Case Of Acute Mesenteric Ischemia Research Articles

Irreversible Transmural Intestinal Necrosis in Acute Mesenteric Ischemia: Retrospective Cohort Study from a High-Volume Hospital.

Background: Owing to the low incidence rate and nonspecific symptoms of acute mesenteric ischemia (AMI), the identification and prediction of irreversible transmural intestinal necrosis (ITIN) and extensive bowel resection (≥100 cm) (EBR) are difficult and critical. This study aimed to investigate the risk factors for ITIN and EBR in patients with AMI. Methods: The clinical data of 254 AMI patients were retrospectively analyzed. Furthermore, the incidence of ITIN and EBR were set as dependent variables, and relevant risk factors were screened using univariate and multivariate logistic regression analyses. The comparisons of surgical characteristics and postoperative recovery outcomes between the EBR and control group were also conducted. Results: The presence of hemorrhagic (odds ratio [OR] = 28.356, P < .001) or other types ascites (OR = 13.051, P = .003), peritonitis (OR = 8.463, P = .005), intestinal diameter >2.35 cm (OR = 5.493, P = .020), and serum creatinine (CREA) >95 μmol/L (OR = 4.866, P = .048) were identified as independent risk factors for ITIN in patients with AMI. In addition, serum C-reactive protein (CRP) >15 mg/L (OR = 38.023, P = .006), and CREA >100 μmol/L (OR = 6.248, P = .035) were proved to be independently associated with EBR for ITIN cases. Compared to the control group, EBR significantly increased the likelihood of requiring enterostomy (P = .001), blood transfusion (P = .002), and transfer to intensive care unit (P = .016), while also prolonging the recovery time for intestinal function (P = .014). Conclusions: The presence of ascites, peritonitis, intestinal diameter >2.35 cm, and serum CREA >95 μmol/L were independently correlated with ITIN for AMI cases, while serum CRP >15 mg/L and CREA >100 μmol/L independently increased the risk of EBR.

The open abdomen in mesenteric ischemia: A tool for patients undergoing revascularization.

We examined outcomes in Acute Mesenteric Ischemia (AMI) with the hypothesis that Open Abdomen (OA) is associated with decreased mortality. We performed a cohort study reviewing NSQIP emergency laparotomy patients, 2016-2020, with a postoperative diagnosis of mesenteric ischemia. OA was defined using flags for patients without fascial closure. Logistic regression was used with outcomes of 30-day mortality and several secondary outcomes. Out of 5514 cases, 4624 (83.9%) underwent resection and 387 (7.0%) underwent revascularization. The OA rate was 32.6%. 10.8% of patients who were closed required reoperation. After adjustment for demographics, transfer status, comorbidities, preoperative variables including creatinine, white blood cell count, and anemia, as well as operative time, OA was associated with OR 1.58 for mortality (95% CI [1.38, 1.81], p<0.001). Among revascularizations, there was no such association (p=0.528). OA was associated with ventilator support >48h (OR 4.04, 95% CI [3.55, 4.62], and p<0.001). OA in AMI was associated with increased mortality and prolonged ventilation. This is not so in revascularization patients, and 1 in 10 patients who underwent primary closure required reoperation. OA should be considered in specific cases of AMI. Retrospective cohort, Level III.

ACUTE MESENTERIC ISCHEMIA WITH BOWEL GANGRENE:CASE SERIES IN A TERTIARY CARE CENTRE

Introduction: Acute Mesenteric ischemia (AMI) is a worrisome clinical condition leading to end stage irreversible bowel necrosis. Inspite of advances in medical eld, it continues to remain a diagnostic challenge for surgeons leading to delay in diagnosis and high mortality. In this series we present 8 cases of AMI with bowel gangrene treated surgically with an aim to describe its presentation and various management strategies at our institution. This prospective series of patients operated for acute mesenteri Methodology: c ischemia with bowel gangrene was conducted in a tertiary care hospital in Eastern India from January 2021 to August 2022. All patients presenting to the emergency department with abdominal pain, features of obstruction with or without peritonitis operated with a pre operative diagnosis of acute mesenteric ischemia conrmed radiologically were taken for the study. This series comprised of 8 patients, of which 5 (62.5%) were Results: male and 3 (37.5%) were female. The mean age of patients was 58.5 ± 8.9 years with a range from 45 to 75 years. The most consistent presenting feature was abdominal pain (100%) followed by vomiting (50%) and distension (50%). Four (50%) of patients had a pre-existing cardiac illness. The mean length of hospital stay was 7.6 ± 3.87 days. Post operative complication occurred in 4 patients. The mortality rate in our series was 37.5%. AMI is a life threatening vascular Conclusion: emergency with high mortality and morbidity. Most present in a delayed stage where irreversible bowel ischemia has set in requiring emergency laparotomy. High index of clinical suspicion is required for early diagnosis and prompt effective treatment to prevent disastrous consequences.

