L-lactate in acute mesenteric ischemia: toward integrated diagnostic and therapeutic stratification

The aim of the review: to present literature data on the role of laboratory methods in the complex diagnosis of acute mesenteric ischemia. The main provisions. To search for scientific publications, we used the PubMed database, the RSCI, the Google Scholar search engine, as well as cited references. Articles relevant to the purpose of the review were selected for the period from 1999 to 2019 in the following terms: “acute mesenteric ischemia”, “pathogenesis”, “diagnosis”, “biomarkers”. Inclusion criteria were limited to acute arterial mesenteric ischemia. Acute mesenteric ischemia is an emergency condition caused by a sudden violation of the blood flow through the mesenteric vessels, which rapidly progresses to a heart attack of the intestinal wall and is accompanied by high mortality. Four main mechanisms of OMI are distinguished: embolism from the left parts of the heart or aorta, thrombosis of arteries or veins of the intestine, non-occlusive acute mesenteric ischemia (NOMI), due to vascular spasm. In this case, destructive disorders occur in the intestinal wall, starting from the mucous membrane to the serous, which leads to bacterial translocation and the development of a systemic inflammatory response syndrome. Early bowel revascularization is a key factor in reducing complications and mortality associated with it. However, in the initial stages of the disease has no specific signs, which complicate its diagnosis. The only way to detect mesenteric blood flow disorders is MSCT with angiography, and with non-occlusive lesions, mesenteric angiography, which in normal clinical practice is not always possible. Conclusion. It can be assumed that the use of laboratory methods will expand the range of diagnostic measures and will make it possible to conduct timely treatment aimed at restoring the mesenteric blood flow and improve the prognosis in patients with acute mesenteric ischemia.

Hypertensive disorders, pulmonary embolism, hemorrhage, sepsis and anesthesia are the main causes of obstetric deaths among women delivered by cesarean section (1). Acute mesenteric ischemia is rare, but is one of the most lethal vascular problems (2). It is caused by embolism, thrombosis or spasm of mesenteric vessels. Superior mesenteric vessels are most frequently involved. Various causes can be atrial fibrillation, myocardial infarct, endocarditis, portal hypertension, portal pyemia, sickle cell disease, and oral contraceptives (3). The intestines and the mesentery become swollen and edematous, and blood-stained discharge exudes into the peritoneal cavity and bowel lumen due to hemorrhagic infarction of the intestines from the duodenojejunal flexure to the splenic flexure (3). The patient complains of severe abdominal pain with vomiting. In the initial stages the abdomen is distended and is mildly tender. Later on, hypovolemic shock develops. It has very high maternal mortality (50–80%). We report a case of lower segment cesarean section (LSCS) leading to maternal mortality within 15 h, due to acute mesenteric ischemia. Acute mesenteric ischemia as a cause of postpartum mortality has not been reported previously in the literature. A 22-year-old primigravida with 40 weeks' pregnancy with the fetus in breech presentation and with leaking per vaginum and labor pains presented as an emergency case. She had not had any antenatal care. On examination the patient was short statured (height 142 cm), malnourished (weight 42 kg) and pale, and her blood pressure was 140/90 mmHg. Per abdomen examination revealed a term-size uterus with a single live baby presenting as breech. On vaginal examination the cervix was 4 cm dilated with the breech at − 2 station and the pelvis was contracted. Emergency LSCS was planned because of the contracted pelvis. Hemoglobin was 8.5 g/dL, urine complete examination was normal. Ultrasound showed a live term fetus with no gross congenital malformation. LSCS was performed at 2430 h under spinal anesthesia and a full-term normal baby extracted as breech. There were no intraoperative complications. The uterus, the adenexae and the gut were apparently normal. The patient was relatively normal for about 6 h except for mild abdominal pain and nausea. After 6 h the patient complained of severe abdominal pain and vomiting for which diclofenac sodium 50 mg and metoclopramide hydrochloride 10 mg were administered by intramuscular injection. At 0930 h the pain increased and there was abdominal distension that was soft and nontender. Vitals were well maintained except for tachycardia (pulse 118/min), which was thought to be due to the pain. Tramadol hydrochloride 50 mg was given to the patient by intravenous injection. At about 1230 h, that is 12 h after the cesarean section, the patient developed sudden hypotension (blood pressure 80 mmHg systolic). On examination the uterus was well contracted with minimal vaginal bleeding. Distension of the abdomen increased slightly but it was soft. Chest X-ray, electrocardiogram and serum electrolyte were within normal limits. To rule out intraperitoneal bleeding, abdominal paracentesis was performed and it was negative. The patient's condition deteriorated very rapidly despite all the emergency measures (intravenous fluids, blood transfusion, dopamine infusion) and her blood pressure did not improve. Exploratory laparotomy was decided on in view of the distended abdomen, persistent pain and falling blood pressure. On laparotomy there was some hemorrhagic fluid in the peritoneal cavity, the uterus and the adenexae were normal and the intestines and the mesentery were edematous with thrombotic vessels and patches of hemorrhage. A general surgeon was called and a case of acute mesenteric ischemia was diagnosed. Intraoperatively, the patient had cardiac arrest and could not be revived. Thromboembolism remains an important cause of maternal mortality and morbidity after cesarean section (1). Pulmonary embolism and deep vein thrombosis are known complications after cesarean section. Acute mesenteric ischemia occurs as a result of thrombosis or embolism in mesenteric vessels with a very high mortality (50–80%). The hallmark of diagnosis is extreme pain. Acute mesenteric ischemia can be diagnosed by duplex ultrasound of celiac and superior mesenteric arteries and arteriography. Early diagnosis and treatment is the only hope to prevent intestinal infarction. If diagnosed early, embolectomy can be performed, but in most cases diagnosis is made late and then at that stage total resection of the affected bowel is required (3). Acute mesenteric ischemia is an unknown postcesarean complication so this condition was not suspected in the present case. It is concluded that we should suspect acute mesenteric ischemia in postoperative patients with extreme pain, vomiting and sudden hypotension so that noninvasive investigations such as Duplex ultrasound scanning can be performed at the earliest to diagnose the condition and to carry out timely surgical intervention to prevent mortality and morbidity.

