diagnosis of nonocclusive mesenteric ischemia had phenoxybenzamine directly infused into the superior mesenteric artery to counteract the existing splanchnic vasoconstriction. The diagnosis was confirmed by later operative intervention and the patient recovered. Vasodilatory drugs may playa significant role in the management of patients with nonocclusive mesenteric ischemia. Nonocclusive mesenteric ischemia has chemia who responded to direct superior become a problem of increasing frequency mesenteric artery infusion of vasodilatory and clinical importance. 1, 2 Although im- drugs. mediate operative intervention is necessary Case History to reverse the small bowel ischemia secondary to acute major arterial or venous occluA 75-year-old woman was admitted to Boston sion,2, 3 early operation contributes little in City Hospital because of an acute myocardial the patient with extensive nonocclusive gut infarction. Pertinent past history included arteischemia because there is no surgically riosclerotic heart disease and hypertension. Two remediable vascular problem. Resection of years previously she had been hospitalized on the affected bowel would, in most cases, be two occasions because of congestive heart failnecessarily so extensive as to ultimately ure, and she was placed on a regimen of potassium, and diuretics. produce a nutritional cripple. Experimen- digitalis, On physical examination on admission, the tal data demonstrate that initial priority heart rhythm was irregular, and a grade of three should be given to volume replacement, of six holosystolic murmur was heard at the control of sepsis, and improved cardiac apex, radiating to the axilla. The abdomen was function with agents other than digitalis. soft, nontender, and there was no organomegAn additional direct measure to increase aly. The temperature was 99°F, and the pulse bowel perfusion, and thus overcome the 64 and irregular. The blood pressure was 110 splanchnic vasoconstriction and interrupt systolic, 80 diastolic. An electrocardiogram the vicious cycles which perpetuate nonoc- showed marked digitalis toxicity with occaclusive bowel ischemia, is desirable. This sional premature ventricular contractions. On the 8th and 9th hospital days, there were report presents a patient with the clinical, episodes of atrial fibrillation associated with angiographic, operative, and pathological diaphoresis, a rise of the blood urea nitrogen diagnosis of nonocclusive mesenteric is- and creatinine and a fall in systolic blood Received June 3, 1974. Accepted July 19, 1974. Address requests for reprints to: Dr. Christos A. Athanasoulis, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts 02114. Supported in part by General Research Support Grant 57-156.
pressure. On the 10th hospital day, the patient complained of abdominal pain and became obtundent. Her temperature rose to 104 OF. The abdomen was tender to palpation with hypoactive bowel sounds. The stool was guaiac-negative. A radiograph of the abdomen showed
146
January 1975
CASE REPORTS
distention of the small and large bowel with thickening of the small bowel wall, suggesting bowel ischemia. A retrograde biplane abdominal aortogram revealed the celiac axis and superior mesenteric artery to be patent. A selective superior mesenteric arteriogram revealed no major arterial or venous occlusion; however, the main superior mesenteric artery and all the branches were diffusely and uniformly constricted (fig. lA). In view of the clinical setting and the angiographic findings, the diagnosis of nonocclusive mesenteric ischemia was made, and it was elected to proceed with the infusion of vasodilators directly into the superior mesenteric artery. Papaverine, at a dose of 0.4 mg per kg (30.0 mg), was rapidly injected as a bolus through the angiographic catheter into the superior mesenteric artery, followed by an infusion of papaverine at a rate of 0.8 mg per kg per hr (60.0 mg) for 1 hr. After the infusion, a repeat superior mesenteric arteriogram showed minimal dilation of jejunal arterial branches, so the infusion of papaverine was discontinued. Phenoxybenzamine, 0.2 mg per kg, was then rapidly injected as a bolus into the superior mesenteric artery, followed by an infusion at a rate of 0.7 mg per kg per hr for 1 hr. During the infusion, the blood pressure and the central
147
venous pressure dropped and the pupils dilated, indicating some systemic effect. At the completion of the infusion, a repeat superior mesenteric arteriogram showed reversal of the vasoconstriction, with marked dilation of the superior mesenteric artery and all its branches (fig. IB).
