What is the management approach for a patient with suspected thrombotic cause of acute epigastric pain?

Management of Thrombotic Causes of Acute Epigastric Pain

For patients with suspected thrombotic causes of acute epigastric pain, prompt diagnosis with CT angiography followed by early endovascular intervention is recommended as the first-line approach to reduce morbidity and mortality.

Initial Assessment and Stabilization

• Resuscitation priorities:

  • Maintain hemodynamic stability with target MAP >65 mmHg 1
  • Assess for and correct coagulopathy with appropriate blood products 1
  • Restrictive blood transfusion strategy:
    • Hemoglobin trigger <70 g/L (target 70-90 g/L) for most patients
    • Higher threshold of 80 g/L (target 100 g/L) for patients with cardiovascular disease 2

• Laboratory evaluation:

  • Complete blood count with peripheral smear (to assess for microangiopathic hemolytic anemia) 3, 4
  • Coagulation studies (PT, PTT, fibrinogen)
  • Cardiac biomarkers (to rule out myocardial infarction) 5
  • Renal and liver function tests

Diagnostic Approach

1. CT Abdomen with IV contrast/CT Angiography:

   • First-line imaging modality for suspected thrombotic causes 2
   • Can detect mesenteric ischemia, aortic dissection, and other vascular pathologies
   • High sensitivity for detecting bleeding at rates of 0.3-1.0 mL/min 1

2. Endoscopy:

   • Early endoscopy (within 24 hours) for patients with suspected GI bleeding 2
   • Upper endoscopy should be considered in patients with risk factors for peptic ulcer, portal hypertension, or angiodysplasia 1

3. Additional imaging:

   • Mesenteric angiography if CT is inconclusive but clinical suspicion remains high
   • Video capsule endoscopy for suspected small bowel bleeding source (87-91.9% diagnostic yield when performed within 48 hours) 1

Management Based on Specific Thrombotic Causes

1. Mesenteric Arterial Thrombosis/Embolism

• Early endovascular intervention:

  • Balloon angioplasty or catheter-directed thrombolysis 6
  • Consider stenting for severe stenotic lesions
  • Early intervention is critical to prevent intestinal necrosis 6

• Anticoagulation:

  • Immediate therapeutic anticoagulation unless contraindicated
  • Consider low molecular weight heparin 48 hours after bleeding has stopped 2

2. Thrombotic Microangiopathy (TMA)

• Therapeutic plasma exchange (TPE):

  • Initiate promptly when peripheral blood smear shows schistocytes with thrombocytopenia 3, 4
  • Continue until clinical and laboratory improvement

• Corticosteroids:

  • May be added in cases of suspected immune-mediated TMA 3

3. Gastrointestinal Bleeding from Thrombotic Sources

• Endoscopic intervention:

  • Recommended for active bleeding
  • Options include clipping, thermal therapy, injection therapy, and band ligation 1

• Angiographic embolization:

  • Second-line treatment if endoscopic treatment fails
  • Technical success rates of 93-100%, but carries 10-50% risk of rebleeding 1

• Surgical intervention:

  • Reserved for cases where endoscopic and radiological interventions fail
  • No patient should proceed to emergency laparotomy without attempts to localize bleeding by radiological and/or endoscopic modalities 2

Management of Anticoagulants/Antiplatelets

1. For patients on anticoagulants:

   • Interrupt direct oral anticoagulant therapy at presentation 2
   • Consider reversal agents (idarucizumab or andexanet) for life-threatening hemorrhage 2
   • For warfarin, reverse with prothrombin complex concentrate and vitamin K in severe hemorrhage 2
   • Restart anticoagulants at 7 days after bleeding has stopped 2

2. For patients on antiplatelets:

   • Continue aspirin for secondary prevention; restart as soon as hemostasis is achieved 2
   • For dual antiplatelet therapy, continue aspirin if P2Y12 receptor antagonist is interrupted 2
   • Restart P2Y12 receptor antagonist within 5 days 2

Follow-up and Prevention

• Iron supplementation for patients discharged with anemia 1
• Gastroenterology follow-up within 2 weeks if discharged 1
• Cardiology follow-up to assess stent status and optimize antiplatelet regimen if applicable 1
• Consider screening for H. pylori and eradication if positive 1

Pitfalls and Caveats

• Thrombotic causes of epigastric pain can mimic more common conditions, leading to delayed diagnosis
• Myocardial infarction can present with epigastric pain, especially in diabetic patients 5
• Acute mesenteric ischemia has high mortality if not diagnosed and treated promptly 6
• Consider thrombotic microangiopathy in patients with unexplained anemia, thrombocytopenia, and acute kidney injury 3, 4