Hypertensive disorders, pulmonary embolism, hemorrhage, sepsis and anesthesia are the main causes of obstetric deaths among women delivered by cesarean section (1). Acute mesenteric ischemia is rare, but is one of the most lethal vascular problems (2). It is caused by embolism, thrombosis or spasm of mesenteric vessels. Superior mesenteric vessels are most frequently involved. Various causes can be atrial fibrillation, myocardial infarct, endocarditis, portal hypertension, portal pyemia, sickle cell disease, and oral contraceptives (3). The intestines and the mesentery become swollen and edematous, and blood-stained discharge exudes into the peritoneal cavity and bowel lumen due to hemorrhagic infarction of the intestines from the duodenojejunal flexure to the splenic flexure (3). The patient complains of severe abdominal pain with vomiting. In the initial stages the abdomen is distended and is mildly tender. Later on, hypovolemic shock develops. It has very high maternal mortality (50–80%). We report a case of lower segment cesarean section (LSCS) leading to maternal mortality within 15 h, due to acute mesenteric ischemia. Acute mesenteric ischemia as a cause of postpartum mortality has not been reported previously in the literature. A 22-year-old primigravida with 40 weeks' pregnancy with the fetus in breech presentation and with leaking per vaginum and labor pains presented as an emergency case. She had not had any antenatal care. On examination the patient was short statured (height 142 cm), malnourished (weight 42 kg) and pale, and her blood pressure was 140/90 mmHg. Per abdomen examination revealed a term-size uterus with a single live baby presenting as breech. On vaginal examination the cervix was 4 cm dilated with the breech at − 2 station and the pelvis was contracted. Emergency LSCS was planned because of the contracted pelvis. Hemoglobin was 8.5 g/dL, urine complete examination was normal. Ultrasound showed a live term fetus with no gross congenital malformation. LSCS was performed at 2430 h under spinal anesthesia and a full-term normal baby extracted as breech. There were no intraoperative complications. The uterus, the adenexae and the gut were apparently normal. The patient was relatively normal for about 6 h except for mild abdominal pain and nausea. After 6 h the patient complained of severe abdominal pain and vomiting for which diclofenac sodium 50 mg and metoclopramide hydrochloride 10 mg were administered by intramuscular injection. At 0930 h the pain increased and there was abdominal distension that was soft and nontender. Vitals were well maintained except for tachycardia (pulse 118/min), which was thought to be due to the pain. Tramadol hydrochloride 50 mg was given to the patient by intravenous injection. At about 1230 h, that is 12 h after the cesarean section, the patient developed sudden hypotension (blood pressure 80 mmHg systolic). On examination the uterus was well contracted with minimal vaginal bleeding. Distension of the abdomen increased slightly but it was soft. Chest X-ray, electrocardiogram and serum electrolyte were within normal limits. To rule out intraperitoneal bleeding, abdominal paracentesis was performed and it was negative. The patient's condition deteriorated very rapidly despite all the emergency measures (intravenous fluids, blood transfusion, dopamine infusion) and her blood pressure did not improve. Exploratory laparotomy was decided on in view of the distended abdomen, persistent pain and falling blood pressure. On laparotomy there was some hemorrhagic fluid in the peritoneal cavity, the uterus and the adenexae were normal and the intestines and the mesentery were edematous with thrombotic vessels and patches of hemorrhage. A general surgeon was called and a case of acute mesenteric ischemia was diagnosed. Intraoperatively, the patient had cardiac arrest and could not be revived. Thromboembolism remains an important cause of maternal mortality and morbidity after cesarean section (1). Pulmonary embolism and deep vein thrombosis are known complications after cesarean section. Acute mesenteric ischemia occurs as a result of thrombosis or embolism in mesenteric vessels with a very high mortality (50–80%). The hallmark of diagnosis is extreme pain. Acute mesenteric ischemia can be diagnosed by duplex ultrasound of celiac and superior mesenteric arteries and arteriography. Early diagnosis and treatment is the only hope to prevent intestinal infarction. If diagnosed early, embolectomy can be performed, but in most cases diagnosis is made late and then at that stage total resection of the affected bowel is required (3). Acute mesenteric ischemia is an unknown postcesarean complication so this condition was not suspected in the present case. It is concluded that we should suspect acute mesenteric ischemia in postoperative patients with extreme pain, vomiting and sudden hypotension so that noninvasive investigations such as Duplex ultrasound scanning can be performed at the earliest to diagnose the condition and to carry out timely surgical intervention to prevent mortality and morbidity.