MIRACULUS OUTCOME OF NON-OCCLUSIVE MESENTRIC ISCHAEMIA (NOMI) IN CARDIOGENIC SHOCK- A CASE REPORT

Introduction: Non-occlusive mesenteric ischemia (NOMI) is an acute mesenteric circulatory disorder which includes all types of mesenteric ischemia without any blockage of blood vessels. It is usually seen in elderly age group with risk factors of previous myocardial infarction, congestive cardiac failure and post-cardiac surgery, renal disease, vasopressor use, aortic insufciency. NOMI is an infrequent cause of acute mesenteric ischemia with atypical symptoms &amp; constitutes 20-30% cases of acute mesenteric ischemia (AMI). The mortality rate is generally high, at least 50%, being the deadliest type of acute mesenteric ischemia (AMI). A high index of suspicion is required. Treatment is based on correction of the underlying cause, supportive therapy, vasodilation and surgery. Presenting a challenging case of an elderly patient with Diabetes Mellitus for 15 years in cardiogenic shock with NOMI. Colonoscopy was diagnostic of ischemic colitis. Patient was managed conservatively with successful outcome NOMI is a rare disease with a difcult d Conclusion: iagnosis because of the unspecic symptomatology. Early recognition with high suspicion of index is necessary. Case highlights the challenges in the diagnosis and the multiple difculties during management. Treatment with supportive therapy, vasodilator drugs and surgery if needed can signicantly improve prognosis &amp; lower mortality

Association of COVID-19 Infection and Acute Mesenteric Ischemia

COVID-19 is an infectious disease that is considered to be a thromboinflammatory disorder. The study was aimed to determine the prevalence of COVID-19 in patients with acute mesenteric ischemia (AMI) and the outcomes of surgical treatment in relation to COVID-19. A total of 140 patients were included in this multicentric study divided into two groups: the test group (n=65) consisted of cases of AMI detected during the COVID-19 pandemic and the control group (n=65) consisted of cases of AMI detected before the pandemic. Test group patients were classified as COVID-positive (COVID+), or COVID-negative (COVID–) if they tested positive, respectively negative test for COVID-19 on admission. Primary outcomes were: prevalence of COVID-19 infection among test group patients, association between COVID-19 infection and inoperability, and between COVID-19 and treatment outcome. Secondary outcomes were association between each blood parameter and inoperability and treatment outcome. There were no statistically significant differences between inoperability and COVID-19 positivity on admission, overall mortality between the control group and the test group and overall mortality between COVID+ and COVID– patients, as well as among those patients that have been surgically treated (p&gt;0.05). There were statistically significant differences between serum amylase levels (p=0.034), and serum LDH levels (p=0.0382) and inoperability, between serum LDH levels and postoperative mortality (p=0.0151), and overall mortality (p=0.00163). High level of LDH and serum pancreatic amylase are associated with a higher rate of inoperability and a higher postoperative and overall mortality rate. COVID-19 does not seem to independently influence the treatment outcome of AMI.

Epidemiology of Acute Mesenteric Ischemia: A Population-Based Investigation.

