S2179 Intradialytic Hypotension Causing Duodenal Ischemia and UGIB

Abstract

INTRODUCTION: ESRD patients on hemodialysis have a high prevalence of predisposing conditions for mesenteric ischemia, but the contribution of intradialytic hypotension, a potentially modifiable risk factor, has not been well described [1]. Duodenum is a highly vascular region making ischemia rare, and therefore management has not been well documented. There are only a few cases of duodenal ischemia reported in post-op or ESRD patients [2] [3]. CASE DESCRIPTION/METHODS: A 69 years old female with a medical history of ESRD, Hypertension, Type 2 DM, seizure disorder was admitted for a distal femur fracture. She had a right femur retrograde Intramedullary nail placed. The hospital course was complicated by ileus and numerous episodes of intradialytic hypotension with MAP's lower than 50's. The patient had intractable nausea and coffee ground emesis with a subsequent drop in hemoglobin to less than 7.0 hence required multiple PRBC transfusions. EGD showed evidence of ischemia and necrotic appearing duodenal mucosa with a substantial clot burden in the first part of the duodenum. Fresh blood oozing out from the duodenal bulb into the antrum was seen as well. Subsequent CT angiogram of the abdomen showed pneumatosis of the duodenal wall concerning for ischemia and ∼50% stenosis of the proximal celiac artery with associated diffuse calcific plaques of the SMA but not significant enough to cause duodenal ischemia by itself. The patient refused surgical intervention and was managed conservatively with IV fluids, pantoprazole, and antibiotics. Duodenal biopsy revealed necrotic tissue with acute inflammation and H pylori IgG was negative. Intradialytic hypotension was managed through sodium modeling with Midodrine pre-dialysis. The patient was discharged to an LTAC facility. DISCUSSION: The patient had a combination of ∼50% celiac artery and SMA stenosis, which could have compromised flow in the gastroduodenal vascular territory via the pancreaticoduodenal collaterals system. But this alone could not have compromised blood flow to a highly vascularized region as the duodenum. In this case, duodenal ischemia and UGIB was precipitated by intradialytic hypotension. To our knowledge, this is the first reported case of duodenal ischemia causing UGIB with underlying intradialytic hypotension. The diagnosis of NOMI (nonocclusive mesenteric ischemia) presenting with UGIB is difficult. It requires a high level of suspicion since a delay in an early diagnosis results in a high mortality rate [4].Figure 1.: duodenal ischemia.Figure 2.: clot in duodenum.Figure 3