Normal saline was substituted for drugs through the arterial catheter, and the patient was transferred to the intensive care unit. Eleven hours later, when the patient's clinical condition was unchanged, a repeat superior mesenteric arteriogram revealed the mesenteric arterial branches to be dilated to the same degree as in the postinfusion arteriogram, with the exception of the middle colic artery which again was constricted. Phenoxybenzamine infusion into the superior mesenteric artery was started again at the rate of 0.7 mg per kg per hr. After 1 hr of infusion, a repeat angiogram showed no effect upon the size of the middle colic artery. An emergency upper gastrointestinal series showed normal stomach and duodenum with distention of the proximal small bowel. On the 11th hospital day and 18 hr after the onset of pain and the initial infusion of drugs into the superior mesenteric artery, the patient's physical condition was unchanged, with
FIG. 1. Superior mesenteric arteriography in a patient with nonocclusive bowel ischemia. A, Base line superior mesenteric arteriogram shows no arterial occlusions, but diffuse uniform constriction involving the branches of the superior mesenteric artery. B, Repeat superior mesenteric arteriogram after infusion of phenoxybenzamine (0.2 mg per kg bolus and 0.7 mg per kg per hr for 1 hr) into the superior mesenteric artery. All technical factors are identical as in A. There is apparent dilation of the superior mesenteric artery branches as compared with the preinfusion angiogram.
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CASE REPORTS
the abdomen being distended and tender on deep palpation. The bowel sounds were absent. The stool became guaiac-positive. An exploratory laparotomy was performed. The small bowel had a bluish discoloration throughout and hemorrhaged easily on palpation, but there was no evidence of full wall necrosis . A segment of the transverse colon, extending from the midtransverse colon to just proximal to the splenic flexure , had patchy areas of gangrene and was resected. A double barrel transverse colostomy was created. Gross examination of the resected specimen revealed the mucosal surface to be hemorrhagic and necrotic . Microscopically, there was hemorrhagic infarction of the mucosa with prominent and extensive edema of the submucosa. Although the necrosis was often confined to mucosa, in some areas it extended through the bowel wall. The postoperative course was complicated by surgical wound infection, hypokalemia, and respiratory alkalosis, but eventually the patient recovered. On the 3rd postoperative day , a superior mesenteric arteriogram was repeated showing superior mesenteric artery and branches of normal size (fig. 2). The actual diameter of the mesenteric artery branches was now found to be larger than in the post-phenoxybenzamine infusion arteriogram. On the 5th postoperative day, an upper gastrointestinal series and small bowel study
FIG. 2. Superior mesenteric arteriogram, 4 days after phenoxybenzamine infusion and 3 days after resection of a segment of the transverse colon, shows the branches of the superior mesenteric artery, apparently normal at this time, to be larger in comparison with the pre- and post-Phenoxybenzamine infusion arteriogram.
Vol. 68, N o.1
showed a marked increase in transit time with evidence of residual bowel wall thickening, apparently due t o edema or hemorrhage . The upper gastrointestinal study was repeated on the 28th postoperative day, and the small bowel was entirely normal. On the 46th hospital day, the patient was discharged without any symptoms or nutritional difficulties .
