Monday, 25 July 2011

Dealing with Gut Attack

Published in Panorama

Recognizing a Gut Attack

Saraswati was losing weight without wanting to do so. Lately she was avoiding having her meals regularly. The reason: she ended up with stomach pain each time she had a full meal, with the pain lasting for an hour or so. Having tolerated the pain for close to a year and six months, she decided enough was enough and decided to see the doctor.

Routine tests for various abdominal conditions including ulcer, appendicitis, gall stones revealed nothing. Similarly an endoscopy returned no diagnosis. Finally, an angiogram revealed Saraswati was on the verge of a gut attack!

Dr.K.R.Suresh, Director and Consultant Vascular Surgeon, Jain Institute of Vascular Sciences, Bangalore, explains, “Gut Attack has the same connotation as a heart attack, brain attack or stroke and leg attack. In this instance, there is decreased blood supply to the intestines or stomach. In Saraswati’s case, an angiogram revealed the three major blood vessels supplying blood to the intestines, were blocked with a 90% narrowing of the abdominal portion of the aorta. Besides, she had two major heart lesions, her right kidney artery was gone and she essentially had one only kidney functioning, the left one. Even the left kidney arteries had narrowed about 60-70%.”

Blood supply to Saraswati’s vital organs was largely compromised and any further delay in diagnosis and consequent treatment would have been catastrophic. Fortunately for her, she had a chronic, rather than an acute gut attack. A set of complex surgeries followed, performed by Vascular Surgeons Dr.Suresh and Dr.Vivekananda to re-establish normal blood supply in her body.

Who then are the people prone to Gut Attacks and how does the condition progress? Explaining the condition which affects about 1 in 100,000 people, with equal chances in either gender, Dr.Suresh, elaborates, “The basis of a Gut Attack is the same as for a heart or brain attack — it happens because of a reduced flow of oxygen-rich blood to your gut. It can be either acute or chronic. The acute gut attack which happens suddenly is the result of a clot somewhere in the body, most commonly in the heart, which becomes dislodged and travels along the blood stream and gets lodged in the blood vessels going to the intestine. When the blood vessels of the intestine get blocked in this manner, the result is catastrophic with severe abdominal pain.”

The chronic gut attack, also referred to as chronic intestinal ischemia is a result of gradual narrowing of blood vessels over a period of years. Atherosclerosis or fat deposits in some of the intestinal arteries may restrict the amount of blood flowing through them. Dr.Suresh explains, “Up to a certain point, say, 50%-60% blockage, the body keeps compensating and the patients may experience some pain occasionally. But as the blood supply reduces, it causes progressively more pain and makes it more difficult for the intestines to do their job. Over a period of months the pains may be so severe that the patients are afraid to eat! Consequently, they start losing weight.”

The pain associated with chronic gut attack, typically starts shortly after meals. The pain is often vague in nature but fairly severe and can last for over an hour and then disappear. Pain may be felt in the middle and upper abdomen, although it can occur in any part of the abdomen. The patients learn to eat small amounts of food six to eight times a day, to begin with and as the pains progressive increase, they avoid eating altogether!

There are no prior indication to the problem of an Acute Gut Attack just like heart attacks may not have warning signals, says Dr.Suresh. “The only symptom is, these people have intense amount of abdominal pain. And if at that time someone is vigilant and is aware that the patient has a basic heart disease, the can diagnose the acute gut attack within few hours. However, an acute abdominal pain is a common symptom of many conditions, making diagnosis that much more difficult, even for a specialist. This is one of the reasons why mortality from the disease is so high! Theoretically, you cannot investigate everyone who comes with severe abdominal pain. Suspicion is aroused when patient history reveals some blood vessel disease, coronary heart disease, irregular heartbeat, et al. Clinical diagnosis is virtually impossible unless you index a suspicion, unless someone just had a heart attack and suddenly has abdominal pains.”

How devastating an acute gut attack can be, depends upon the placement of the clot once it gets dislodged from its origin. A small clot lodged towards the end of the intestinal blood vessel, may not create much of a problem, opines Dr.Suresh. However, such a clot in the beginning of the intestinal artery can suddenly cut off the whole intestinal blood supply. “The mortality from this is very high, as much as 40% or more. If before the intestine dies, before gangrene sets in, you diagnose the problem, the patient can be saved,” reveals Dr.Suresh.