There is a lack of population-based studies on acute mesenteric ischemia (AMI). We have therefore performed a nationwide epidemiological study in Estonia, addressing incidence, demographics, interventions and mortality of AMI. A retrospective population-based review was conducted of all adult cases of AMI accrued from the digital Estonian Health Insurance Fund and Causes of Death Registry for 2016-2020 based on international classification of diseases (ICD-10) diagnostic codes and procedure codes (NOMESCO). Overall, 577 cases of AMI were identified-an annual incidence of 8.7 per 100,000. The median age was 79 (range 32-104) and 57% were female. Predominating comorbidities included hypertensive disease (81%), atherosclerosis (67%), and atrial fibrillation (52%). The majority of cases (60%) were caused by superior mesenteric artery occlusion (thrombosis 54%, embolism 12%, and unclear 34%). Inferior mesenteric artery occlusion occurred in 7%, non-occlusive mesenteric ischemia in 7%, venous thrombosis in 4%, whereas the type remained unclear in 21% of cases. 40% of patients received intervention (revascularization and/or intestinal resection) and 13% active non-operative treatment. In 21% an exploratory laparotomy or laparoscopy revealed unsalvageable bowel prompting end-of-life care, which was the only management in a further 25% of cases. The population-based annual incidence of AMI in Estonia was 8.7 per 100,000 during the study period. The overall hospital mortality and 1year mortality were 64% and 74%, respectively. In the 53% of patients who received active treatment hospital mortality was 32% and 1year all-cause mortality was 51%. ClinicalTrials.gov Identifier NCT04867499.

Precise diagnosis of acute mesenteric ischemia using indocyanine green imaging prevents small bowel resection: A case report.

IntroductionAcute mesenteric ischemia (AMI) is a rare life-threatening condition that causes intestinal necrosis. Prompt intervention is essential to mitigate high mortality. In this report, we describe a case of AMI where precise diagnosis using indocyanine green (ICG) imaging to confirm sufficient bowel perfusion and viability, helped in preventing intestinal resection.Presentation of caseA 91-year-old male was diagnosed with AMI associated with superior mesenteric artery thrombosis using computed tomography and underwent exploratory laparotomy. Under white light, there was no outward evidence of small-bowel necrosis. Hence, ICG was used to confirm adequate bowel perfusion and viability. The operation was terminated without resection of the small intestine. When anticoagulation therapy was initiated postoperatively, the thrombus subsided. Although the patient had no subsequent recurrence, he died of dysphagic pneumonia two months after the surgery.DiscussionPhysicians often choose to perform trial laparotomy to diagnose intestinal ischemia due to AMI.However, it was difficult to assess the viability of the entire intestinal tract using white light alone, and the introduction of ICG in the evaluation of intestinal perfusion will facilitate the identification and objective evaluation of the intestinal ischemic zone. There have been few reports on application of fluorescent-guided determination of the viable zone of the small intestine, which will help surgeons to make precise diagnosis.ConclusionThis case demonstrates ICG fluorescence imaging as a useful method for objectively assessing bowel viability.

54-Year-Old Woman With Altered Mental Status and Abdominal Pain

54-Year-Old Woman With Altered Mental Status and Abdominal Pain

Intestinal Infarction in COVID-19 Pandemic: A Case Series.

Novel coronavirus disease 2019 (COVID-19) as a potential health risk factor continues to spread worldwide. Although common symptoms include headache and respiratory symptoms, some studies have suggested that COVID-19 may cause coagulation disorders and thrombolytic events, disrupt blood flow to the visceral organs, and cause some complications such as mesenteric ischemia. The authors reported four cases of acute mesenteric ischemia associated with COVID-19 confirmed in patients hospitalized in Imam Reza Hospital (a COVID-19 referral center in Mashhad University of Medical Sciences, Mashhad, Iran). The authors described the pathological findings that may be associated with this infection. The authors collected clinical data, imaging, microscopic, and operative findings of four patients with severe COVID-19 infection and evidence of intestinal necrosis. These four cases of severe COVID-19 pneumonia simultaneously showed intestinal necrosis during the infection process, indicating a relationship between coronavirus and mesenteric vascular events. Physicians should be aware of thrombosis symptoms in the digestive system in patients with severe COVID-19.