Discussion 2 Williams has presented a detailed discussion of the advantages, in cases of nonocclusive mesenteric ischemia, and in absence of physical signs of peritonitis, of a delayed rather than immediate operative intervention. This utilizes the principle of a "second look" which has been established as desirable in cases of occlusive arterial gut ischemia. When no vascular occlusion is present, in place of the diagnostic but non therapeutic "first look" operation, resuscitative measures should be employed to increase splanchnic perfusion. Splanchnic vasoconstriction, which plays a significant role in the self-perpetuation of this disease,2 , .- 8 has been arteriographically demonstrated in 6 of 12 patients recently studied by our group.9 It was more prominent later in the course of the disease and usually was nonuniform, affecting some jejunal or ileal arterial branches more than others. The patient reported herein is the 1st to manifest diffuse splanchnic vasoconstriction. If physical signs of peritonitis are not present, it is reasonable to delay the operation for 8 to 12 hr while the patient's general hemodynamic status is improved, thereby decreasing the need for reflex mediated splanchnic vasoconstriction. Since mesenteric ischemia itself is capable of inducing systemic changes, 10, 11 it also seems reasonable to attempt to correct the vasoconstriction directly . 2, 4- 7 , 12 After 8 to 10 hr of this therapy, when the second look operation is performed, there is sharper demarcation between infarcted and recoverable bowel, so rational resectional surgery can be carried out. Thus, this approach decreases the extent of small bowel resection and should also decrease the incidence of anastomotic leaks which are known to frequently complicate early
January 1975
149
CASE REPORTS
resections. 13 The delayed operation, as opposed to continued observation, is necessary , because approximately 10% of these patients do have full wall necrosis of a bowel segment which needs resection, and because the nonoperative diagnosis of nonocclusive mesenteric ischemia remains one of presumption. It was wrong in 19% of our most recent cases. Some clinical success with interruption of splanchnic vasoconstriction via sympathetic block or epidural anesthesia has been reported, but such techniques are difficult to control and have not always provided good results. 14 The use of a superior mesenteric arterial catheter, which has been introduced as part of the diagnostic work-up of patients with suspected acute bowel ischemia, seems more reasonable. Boley and Siegelman 6 have infused papaverine in a number of patients to counteract superior mesenteric arterial vasoconstriction . The advantage of papaverine is lack of systemic effects at infusion rates of 1 mg per min for several hours or days. The disadvantage is that several hours of infusion are required before papaverine achieves its major effect; therefore, an angiographic assessment of vasodilatory response becomes rather difficult . Boley and Siegelman have attempted to circumvent that difficulty, with test infusions of 3 mg of papaverine per min for 15 min, at the end of which period a superior mesenteric arteriogram is expected to show some degree of vasodilation as compared to the pretreatment arteriogram, if indeed mesenteric vasoconstriction is present. In the patient here reported we used the same principle of a test infusion of papaverine into the superior mesenteric artery for 1 hr, but in our opinion, the degree of vasodilatioh achieved was not adequate enough to justify continuation of the infusion with the same drug. Phenoxybenzamine was then infused on the basis of the experimental data of Britt and Cheek, I S with an obvious dilation of the superior mesenteric arterial branches after 1 hr of infusion . We think that this type of clear-cut response of the mesenteric arterial bed that can be angiographically assessed within 1
hr of infusion is more advantageous. The mild systemic effects that may be noted during phenoxybenzamine infusion should present no problem in the management of a patient, when the hemodynamic status is continuously and closely monitored, as with all intraarterial infusions of vasoactive drugs. Other drugs such as priscoline l6 and prostaglandin E11 2 have been clinically or experimentally used by other investigators for that same purpose. Our previous experience would indicate that bowel ischemia has been progressive in most of our patients, even when the general hemodynamic condition has been improved. The patient reported herein had mesenteric arterial infusions of vasodilatory drugs and did not follow the same pattern. It must be acknowledged, however, that the results are not conclusive. They merely support the need to evaluate this approach further. REFERENCES 1. Ottinger L, Austen WG: A study of 136 patients with mesenteric infarctions. Surg Gynecol Obstet 124:251. 1967 2. Williams LF: Vascular insufficiency of the intestines . Gastroenterology 61:757, 1971. 3. Marston A: Acute mesenteric vascular occlusions. In Vascular Disorders of the Intestine. Edited by SJ Boley, SS Schwartz, LF Williams. New York, Appleton-Century-Crofts, 1971, p 509 4. Williams LF Jr, Kim JP: Nonocclusive mesenteric ischemia . In Vascular Disorders of the Intestine. Edited by SJ Boley, SS Schwartz. LF Williams, New York, Appleton-Century-Crofts, New York, 1971, p 519 5. Baum S: Small vessel angiography of the gut. In Small Vessel Angiography. Edited by Hila!. St. Louis, CV Mosby Co, 1973, p 454 6. Boley SJ, Siegelman SS: Experimental and clinical nonocclusive mesenteric ischemia: Pathophysiology, diagnosis and management. In Small Vessel Angiography . Edited by Hila!. St. Louis, CV Mosby Co, 1973, p 438 7 . Jacobson ED : Mesenteric circulatory regulation in normal and ischemic states. In, Small Vessel Angiography . Edited by Hila!. St. Louis, CV Mosby Co, 1973, p 434 8. Jacobson ED: Physiologic aspects of the intestinal circulation. In Vascular Disorders of the Intestine. Edited by SJ Boley, Schwartz, LF Williams,