The risk factors for chronic gut attack are those that may cause your arteries to be affected by atherosclerosis. These factors include age, hypertension, diabetes, elevated levels of cholesterol and triglycerides, tobacco consumption and smoking, obesity, sedentary life styles. Patients with history of heart and vascular diseases are particularly prone to the acute form of the condition.

What age groups of people can be affected by a gut attack? Dr.Suresh explains, “Acute attack is likely to happen in younger patients, especially in India where congenital and rheumatic heart disease are common. Youngsters could have had a heart valve replaced. They could’ve had these problems even at 15, 20 years of age. Similarly, any age group of people could have a clotting problem. Any condition leading to a hardening of the arteries can result in a gut attack. These are generally diabetics and hypertensive patients and the likely risk age is 40 years plus.”

Dr.Vivekananda adds, “All people who have a basic tendency to form clots, can have an acute gut attack, as they can a heart attack, leg attack or a stroke. For instance, abuse of oral contraceptive pills with high estrogen levels, without doctors’ supervision, can lead to clot formation. Even hormone replacement theory, if not properly supervised, could lead to clot formation. Again, people with rheumatic fever and rheumatic heart condition, have a high chance of throwing a small clot which can get lodged in the intestinal blood vessels and cause a gut attack.”

Deficiency of certain proteins, particularly in the vegetarian diet, may also lead to Hypercoagulability conditions; certain congenital defects having a bearing on certain proteins, could promote clotting; even certain viral syndromes could cause some of the clotting factors to increase, and all this could predispose one to risk of a gut attack, says Dr.Suresh.

What is the time period within which an acute gut attack can reach fatal proportions? “It could be as short as 6 hours,” explains Dr.Suresh. “After six hours, the tissues start dying and we can have massive clot occurring. Death occurs not just because of the death of the tissues, but due to a lot of biochemical and physiological changes that take place in the body as a result of the gut attack. Usually you have 6-24 hours to deal with the situation if the clot/s are not big and if you get small clots in the branch arteries rather than in the main artery; these are the patients who can be saved.”

So how is gut attack diagnosed? Laboratory tests may show an elevated white blood cell (WBC) count and acidosis in the case of acute gut attack. Dr.Suresh explains, “The first step would be to do a Doppler Ultrasound. However, if the gut is filled with gas, it is difficult to do an ultrasound of the blood vessels. The next thing to do would be to do an angiogram. Acute gut attack is a surgical emergency, requiring the clot to be removed from the artery. In some cases, a bypass may become necessary.”

Lab tests apart, Doppler Ultrasound, CT Angiogram and MRI Angiogram are done. Once chronic gut attack is suspected, arteriography is usually diagnostic, says Dr.Suresh. “Once the angiogram shows a block, the best option would be surgery. Surgical treatment may include endarterectomy which removes the atherosclerotic obstructions from the inner layers of the arteries. We can also do an angioplasty, which means putting a balloon to dilate the blocked artery.”

Is treatment with medication possible at some stage of the disease? Dr.Suresh is unequivocal on the issue: “Yes, the early stages of the condition rarely require surgical intervention. But again, gut attack, as opposed to heart attack, can’t really be tackled with medication. But when diagnosed early, what we can do to check its progress is advocate diet and lifestyle modification and elimination of risk factors that contribute to hypertension, diabetes, increased cholesterol and triglyceride, abstain from smoking and alcohol, regular exercises and prevent obesity.”

What are the risks of Surgery? “In the acute stage, the risk is extremely high,” admits Dr.Suresh, “not only because of the surgery itself but usually because the patients already have other problems, particularly heart disorders. Mortality can be as high as 70% - 80%. If we diagnose the condition early and if the patient does not have a major heart problem then the results are good with mortality of about 10%.”

Surgery, however is not indicated in patients having major systemic problems where the vital organs are involved, opines Dr.Suresh.

What is the prognosis for patients undergoing surgery? A candid Dr.Suresh responds, “The long term prognosis is hard to comment upon. The surgery itself is not a common one because the disease itself is uncommon. Your recurrence rate over two years for any occlusion or block is between 10-30%, especially if these patients are diabetics. In smokers, this percentage may be less if they quit smoking.”


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