The Utility of Biomarkers in Diagnosing and Predicting Outcomes in Acute Mesenteric Ischemia

Background: Acute intestinal ischemia stands as the most lethal acute condition encountered by general surgeons and one of the deadliest pathologies in medicine triggered by thromboembolic events. The patients’ survival decreases dramatically to a lower than 30% rate when diagnosed after 24 hours, thus early diagnosis with proper surgical or vascular intervention is mandatory. This study aims to determine the utility of biomarkers and routine blood tests in assessing the severity and mortality risk for patients with acute mesenteric ischemia. Methods: The study was developed on a prospective cross-sectional design over a period of five years, finding a total of 147 patients who underwent emergency surgery after a high suspicion of acute mesenteric ischemia. The available biomarkers used in our Clinic comprised a complete blood count, total bilirubin, CK, CK-MB, LDH, AST, ALT, amylase, and cholinesterase. Results: The leukocyte count (OR=1.105), hemoglobin (OR=3.912), LDH (OR=1.144), NLR (OR=1.154), and LLR (OR=1.286) were all independent and significant risk factors for AMI diagnosis. These covariates proved a good and reliable tool for diagnosing AMI with a 75.3% predicted probability. Conclusion: The prediction tool proved reliable, although it should only be considered in the clinical context where the surgeon suspects a case of acute mesenteric ischemia. The proposed model should be further investigated and validated in larger studies.

Mesenteric ischemia in COVID-19 patients: A review of current literature.

BACKGROUNDCoronavirus disease 2019 (COVID-19) virus has affected all the systems of the body, defying all impressions of it being a respiratory virus only.AIMTo see the association of mesenteric ischemia with COVID-19.METHODSAfter initial screening and filtering of the titles on PubMed and Google Scholar, 124 articles were selected. Articles were read in full, and the references were skimmed for relevance. Twenty-six articles (case reports and case series) were found to eligible for inclusion. References of these 26 articles were checked for any additional cases. Two more publications were found, and a total of 28 articles (22 case reports and 6 case series) have been included for review in this manuscript. RESULTSA total of 41 cases of acute mesenteric ischemia in COVID-19 patients have been reported in the literature since the outbreak of this pandemic. Most of them include patients with comorbidities.CONCLUSIONIn conclusion, based on this literature review and precise published knowledge regarding acute mesenteric ischemia in patients with COVID-19, it is essential to understand its relevance in all patients with gastrointestinal symptoms. The threshold for the diagnostic investigations should also be kept low for the timely diagnosis and management of this disorder.

Prospects of Intraoperative Multimodal OCT Application in Patients with Acute Mesenteric Ischemia.

Introduction: Despite the introduction of increasingly multifaceted diagnostic techniques and the general advances in emergency abdominal and vascular surgery, the outcome of treatment of patients with acute impaired intestinal circulation remains unsatisfactory. The non-invasive and high-resolution technique of optical coherence tomography (OCT) can be used intraoperatively to assess intestine viability and associated conditions that frequently emerge under conditions of impaired blood circulation. This study aims to demonstrate the effectiveness of multimodal (MM) OCT for intraoperative diagnostics of both the microstructure (cross—polarization OCT mode) and microcirculation (OCT angiography mode) of the small intestine wall in patients with acute mesenteric ischemia (AMI). Methods and Participants: A total of 18 patients were enrolled in the study. Nine of them suffered from AMI in segments II-III of the superior mesenteric artery (AMI group), whereby the ischemic segments of the intestine were examined. Nine others were operated on for adenocarcinoma of the colon (control group), thus allowing areas of their normal small intestine to be examined for comparison. Data on the microstructure and microcirculation in the walls of the small intestine were obtained intraoperatively from the side of the serous membrane using the MM OCT system (IAP RAS, Russia) before bowel resection. The MM OCT data were compared with the results of histological examination. Results: The study finds that MM OCT visualized the damage to serosa, muscularis externa, and blood vessels localized in these layers in 100% of AMI cases. It also visualized the submucosa in 33.3% of AMI cases. The MM OCT images of non-ischemic (control group), viable ischemic, and necrotic small intestines (AMI group) differed significantly across stratification of the distinguishable layers, the severity of intermuscular fluid accumulations, and the type and density of the vasculature. Conclusion: The MM OCT diagnostic procedure optimally meets the requirements of emergency surgery. Data on the microstructure and microcirculation of the intestinal wall can be obtained simultaneously in real time without requiring contrast agent injections. The depth of visualization of the intestinal wall from the side of the serous membrane is sufficient to assess the volume of the affected tissues. However, the methodology for obtaining MM OCT data needs to be improved to minimize the motion artefacts generated in actual clinical conditions.