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CASE REPORTS
New York, Appleton-Century-Crofts, 1971, p 19 9. Wittenberg J, Athanasoulis CA, Shapiro JR, et al: A radiological approach to the patient with acute extensive bowel ischemia. Radiology 106:13, 1974 10. Vyden JK: The systemic effects of acute superior mesenteric vascular insufficiency. In Vascular Disorders of the Intestine. Edited by SJ Boley, SS Schwartz, LF Williams. New York, AppletonCentury-Crofts, 1971, p 279 11. Boley SJ, Gliedman ML: Circulatory responses to mesenteric ischemia. In Vascular Disorders of the Intestine. Edited by SJ Boley, SS Schwartz, LF Williams. New York, Appleton-CenturyCrofts, 1971, p 323
Vol. 68, No.1
12. Viano RB, Treat E, Shanbour LL, et al: Selective dilation of the constricted superior mesenteric artery. Gastroenterology 62:39, 1972 13. Pierce CE, Brochenbough EC: The spectrum of mesenteric infarction. Am J Surg 119:233, 1970 14. Jackson BB, Lykins R: Serial epidural analgesia in mesenteric arterial failure. Arch Surg 90:177, 1965 15. Britt LG, Cheek RC: Non-occlusive mesenteric vascular disease. Clinical and experimental observations. Ann Surg 169:704, 1969 16. Baum S, Dratch P, Nusbaum M, et al: Treatment of non-occlusive mesenteric ischemic disease by the selective arterial infusion of vasodilating agents. Radiology (in press),
Vol. 68, No.1
Printed in U.S.A.
VASODILATORY DRUGS IN THE MANAGEMENT OF NONOCCLUSIVE BOWEL ISCHEMIA CHRISTOS A. ATHANASOULlS, M.D., JACK WITTENBERG, M.D., RALPH BERNSTEIN, M.D., AND tESTER F. WILLIAMS, M.D.
Department of Radiology and the First Surgical and Third Medical Services, Boston City Hospital; and Department of Radiology, Boston University School of Medicine, Boston, Massachusetts
A patient with a clinical and angiographic diagnosis of nonocclusive mesenteric ischemia had phenoxybenzamine directly infused into the superior mesenteric artery to counteract the existing splanchnic vasoconstriction. The diagnosis was confirmed by later operative intervention and the patient recovered. Vasodilatory drugs may playa significant role in the management of patients with nonocclusive mesenteric ischemia. Nonocclusive mesenteric ischemia has chemia who responded to direct superior become a problem of increasing frequency mesenteric artery infusion of vasodilatory and clinical importance. 1, 2 Although im- drugs. mediate operative intervention is necessary Case History to reverse the small bowel ischemia secondary to acute major arterial or venous occluA 75-year-old woman was admitted to Boston sion,2, 3 early operation contributes little in City Hospital because of an acute myocardial the patient with extensive nonocclusive gut infarction. Pertinent past history included arteischemia because there is no surgically riosclerotic heart disease and hypertension. Two remediable vascular problem. Resection of years previously she had been hospitalized on the affected bowel would, in most cases, be two occasions because of congestive heart failnecessarily so extensive as to ultimately ure, and she was placed on a regimen of potassium, and diuretics. produce a nutritional cripple. Experimen- digitalis, On physical examination on admission, the tal data demonstrate that initial priority heart rhythm was irregular, and a grade of three should be given to volume replacement, of six holosystolic murmur was heard at the control of sepsis, and improved cardiac apex, radiating to the axilla. The abdomen was function with agents other than digitalis. soft, nontender, and there was no organomegAn additional direct measure to increase aly. The temperature was 99°F, and the pulse bowel perfusion, and thus overcome the 64 and irregular. The blood pressure was 110 splanchnic vasoconstriction and interrupt systolic, 80 diastolic. An electrocardiogram the vicious cycles which perpetuate nonoc- showed marked digitalis toxicity with occaclusive bowel ischemia, is desirable. This sional premature ventricular contractions. On the 8th and 9th hospital days, there were report presents a patient with the clinical, episodes of atrial fibrillation associated with angiographic, operative, and pathological diaphoresis, a rise of the blood urea nitrogen diagnosis of nonocclusive mesenteric is- and creatinine and a fall in systolic blood Received June 3, 1974. Accepted July 19, 1974. Address requests for reprints to: Dr. Christos A. Athanasoulis, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts 02114. Supported in part by General Research Support Grant 57-156.