ABSTRACTBACKGROUND:Acute mesenteric ischemia is a serious condition with high mortality rate, resulting internal organ damage and intestinal necrosis due to sudden occlusion in the arteries feeding the abdominal solid organs and intestines. The most common causes of acute mesenteric artery ischemia are embolic processes and thrombosis that develops on the basis of primary mesenteric artery atherosclerosis. Whole blood viscosity (WBV) was defined by De Simon and could be calculated with a formula that consists of total plasma protein and hematocrit (HCT). In our study, we aimed to investigate the predictive value of WBV for acute mesenteric ischemia caused by primary mesenteric artery occlusion.METHODS:Between January 2015 and February 2021, a total of 55 patients with a retrospective diagnosis of acute mesenteric ischemia (AMI) and 50 healthy volunteers as a control group were included in the study. WBV was calculated with the De Simon formula using the HCT and plasma protein levels from the blood tests of healthy volunteers and patients at the time of admission with acute abdomen.RESULTS:No significant differences between the two groups in terms of baseline demographic characteristics except the prevalence of age (72.1±12.4 vs. 65.7±6.4; p<0.001) and hypertension (40% vs. 23% p=0.002). AMI patients had significantly higher WBV values both at low shear rate (LSR) ([46.3±21.7 vs. 33.4±13.1, p<0.001] and high shear rate [HSR] [16.5±11 vs. 15.8±0.7, p<0.001]). The univariate analysis identified several variables for predicting AMI including age (odds ratio [OR]: 1.066 confidence interval [CI]: 1.023–1.111, p=0.003), hypertension (OR: 3.612 CI: 1.564–8.343, p=0.003), WBV at HSR (OR: 2.074 CI: 1.193–3.278, p=0.002), and WBV at LSR (OR: 2.156 CI: 1.331–3.492, p=0.002). However, after multivariate analysis, only hypertension (OR: 3.537 CI: 1.298–9.639, p=0.014) and age (OR: 1.085 CI: 1.026–1.147, p=0.004) showed significance. In receiver operating characteristic analysis, a cut-off value of 43.5 WBV for LSR had a 72% sensitivity and a 70% specificity for prediction of mesenteric ischemia patients (area under curve [AUC]: 0.743, p<0.001) and a cut-off value of 16.29 WBV for HSR had a 78% sensitivity and 76% specificity for prediction of mesenteric ischemia patients (AUC: 0.773, p<0.001).CONCLUSION:In our study, we determined that the WBV value obtained with the De Simon formula is a valuable parameter in predicting the development of acute mesenteric artery ischemia caused by primary mesenteric artery occlusion.