Clinical Predictors of mortality in Acute Mesenteric Ischemia

Background: Acute mesenteric ischemia (AMI) is an emergency condition, which is accompanied by fatal complications. Clinical signs and symptoms are often unspecific. In addition, there is no single laboratory test to diagnose acute mesenteric ischemia. Early and accurate diagnosis of intestinal ischemia is important to provide rapid and correct treatment and reduce morbidity and mortality rates. Objective: To determine the clinical predictors of outcome in patients with acute mesenteric ischemia at Emergency Hospital, Mansoura University. Materials and Methods: This was a prospective study, which was conducted on patients that were admitted to Emergency Hospital, Mansoura University over a year from December 2019 to December 2020. All patients above 18 years old with acute mesenteric ischemia were included while whom less than 18 years old were excluded. Results: this study had 50 patients (21 males and 29 females) with average age of 66 years old. The results showed that majority of the studied cases died, while only 42% (21 cases) of AMI cases survived. Hypercholesterolemia was considered the most frequently reported Co-morbidity followed by HTN, AF and lastly DM and cardiomegaly. There were statistically significant differences as regards co-morbidities (presence of 2 or more co-morbidities). Conclusion: Acute Mesenteric Ischemia is a serious condition with high mortality rate especially in advanced age and in cases associated with comorbidities, presence of 2 or more co-morbidities, hypertension, hypercholesterolemia, past surgical history increase the incidence of death.

Clinical Features and Factors Affecting Postoperative Mortality for Obstructive Acute Mesenteric Ischemia in China: A Hospital- Based Survey.

PurposeThe study aimed to report the clinical manifestation and identify the risk factors for postoperative mortality in patients who were diagnosed with obstructive acute mesenteric ischemia (AMI) based on a survey of a hospital in western China.Patients and MethodsWe reviewed clinical data of 108 patients with obstructive AMI at West China Hospital, Sichuan University, from 2011 to 2017. Clinical characteristic was described and compared. Factors affecting postoperative survival were analyzed.ResultsA total of 108 obstructive AMI cases were included in this study, with an overall average age of 57.1 years, including 58 arterial occlusive mesenteric ischemia (AOMI) and 50 mesenteric venous thrombosis (MVT). AOMI patients were older and had a significantly higher frequency of these comorbidities, including heart disease, hypertension, and diabetes. In comparison, MVT had a significantly higher proportion of male patients and a higher frequency of liver disease. A total of 77 patients underwent laparotomy, and the 30-day postoperative mortality rate was 29.9%. Multivariate logistic regression analysis showed that the time interval from admission to surgery (adjust OR 1.19; 95% CI [1.07–1.34], P = 0.005), platelet count (adjust OR = 0.98; 95% CI [0.97–0.99], P = 0.008) and AOMI (adjust OR = 5.55; 95% CI [1.36–22.55], P = 0.017) were independent predictors of 30-day mortality after exploratory laparotomy for obstructive AMI. Further analysis of the 45 AOMI showed that the time interval from admission to surgery (adjustOR 1.22; 95% CI [1.01–1.47], P = 0.036) and platelet count (adjustOR = 0.98; 95% CI [0.97–0.99], P = 0.020) were independent risk factors for 30-day postoperative mortality of AOMI.ConclusionEarly identification of AOMI, improving the efficiency of enhanced CT examination, strengthening doctor–patient communication, active laparotomy, and optimize platelet management may also help reduce the overall short-term mortality of obstructive AMI. Building the multidisciplinary team model of diagnostic imaging, vascular intervention, and surgical treatment to manage obstructive AMI may be urgently needed in western China.

Role of multislice computed tomography angiography in the diagnosis of clinically suspected acute mesenteric ischemia

Background The study aims to determine the accuracy of computed tomography angiography (CTA) in the diagnosis of cases of acute mesenteric ischemia (AMI). Patients and methods Fifty patients clinically suspected to have AMI were included and evaluated by multislice computed tomography (MSCT) abdominal angiography to detect the sensitivity, specificity, and diagnostic accuracy of the procedure. Results The final diagnosis confirmed mesenteric vascular occlusion (MVO) in 29 (58%) patients; of the 29 patients with MVO, 10 (34.5%) patients had arterial occlusion and 19 (65.5%) had venous occlusion. MSCT showed MVO in 28 (56%) patients; of the 28 patients with MVO, 10 (35.7%) patients had arterial occlusion and 18 (64.3%) patients had venous occlusion. As regards the 28 patients diagnosed by MSCT as MVO, the final diagnosis approved MVO in 27 of them while one patient was negative. CTA showed a sensitivity of 93.1%, specificity of 95.24%, and an overall accuracy of 94%. Conclusion CTA is an accurate tool that helps in the diagnosis of bowel ischemia with high accuracy in diagnosis. This supports the role of CTA as the ideal first-step imaging procedure in cases suspected to have AMI.