pressure. On the 10th hospital day, the patient complained of abdominal pain and became obtundent. Her temperature rose to 104 OF. The abdomen was tender to palpation with hypoactive bowel sounds. The stool was guaiac-negative. A radiograph of the abdomen showed
146
January 1975
CASE REPORTS
distention of the small and large bowel with thickening of the small bowel wall, suggesting bowel ischemia. A retrograde biplane abdominal aortogram revealed the celiac axis and superior mesenteric artery to be patent. A selective superior mesenteric arteriogram revealed no major arterial or venous occlusion; however, the main superior mesenteric artery and all the branches were diffusely and uniformly constricted (fig. lA). In view of the clinical setting and the angiographic findings, the diagnosis of nonocclusive mesenteric ischemia was made, and it was elected to proceed with the infusion of vasodilators directly into the superior mesenteric artery. Papaverine, at a dose of 0.4 mg per kg (30.0 mg), was rapidly injected as a bolus through the angiographic catheter into the superior mesenteric artery, followed by an infusion of papaverine at a rate of 0.8 mg per kg per hr (60.0 mg) for 1 hr. After the infusion, a repeat superior mesenteric arteriogram showed minimal dilation of jejunal arterial branches, so the infusion of papaverine was discontinued. Phenoxybenzamine, 0.2 mg per kg, was then rapidly injected as a bolus into the superior mesenteric artery, followed by an infusion at a rate of 0.7 mg per kg per hr for 1 hr. During the infusion, the blood pressure and the central
147
venous pressure dropped and the pupils dilated, indicating some systemic effect. At the completion of the infusion, a repeat superior mesenteric arteriogram showed reversal of the vasoconstriction, with marked dilation of the superior mesenteric artery and all its branches (fig. IB).
Normal saline was substituted for drugs through the arterial catheter, and the patient was transferred to the intensive care unit. Eleven hours later, when the patient's clinical condition was unchanged, a repeat superior mesenteric arteriogram revealed the mesenteric arterial branches to be dilated to the same degree as in the postinfusion arteriogram, with the exception of the middle colic artery which again was constricted. Phenoxybenzamine infusion into the superior mesenteric artery was started again at the rate of 0.7 mg per kg per hr. After 1 hr of infusion, a repeat angiogram showed no effect upon the size of the middle colic artery. An emergency upper gastrointestinal series showed normal stomach and duodenum with distention of the proximal small bowel. On the 11th hospital day and 18 hr after the onset of pain and the initial infusion of drugs into the superior mesenteric artery, the patient's physical condition was unchanged, with
FIG. 1. Superior mesenteric arteriography in a patient with nonocclusive bowel ischemia. A, Base line superior mesenteric arteriogram shows no arterial occlusions, but diffuse uniform constriction involving the branches of the superior mesenteric artery. B, Repeat superior mesenteric arteriogram after infusion of phenoxybenzamine (0.2 mg per kg bolus and 0.7 mg per kg per hr for 1 hr) into the superior mesenteric artery. All technical factors are identical as in A. There is apparent dilation of the superior mesenteric artery branches as compared with the preinfusion angiogram.