What We Can Learn from Cases of Synchronous Acute Mesenteric Obstruction and Nonocclusive Mesenteric Ischemia: How to Reduce the Acute Mesenteric Ischemia-Related Mortality Rate

Backgraund. Chronic mesenteric ischemia is more often accompanied by clinical signs characteristic of colitis. Acute mesenteric ischemia, unlike chronic, is accompanied by nonspecific symptoms and is a serious disease that requires urgent diagnosis. Aims. The aim of the study was to evaluate the effectiveness of MSCT in the diagnosis of acute and chronic mesenteric ischemia based on our observations. Materials and methods. The retrospective study included 135 patients with abdominalgia and suspected mesenteric ischemia who underwent multiphase CT of the abdominal cavity with intravenous bolus contrast enhancement. Group 1 included 105 patients with mesenteric ischemia; group 2 included 30, without confirmed mesenteric ischemia, with the presence of a symptom of mesenteric ischemia in the form of abdominalgia Results. We studied 135 patients, including 105 patients with mesenteric ischemia, 59 women and 46 men of average age 60±14.9 years. The acute form of ischemia (58%) was determined 1.5 times more often than the chronic one. Occlusive and nonocclusive acute mesenteric ischemia occurred in equal proportions. Mesenteric arterial thrombosis was the cause of acute mesenteric ischemia in 23% of cases. Mesenteric venous thrombosis was the cause of chronic intestinal ischemia in 61%, in 5% — acute form. Mixed arterial-venous genesis of mesenteric ischemia was determined in 4% against the background of strangulation obstruction. Dunbar syndrome as a cause of chronic intestinal ischemia was diagnosed in 16%. Chronic ischemic enterocolitis accounted for 10% of all cases of mesenteric ischemia and 23% of chronic ischemia. Symptoms and symptom complexes characteristic of the studied series of diseases with acute or chronic mesenteric ischemia were delineated. Sensitivity, specificity and prognostic value of CT with intravenous bolus contrast enhancement in diagnostics of diseases accompanied by mesenteric ischemia reached 100%. Conclusions. Multiphase CT of the abdominal cavity with bolus contrast enhancement is highly informative in the diagnosis of acute and chronic forms of mesenteric ischemia. Direct CT signs of impaired blood flow in the arteries or veins of the mesentery were indisputable. Indirect signs of mesenteric ischemia were aimed at a thorough analysis of the condition of mesenteric vessels.

The role of adropin, HIF-1α and apelin biomarkers in the diagnosis of acute mesentaric ischemia.

Differentiation of acute mesenteric ischaemia on the basis of aetiology is of great importance because of variation in disease progression, response to treatment and outcome. The aim of this study was to analyse the published data on survival following acute mesenteric ischaemia over the past four decades in relation to disease aetiology and mode of treatment. A systematic review of the available literature from 1966 to 2002 was performed. Quantitative analysis of data derived from 45 observational studies containing 3692 patients with acute mesenteric ischaemia showed that the prognosis after acute mesenteric venous thrombosis is better than that following acute arterial mesenteric ischaemia; the prognosis after mesenteric arterial embolism is better than that after arterial thrombosis or non-occlusive ischaemia; the mortality rate following surgical treatment of arterial embolism and venous thrombosis (54.1 and 32.1 per cent respectively) is less than that after surgery for arterial thrombosis and non-occlusive ischaemia (77.4 and 72.7 per cent respectively); and the overall survival after acute mesenteric ischaemia has improved over the past four decades. There are large differences in prognosis after acute mesenteric ischaemia depending on aetiology. Surgical treatment of arterial embolism has improved outcome whereas the mortality rate following surgery for arterial thrombosis and non-occlusive ischaemia remains poor.

