Nonocclusive Mesenteric Ischemia Research Articles

Abdominal atherosclerosis is not a risk factor of nonocclusive mesenteric ischemia among critically ill patients: a propensity matching study

BackgroundAlthough risk factors of occlusive acute mesenteric ischemia are well known, triggering factors of nonocclusive mesenteric ischemia (NOMI) remain unclear. Alongside to the known risk factors for NOMI, the role of atherosclerosis is not fully elucidated. The purpose of our study was to evaluate whether abdominal atherosclerosis is a risk factor for NOMI.MethodsFrom January 2018 to December 2021, all consecutive patients admitted to the intensive care unit who underwent contrast-enhanced CT for suspicion of NOMI were evaluated for inclusion. Clinical and biological data at the time of the CT scan were retrospectively extracted from medical charts and reviewed by a single radiologist. The cohorts were matched by a 1:1 propensity score based on the patient clinical, biological data, and abdominal CT features associated with NOMI. Noncontrast CT acquisitions were used to calculate calcium scores of the abdominal aorta, celiac trunk, superior mesenteric artery (SMA), and common iliac artery according to the Agatston method. Analyses were performed before and after propensity score matching.ResultsAmong the 165 critically ill patients included, 59 (36%) had NOMI. Before matching analysis, the SMA and total abdominal Agatston calcium scores were not different between patients without and with NOMI (52.00 [IQR = 0, 473] vs. 137.00 [IQR = 0, 259], P = 0.857, respectively, and 7253 [IQR = 1220, 21738] versus 5802 [IQR = 2075, 15,084]; P = 0.723). The results were similar after matching 38 patients with NOMI and 38 without: 153 [IQR = 0, 665] versus 85 [IQR = 0, 240] (P = 0.312) for the SMA calcium score, and 7915 [IQR = 1812, 21561] versus 4139 [IQR = 1440, 9858] (P = 0.170) for the total abdominal Agatston calcium score.ConclusionOur results suggest that atherosclerosis is not a risk factor for NOMI in critically ill patients.

Non-occlusive mesenteric ischemia in critically ill patients.

Non-occlusive mesenteric ischemia (NOMI) is a life-threatening acute condition that has an overall in-hospital mortality rate of up to 75%. Critically ill patients are often admitted to intensive care units (ICUs) due to shock, and these patients are frequently at risk of developing NOMI. The objective of this study was to determine the clinical features of critically ill patients with NOMI and evaluate the risk factors for in-hospital mortality among these patients. We reviewed the electronic medical records of 7,346 patients who underwent abdominal contrast-enhanced computed tomography during their ICU stay at Samsung Medical Center (Seoul, Korea) between January 1, 2010 and December 31, 2019. After reviewing each patient's computed tomography (CT) scans, 60 patients were diagnosed with NOMI and included in this analysis. The patients were divided into survivor (n = 23) and non-survivor (n = 37) groups according to the in-hospital mortality. The overall sequential organ failure assessment (SOFA) score for the included patients upon admission to the ICU was 8.6 ± 3.1, and medical ICU admissions were most common (66.7%) among the patients. The SOFA score upon admission to the ICU was higher for the non-survivors than for the survivors (9.4 vs. 7.4; p = 0.017). Non-survivors were more often observed in the medical ICU admissions (39.1% vs. 83.8%) than in the surgical ICU admissions (47.8% vs. 10.8%) or the cardiac ICU admissions (13.0% vs. 5.4%). Laboratory test results, abdominal CT findings, and the use of vasopressors and inotropes did not differ between the two groups. In a multivariable analysis, SOFA scores >8 upon admission to the ICU (odds ratio [OR] 4.51; 95% 1.12-18.13; p = 0.034), patients admitted to the ICU with medical problems (OR 7.99; 95% 1.73-36.94; p = 0.008), and abdominal pain (OR 4.26; 95% 1.05-17.35; p = 0.043) were significant prognostic predictors for in-hospital mortality. The SOFA score >8 upon admission to the ICU, admission to the ICU for medical problems, and abdominal pain at diagnosis are associated with increased mortality among patients with NOMI.

Basic demographic characteristics and prevalence of comorbidities in acute mesenteric ischemia: a systematic review and proportional meta-analysis

Purpose The aim of this systematic review and meta-analysis was to examine and assess the basic demographic characteristics and prevalence of comorbidities in acute mesenteric ischemia (AMI) and its various subtypes. Patients and methods A literature search was conducted by using the databases PubMed, EMBASE, and Google Scholar (to June 1, 2022). Random-effects or fixed-effects models were selected to pool means and proportions and their corresponding 95% confidence intervals (CI), based on heterogeneity between studies. The results of meta-analyses for basic demographic characteristics and prevalence (proportions) of each specific comorbidities of acute mesenteric ischemia (AMI) and its various subtypes were described. Results Ninety-nine studies were included in the meta-analysis, including 17,103 patients with AMI. Furthermore, 7941 patients with subclass diagnoses of AMI were identified, including 3,239 patients with arterial occlusive mesenteric ischemia (AOMI), 2,977 patients with nonocclusive mesenteric ischemia (NOMI), and 1,725 patients with mesenteric venous thrombosis (MVT). As a surgical emergency, AMI is associated with older patients and a high likelihood of multisystem comorbidities. Comorbidities of AMI involved multiple systemic diseases, including cardiovascular disease, endocrine and metabolic diseases, kidney diseases, digestive diseases, respiratory diseases, cerebrovascular diseases, vascular diseases, and cancer. Conclusion The basic demographic characteristics and the prevalence of comorbidities of different subtypes of AMI are different. The management of comorbidities should be an essential part of improving the prognosis of AMI patients and may contribute to precise prevention of AMI.