148
CASE REPORTS
the abdomen being distended and tender on deep palpation. The bowel sounds were absent. The stool became guaiac-positive. An exploratory laparotomy was performed. The small bowel had a bluish discoloration throughout and hemorrhaged easily on palpation, but there was no evidence of full wall necrosis . A segment of the transverse colon, extending from the midtransverse colon to just proximal to the splenic flexure , had patchy areas of gangrene and was resected. A double barrel transverse colostomy was created. Gross examination of the resected specimen revealed the mucosal surface to be hemorrhagic and necrotic . Microscopically, there was hemorrhagic infarction of the mucosa with prominent and extensive edema of the submucosa. Although the necrosis was often confined to mucosa, in some areas it extended through the bowel wall. The postoperative course was complicated by surgical wound infection, hypokalemia, and respiratory alkalosis, but eventually the patient recovered. On the 3rd postoperative day , a superior mesenteric arteriogram was repeated showing superior mesenteric artery and branches of normal size (fig. 2). The actual diameter of the mesenteric artery branches was now found to be larger than in the post-phenoxybenzamine infusion arteriogram. On the 5th postoperative day, an upper gastrointestinal series and small bowel study
FIG. 2. Superior mesenteric arteriogram, 4 days after phenoxybenzamine infusion and 3 days after resection of a segment of the transverse colon, shows the branches of the superior mesenteric artery, apparently normal at this time, to be larger in comparison with the pre- and post-Phenoxybenzamine infusion arteriogram.
Vol. 68, N o.1
showed a marked increase in transit time with evidence of residual bowel wall thickening, apparently due t o edema or hemorrhage . The upper gastrointestinal study was repeated on the 28th postoperative day, and the small bowel was entirely normal. On the 46th hospital day, the patient was discharged without any symptoms or nutritional difficulties .
Discussion 2 Williams has presented a detailed discussion of the advantages, in cases of nonocclusive mesenteric ischemia, and in absence of physical signs of peritonitis, of a delayed rather than immediate operative intervention. This utilizes the principle of a "second look" which has been established as desirable in cases of occlusive arterial gut ischemia. When no vascular occlusion is present, in place of the diagnostic but non therapeutic "first look" operation, resuscitative measures should be employed to increase splanchnic perfusion. Splanchnic vasoconstriction, which plays a significant role in the self-perpetuation of this disease,2 , .- 8 has been arteriographically demonstrated in 6 of 12 patients recently studied by our group.9 It was more prominent later in the course of the disease and usually was nonuniform, affecting some jejunal or ileal arterial branches more than others. The patient reported herein is the 1st to manifest diffuse splanchnic vasoconstriction. If physical signs of peritonitis are not present, it is reasonable to delay the operation for 8 to 12 hr while the patient's general hemodynamic status is improved, thereby decreasing the need for reflex mediated splanchnic vasoconstriction. Since mesenteric ischemia itself is capable of inducing systemic changes, 10, 11 it also seems reasonable to attempt to correct the vasoconstriction directly . 2, 4- 7 , 12 After 8 to 10 hr of this therapy, when the second look operation is performed, there is sharper demarcation between infarcted and recoverable bowel, so rational resectional surgery can be carried out. Thus, this approach decreases the extent of small bowel resection and should also decrease the incidence of anastomotic leaks which are known to frequently complicate early
January 1975
149
CASE REPORTS
resections. 13 The delayed operation, as opposed to continued observation, is necessary , because approximately 10% of these patients do have full wall necrosis of a bowel segment which needs resection, and because the nonoperative diagnosis of nonocclusive mesenteric ischemia remains one of presumption. It was wrong in 19% of our most recent cases. Some clinical success with interruption of splanchnic vasoconstriction via sympathetic block or epidural anesthesia has been reported, but such techniques are difficult to control and have not always provided good results. 