Acute mesenteric ischemia: Pathophysiology, diagnosis, and treatment

Acute arterial occlusive mesenteric ischemia with transmural intestinal necrosis (TIN) is a fatal disease, which is difficult to diagnose on multidetector computed tomography (MDCT). The aim of the present study was to determine the relationship of superior mesenteric artery (SMA) thrombus density with TIN on MDCT in patients with acute mesenteric ischemia (AMI) due to SMA thromboembolism. In this retrospective study, 33 patients who underwent abdominal MDCT and angiography for AMI due to SMA thromboembolism were divided into two groups: the AMI with TIN group and the AMI without TIN group. We analyzed the relationships of clinical characteristics, qualitative MDCT signs, and SMA thrombus density with TIN. The SMA thrombus density was measured on non-contrast MDCT. Univariate and multivariate analyses were performed to determine the risk factors for predicting TIN. The diagnostic performances of risk factors were evaluated by receiver-operating characteristic (ROC) curve analysis. Of the patients with AMI enrolled in this study, 33.3% (11/33) were diagnosed with TIN. Peritonitis (P=0.042), bowel wall thinning (P=0.033), and pneumatosis/portomesenteric gas (P=0.010) were significantly associated with TIN. AMI patients with TIN exhibited a higher SMA thrombus density than AMI patients without TIN [41.2±6.1 vs. 34.2±3.0 Hounsfield unit (HU), P=0.003]. Multivariate analysis showed that SMA thrombus density was an independent predictor of TIN [P=0.044, hazard ratio (HR): 1.82, 95% confidence interval (CI): 1.02-3.25]. For diagnosing AMI with TIN, the area under the ROC curve (AUC) of SMA thrombus density (0.83) was larger than those of peritonitis (0.68), bowel wall thinning (0.66), and pneumatosis/portomesenteric gas (0.71). In patients with AMI, erythrocyte-rich thrombus blocking the SMA trunk which has a higher density on MDCT is prone to the occurrence of TIN compared with erythrocyte-scarce thrombus with a lower density. SMA thrombus density could be an independent risk factor for TIN in patients with AMI due to SMA thromboembolism.

Trends in Treatment and Mortality for Mesenteric Ischemia in the United States from 2000 to 2012

One of the causes of acute intestinal ischemia and necrosis is mesenteric venous thrombosis or its larger-scale and prognostically less favorable variant, i. e., portomesenteric thrombosis. Despite the fact that the main method of treatment for mesenteric venous thrombosis is anticoagulant therapy, the necessity to perform the operation of intestinal resection for mesenteric venous thrombosis remains high, accounting for 17-91%, with the pathology-related mortality amounting to 41%. This study was aimed at analyzing possibilities of diagnostic methods and the use of various strategies in treatment of patients with massive mesenteric and portomesenteric venous thrombosis. The work was based on therapeutic outcomes in a total of 25 patients with mesenteric venous thrombosis. Of these, 19 patients underwent conservative treatment and 6 patients were subjected to resection of the necrotized intestine. The patients' age ranged from 33 to 92 years (mean 63±11 years). There were 15 (60%) men and 10 (40%) women. The diagnosis of mesenteric venous thrombosis was verified by means of the following instrumental diagnostic methods: laparoscopy (n=10), laparotomy (n=6), and computed tomography of the abdominal cavity with intravenous contrast enhancement (n=9). Amongst all patients admitted to our clinic with acute intestinal ischemia over a 12-year period, mesenteric venous thrombosis accounted for 7.7%. The need for small bowel resection appeared in 6 patients, with 5 of them requiring further programmed relaparotomy and formation of an anastomosis. All those 6 patients had presented with a clinical picture of peritonitis. The remaining 19 patients received anticoagulant therapy alone. 7 of the 25 patients with mesenteric venous thrombosis died, with the overall in-hospital mortality thus amounting to 28%. The mortality rate in the group of operated-on patients and in the group of conservative treatment amounted to 50% and 21%, respectively (p=0.169). The volume and spread of venous thrombosis in the portomesenteric venous system also significantly influenced the lethality rate. Amongst 14 patients having developed thrombosis only in the system of the superior mesenteric vein, mortality was 21%. In those with massive portomesenteric venous thrombosis (11 patients), mortality was 36% (p=0.409). Intravenous contrast-enhanced computed tomography and diagnostic laparoscopy should be recognized as the main methods of making the diagnosis of mesenteric venous thrombosis. Anticoagulant therapy may prevent the development of intestinal venous gangrene and improve therapeutic outcomes in patients with mesenteric venous thrombosis.

