Cardiovascular

Stopping bowel ischemia

Brought to the emergency department (ED) by her daughter, Alice Lister, age 75, complains of abdominal pain that “suddenly became too much to bear.” Her daughter says her mother also had episodes of nausea, vomiting, diarrhea, and abdominal cramps.

Assessment hints 
Ms. Lister, who has a history of atrial fibrillation and peripheral vascular disease, has been recovering from a recent splenectomy. On assessment, she has a dry mouth, skin tenting, low blood pressure, and a rapid, weak pulse. She has no bowel sounds and exhibits guarding. Her stool is guaiac-positive, and her white blood cell count is elevated at 17,000/mm3.
You recognize that her history and signs and symptoms may indicate bowel ischemia—a medical emergency. When you tell the physician your findings and your suspicion, he orders a computed tomography angiography (CTA) scan, which confirms an ischemic bowel.

On the scene
Because Ms. Lister may have nothing by mouth, you administer normal saline solution I.V. for hydration, as ordered. You also administer oxygen to increase vascular perfusion. Then, you insert an indwelling urinary catheter to monitor output and a nasogastric tube to relieve distention. After placing Ms. Lister on a cardiac monitor, you give the prescribed analgesic.

Outcome
Because the CTA scan shows that the bowel isn’t severely damaged, Ms. Lister needs only the bowel rest and hydration you’re providing. If the bowel were severely damaged, she would need surgery to remove the damaged area. If thrombosis in the mesenteric artery decreased blood flow to the colon or if thrombosis in the mesenteric vein increased congestion, a surgeon would have to remove the thrombi. The patient might need a stent and would need anti­­coagulation therapy.
Because of your quick wits and actions, Ms. Lister’s bowel isn’t severely damaged, and she avoids surgery. Your critical thinking and assessment skills plus your knowledge of bowel ischemia spared her from surgery and may have saved her life. Normally, the bowel receives 20% to 35% of resting cardiac output. When the supply decreases, serious damage can develop fast.

Education and follow-up
GI complaints can result from many causes, including food poisoning and the flu. But the combination of Ms. Lister’s symptoms (especially pain that’s more severe than expected for the assessment findings), her cardiac history, her recent surgery, and her dehydration made you think beyond the usual possibilities.
The recent surgery suggested the possibility of thrombi disrupting the blood supply to the intestines. And hypoperfusion to the bowel from the atrial fibrillation and dehydration could cause the ischemic episode. Other possible predisposing factors include shock, recent myocardial infarction, vascular surgery, drugs that can cause arterial stenosis, colon cancer, diabetes, hemodialysis, sickle cell disease, and pregnancy.
On discharge, you teach Ms. Lister about the predisposing factors for bowel ischemia and make sure she and her daughter understand they should never take severe abdominal pain lightly.  Abdominal pain that comes on suddenly, especially when accompanied by nausea and vomiting, requires a trip to the ED. A patient—especially an elderly one—who has predisposing factors may be experiencing much more than food poisoning or the flu.

Visit www.AmericanNurseToday.com/journal for a list of selected references.


Shari J. Lynn is a transitions practicum coordinator and instructor at Johns Hopkins University School of Nursing in Baltimore, Maryland.

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