Using the OUTBACK Catheter to Overcome Aortic Reentry Issues in Retrograde Open Mesenteric Stenting

The purpose of this study was to describe the use of the OUTBACK catheter to overcome aortic reentry issues in acute mesenteric ischemia (AMI) treated by retrograde open mesenteric stenting (ROMS). The technique is demonstrated in two female patients presenting with late AMI related to flush occlusion of the superior mesenteric artery (SMA). In such cases of thrombotic AMI with clear preoperative evidence of intestinal necrosis, ROMS is the first-line revascularization technique in our intestinal stroke center. Following an open approach of the SMA through laparotomy, the SMA was punctured in a retrograde fashion. Retrograde mesenteric subintimal recanalization was initiated. In case of aortic reentry issue, the OUTBACK Elite (Cordis, Hialeah, Fl) catheter was advanced through the occlusion over a 0.014 guidewire. The aortic reentry was created by puncture of the aortic wall with the OUTBACK needle, positioned in the desired position. After low-profile balloon angioplasty of the reentry site and 0.035 guidewire exchange, ROMS was performed using balloon-expandable covered stent. The OUTBACK catheter appears to be a safe and effective tool to overcome aortic reentry issues in ROMS. This technical tip might therefore increase the technical success rate of challenging ROMS and decrease the need for bailout bypass in the septic context of AMI.

Hyperspectral Imaging (HSI) in Acute Mesenteric Ischemia to Detect Intestinal Perfusion Deficits

BackgroundAcute mesenteric ischemia is a life-threatening acute condition, which requires an interdisciplinary approach, including vascular recanalization and surgical treatment. Visual evaluation of intestinal perfusion might be misleading, and therefore, additional tools are necessary to reliably be able to resect the ischemic intestine. Hyperspectral imaging (HSI) has been shown to be feasible and safe for real-time assessment of tissue perfusion in visceral surgery but has never been used in cases of acute mesenteric ischemia. Therefore, we applied HSI in acute mesenteric ischemia to evaluate it for potential aid in the objectively discriminating ischemic and well-perfused intestine during explorative laparotomy. MethodsWe recorded HSI measurements in 11 cases of acute mesenteric ischemia during explorative laparotomy. We evaluated the recorded images for macroscopic visual perfusion quality and divided it into three groups. Of those three groups, we calculated and compared the HSI indexes of tissue saturation, near-infrared perfusion index, organ hemoglobin index, and tissue water index, as well as the reflectance spectra. ResultsWe found significant differences in tissue saturation (0.7% versus 0.45%; P = 0.002) and near-infrared perfusion index (0.58 versus 0.23; P < 0.001) in poorly perfused intestinal segments compared with the viable intestine. Furthermore, we could detect an increasing peak at 630 nm of the reflectance spectra in less viable tissues, indicating a maximum in necrotic tissues. We attributed this peak to an increase in met-hemoglobin content in necrotic tissues, which is supported by the increase in the HSI organ hemoglobin index. ConclusionsHSI is able to discriminate tissue perfusion in acute mesenteric ischemia reliably and therefore might be helpful for resection. In addition, HSI gives information on tissue viability via reflectance spectra.

A case report of retrograde open mesenteric stenting for acute mesenteric ischemia

Occasionally, acute mesenteric ischemia cases present with vessels, which are very difficult to cannulate via the percutaneous method. Furthermore, there is a dire need to preserve as much bowel as possible in these cases. Another problem is the long operative time required for open revascularization in these cases and the associated risks. We present such a case of acute mesenteric ischemia with gangrenous distal ileum in an 87-year-old female with multiple comorbidities who was treated with retrograde open mesenteric stenting and resection and anastomosis of the gangrenous segment of the bowel. We recommend vascular surgeon involvement in all cases of laparotomies for acute mesenteric ischemia and we should consider retrograde open mesenteric stenting if cannulation of mesenteric arteries via percutaneous approach is not possible.