Background: Acute Mesenteric Ischemia (AMI): Acute mesenteric ischemia is a sudden loss of blood flow to a portion of the small intestine, which can lead to tissue death if not treated promptly. It is often caused by an embolus, thrombosis, or non-occlusive ischemia, usually in the superior mesenteric artery. AMI presents with severe, diffuse abdominal pain that is disproportionate to physical findings, accompanied nausea, vomiting, and sometimes bloody diarrhea. It is a life-threatening condition requiring immediate intervention, typically surgical or endovascular, to restore blood flow. Delay in treatment can lead to bowel necrosis, sepsis, and death if left untreated. Acute Limb Ischemia (ALI): Acute limb ischemia refers to a sudden decrease in limb perfusion that threatens the viability of the limb. It is commonly caused by embolism, thrombosis, or trauma. Symptoms include the "6 P's": pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermic (coldness). The rapid progression of symptoms necessitates urgent intervention or delay in the treatment can lead to sepsis, gangrene and to death if left untreated. Objective: To assess the occurrence of vascular complications in POST COVID-19 patients and to study the relation of risk factor associated with the covid affected patient in ALI and AMI and the morbitity and mortality. Results: The study investigates the incidence of Acute Mesenteric Ischemia AMI and Acute Limb Ischemia ALI in postCOVID19 patients. Using a retrospective analysis of patients treated in a tertiary hospital, we evaluate the impact of COVID19 on the incidence of vascular complications. The results indicate a significant rise in both AMI and ALI, particularly among men with comorbid conditions such as smoking. The study emphasizes the importance of early diagnosis, surgical intervention, and the need for prophylactic measures to reduce morbidity and mortality.

Acute mesenteric ischemia (AMI) is a life-threatening disease that leads to bowel infarction and death. The optimal management of AMI remains controversial. The present meta-analysis aimed to estimate the prognostic impact of surgical (SG) versus endovascular or hybrid intervention (EV) as the first-line treatment for acute arterial occlusive mesenteric ischemia and to assess whether endovascular strategy was actually effective in reducing bowel resection. MEDLINE, Scopus and the Cochrane Library databases were searched. There have been no randomized controlled trials comparing SG versus EV for the treatment of AMI. We undertook this systematic review and meta-analysis according to MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines, assessing the included study quality with the Newcastle-Ottawa scale. Seven studies comparing EV versus SG as first strategy for the treatment of AMI were selected for the analyses, reporting of 3020 patients. EV was associated with a reduced risk of in-hospital mortality (RR 0.68; 95% CI 0.59-0.79; fixed-effects analysis; p<0.0001; I 2=4.9%; τ 2=0.025). Pooled prevalence of mortality was 19% for EV and 34% for SG. EV also showed a benefit impact on risk of bowel resection and second-look laparotomy. The present meta-analysis outlines that endovascular revascularization strategy seems to offer advantages in terms of in-hospital mortality and morbidity in case of arterial occlusive AMI. A multidisciplinary team consisting of radiologists, interventional radiologists, cardiovascular and general surgeons comes out to be essential to tailor the right procedure to the patient and improve the outcomes associated with AMI.

Imaging in Intestinal Ischemic Disorders