14 The use of a superior mesenteric arterial catheter, which has been introduced as part of the diagnostic work-up of patients with suspected acute bowel ischemia, seems more reasonable. Boley and Siegelman 6 have infused papaverine in a number of patients to counteract superior mesenteric arterial vasoconstriction . The advantage of papaverine is lack of systemic effects at infusion rates of 1 mg per min for several hours or days. The disadvantage is that several hours of infusion are required before papaverine achieves its major effect; therefore, an angiographic assessment of vasodilatory response becomes rather difficult . Boley and Siegelman have attempted to circumvent that difficulty, with test infusions of 3 mg of papaverine per min for 15 min, at the end of which period a superior mesenteric arteriogram is expected to show some degree of vasodilation as compared to the pretreatment arteriogram, if indeed mesenteric vasoconstriction is present. In the patient here reported we used the same principle of a test infusion of papaverine into the superior mesenteric artery for 1 hr, but in our opinion, the degree of vasodilatioh achieved was not adequate enough to justify continuation of the infusion with the same drug. Phenoxybenzamine was then infused on the basis of the experimental data of Britt and Cheek, I S with an obvious dilation of the superior mesenteric arterial branches after 1 hr of infusion . We think that this type of clear-cut response of the mesenteric arterial bed that can be angiographically assessed within 1
hr of infusion is more advantageous. The mild systemic effects that may be noted during phenoxybenzamine infusion should present no problem in the management of a patient, when the hemodynamic status is continuously and closely monitored, as with all intraarterial infusions of vasoactive drugs. Other drugs such as priscoline l6 and prostaglandin E11 2 have been clinically or experimentally used by other investigators for that same purpose. Our previous experience would indicate that bowel ischemia has been progressive in most of our patients, even when the general hemodynamic condition has been improved. The patient reported herein had mesenteric arterial infusions of vasodilatory drugs and did not follow the same pattern. It must be acknowledged, however, that the results are not conclusive. They merely support the need to evaluate this approach further. REFERENCES 1. Ottinger L, Austen WG: A study of 136 patients with mesenteric infarctions. Surg Gynecol Obstet 124:251. 1967 2. Williams LF: Vascular insufficiency of the intestines . Gastroenterology 61:757, 1971. 3. Marston A: Acute mesenteric vascular occlusions. In Vascular Disorders of the Intestine. Edited by SJ Boley, SS Schwartz, LF Williams. New York, Appleton-Century-Crofts, 1971, p 509 4. Williams LF Jr, Kim JP: Nonocclusive mesenteric ischemia . In Vascular Disorders of the Intestine. Edited by SJ Boley, SS Schwartz. LF Williams, New York, Appleton-Century-Crofts, New York, 1971, p 519 5. Baum S: Small vessel angiography of the gut. In Small Vessel Angiography. Edited by Hila!. St. Louis, CV Mosby Co, 1973, p 454 6. Boley SJ, Siegelman SS: Experimental and clinical nonocclusive mesenteric ischemia: Pathophysiology, diagnosis and management. In Small Vessel Angiography . Edited by Hila!. St. Louis, CV Mosby Co, 1973, p 438 7 . Jacobson ED : Mesenteric circulatory regulation in normal and ischemic states. In, Small Vessel Angiography . Edited by Hila!. St. Louis, CV Mosby Co, 1973, p 434 8. Jacobson ED: Physiologic aspects of the intestinal circulation. In Vascular Disorders of the Intestine. Edited by SJ Boley, Schwartz, LF Williams,
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CASE REPORTS
New York, Appleton-Century-Crofts, 1971, p 19 9. Wittenberg J, Athanasoulis CA, Shapiro JR, et al: A radiological approach to the patient with acute extensive bowel ischemia. Radiology 106:13, 1974 10. Vyden JK: The systemic effects of acute superior mesenteric vascular insufficiency. In Vascular Disorders of the Intestine. Edited by SJ Boley, SS Schwartz, LF Williams. New York, AppletonCentury-Crofts, 1971, p 279 11. Boley SJ, Gliedman ML: Circulatory responses to mesenteric ischemia. In Vascular Disorders of the Intestine. Edited by SJ Boley, SS Schwartz, LF Williams. New York, Appleton-CenturyCrofts, 1971, p 323
Vol. 68, No.1
12. Viano RB, Treat E, Shanbour LL, et al: Selective dilation of the constricted superior mesenteric artery. Gastroenterology 62:39, 1972 13. Pierce CE, Brochenbough EC: The spectrum of mesenteric infarction. Am J Surg 119:233, 1970 14. Jackson BB, Lykins R: Serial epidural analgesia in mesenteric arterial failure. Arch Surg 90:177, 1965 15. Britt LG, Cheek RC: Non-occlusive mesenteric vascular disease. Clinical and experimental observations. Ann Surg 169:704, 1969 16. Baum S, Dratch P, Nusbaum M, et al: Treatment of non-occlusive mesenteric ischemic disease by the selective arterial infusion of vasodilating agents. Radiology (in press),