Colonic Ischemia as an Early Marker of Acute Mesenteric Ischemia

Introduction - Acute mesenteric ischemia (AMI) and colonic ischemia (CI) share risk factors and pathophysiologic mechanisms and they may be quite intricate and appear in the same patient simultaneously or in different time frames. However, in the majority of patients with CI a specific major vascular lesion cannot be identified, as opposed to AMI. According to the American College of Gastroenterology (ACG), CT angiography should be performed in all patients with severe CI in order to exclude AMI. The main purposes of this study were to stratify CI severity to determine if there was an association with AMI, and to identify determinants of AMI in severe CI. Methods - All patients admitted in our centre in a 5-year-period with the diagnosis of CI were retrospectively reviewed. Statistical analysis was performed with SPSS V25 Results - A total of 241 patients were included, 213 with isolated CI and 28 with CI+AMI. No cases of AMI were found in mild CI but 1.5% of moderate CI and 56.8% of severe CI had simultaneously AMI. The severe isolated CI was compared with the severe CI+AMI group. Hematochezia was more frequent in isolated CI (p<0.001) whereas isolated right CI was more common in CI+AMI (p<0.01). Lactate level was significantly higher in the CI+AMI (7.6±4.6 Vs 2.4±1.3; p=0.001). Atrial fibrillation and coronary disease were more common in the CI+AMI (p<0.05). Global mortality rate was 16.7% in isolated CI, whereas in CI+AMI it reached 77.8% (p<0.001). Conclusion - The knowledge of an association between CI and AMI prompts to look for underlying occlusive vascular disease in patients with severe CI. Our results support the ACG recommendation for CT angiography in all patients with severe CI. Elevated lactate level, right isolated CI, atrial fibrillation and coronary disease are predictors of AMI in patients with severe CI in this study.

3209 Mesenteric Vein Thrombosis: An Unusual Cause of Small Bowel Obstruction

INTRODUCTION: Mesenteric venous thrombosis (MVT) is an uncommon cause of acute to sub-acute abdominal pain. Early recognition and treatment have survival implications. CASE DESCRIPTION/METHODS: A 42 year-old male with past medical history of hypertension and obstructive sleep apnea presented with 3 weeks of worsening abdominal pain, nausea and vomiting. Physical exam revealed diffusely tender abdomen with mild guarding, no rebound tenderness and normoactive bowel sounds. Pertinent labs on admission included an elevated white count of 13.5 K/mm3 and lactate of 2 mmol/L. A non-contrast CT abdomen demonstrated small bowel loops with abnormal wall thickening and associated inflammatory changes. He was started on broad spectrum antibiotics for enteritis, however he had worsening abdominal pain and an abdominal x-ray revealed small bowel obstruction. Patient was made NPO and conservatively managed with IV fluids. His hospital course was complicated by fever of 100.8 F and leukocytosis of 26.3 K/mm3 Infectious work up was unremarkable and a CT abdomen with contrast revealed thrombosis of main portal, superior mesenteric and splenic vein. Hypercoagulable workup resulted in decreased Protein S activity (1779X) and Factor II heterozygosity (prothrombin G20210A mutation). DISCUSSION: MVT accounts for 6%–9% of all the cases of acute mesenteric ischemia. Most common presenting symptom is abdominal pain which occurs in 91–100% of the cases followed by nausea, vomiting and melena. Associated portal venous thrombosis can be seen if the disease originates in the major veins instead of the small vena rectae. Young patients without known risk factors for venous thromboembolic (VTE) and thrombosis in unusual sites such as portal, mesenteric and cerebral veins should be evaluated for thrombophilias. Approximately 20-40% of patients have previous history of deep vein thrombosis or may have a pre-existing hereditary hypercoagulable state such as protein C deficiency, protein S deficiency, anti thrombin III deficiency, factor V Leiden deficiency, or antiphospholipid syndrome. In general, outcomes in MVT are better when compared to arterial thrombosis with mortality of 44% as compared to 66–89% respectively. Studies have shown that early use of heparin has been associated with improved survival. Early recognition of MVT and treatment with anti coagulation has led to non-surgical treatment and improved outcomes.