Recurrent bowel necrosis from non-occlusive mesenteric ischemia induced by diabetes ketoacidosis in an adult patient causing mortality: a rare cause of mortality associated with poorly controlled diabetes in adults

Diabetes ketoacidosis (DKA) is associated with severe dehydration resulting in non-obstructive mesenteric ischemia (NOMI), which can contribute to severe patient complications. Recurrent episodes of NOMI with DKA in adults can be associated with mortality rarely. We presented a case of an adult patient with poorly controlled insulin-dependent type 2 diabetes mellitus due to poor socioeconomic background who presented to the emergency department with multiple episodes of bowel necrosis causing mortality.

Mesenteric Ischemia After Cardiac Surgery in Dialysis Patients: An Overlooked Risk Factor.

No study has examined the association of the calcification of abdominal artery orifices with nonocclusive mesenteric ischemia (NOMI) in dialysis patients undergoing cardiac surgery. Thus, this study aimed to determine whether calcification of abdominal blood vessel orifices in hemodialysis patients may be a risk factor for NOMI and examine the long-term survival of dialysis patients after undergoing cardiac surgery. From April 2014 to September 2020, 100 dialysis patients underwent cardiac surgery at our hospital. The calcification of the celiac artery (CA) and superior mesenteric artery (SMA) was evaluated by computed tomography, and the degree of orifice stenosis was graded as follows: patent, 0; partial occlusion, 1; and complete occlusion, 2. Eight patients experienced NOMI, and all of them died. SMA calcification scores were not significantly different between the NOMI and non-NOMI groups (1.38±0.52 vs. 1.13±0.69; P = 0.247). However, the average CA orifice calcification score was significantly greater in the NOMI group than in the non-NOMI group (1.63±0.52 vs. 1.15±0.65; P = 0.039), and the SMA+CA orifice calcification scores were significantly different between the groups (3.00±0.76 vs. [non-NOMI] 2.25±1.18; P = 0.028). In all patients, the 30-day and in-hospital mortality rates were 13% and 18%, respectively. All patients were completely followed up with a mean follow-up period of 604±585 days. Kaplan-Meier survival curves showed that patients with SMA and CA calcification tended to have a shorter overall survival than patients without calcification; however, no significant difference was noted. The calcification of CA and/or SMA orifices was associated with postoperative NOMI and poor long-term survival among dialysis patients undergoing cardiac surgery.

Acute Mesenteric Ischemia: Evaluation, Management, and Interventions

AbstractAcute mesenteric ischemia (AMI) is a dreaded, highly morbid pathology. Often this is due to acute occlusion of the superior mesenteric artery. This can be from thrombus or embolism; however, AMI can also be the result of mesenteric venous thrombus or nonocclusive mesenteric ischemia. There have been many recent advances in diagnosis and treatment including endovascular therapies. While there is increasing data to support an endovascular first approach, with improved 30-day mortality rates and in-hospital mortality, many patients will still require surgical intervention at some point. This article will review AMI for the interventional radiologist including etiologies, diagnosis, and management.

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.

Pneumatosis Intestinalis Induced by Alpha-Glucosidase Inhibitors in Patients with Diabetes Mellitus.

Alpha-glucosidase inhibitor (αGIs)-induced pneumatosis intestinalis (PI) has been narrated in case reports but never systematically investigated. This study aimed to investigate the concurrency of PI and αGIs. A literature search was performed in PubMed, Google Scholar, WorldCat, and the Directory of Open-Access Journals (DOAJ) by using the keywords “pneumatosis intestinalis”, “alpha-glucosidase inhibitors”, and “diabetes”. In total, 29 cases of αGIs-induced PI in 28 articles were included. There were 11 men, 17 women, and one undefined sex, with a median age of 67. The most used αGI was voglibose (44.8%), followed by acarbose (41.4%) and miglitol (6.8%). Nine (31%) patients reported concomitant use of prednisone/prednisolone with or without immunosuppressants. The main symptoms were abdominal pain (54.5%) and distention (50%). The ascending colon (55.2%) and the ileum (34.5%) were the most affected. Nineteen (65.5%) patients had comorbidities. Patients with comorbidities had higher rates of air in body cavities, the portal vein, extraintestinal tissues, and the wall of the small intestine. Only one patient was found to have non-occlusive mesenteric ischemia. Twenty-five patients were treated with conservative therapy alone, and two patients received surgical intervention. All patients recovered. In conclusion, comorbidities, glucocorticoids, and immunosuppressants aggravate αGIs-induced PI. Conservative therapy is recommended when treating αGIs-induced PI.

Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis

ObjectiveTo estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality.DesignSystematic review and meta-analysis.Data sourcesMEDLINE (Ovid), Web of Science, Scopus and Cochrane...

Management of Nonocclusive Mesenteric Ischemia in Patients with Cardiac Failure.

This study aimed to evaluate the surgical procedures, outcomes, and prognostic factors in patients with ischemic heart disease who were operated on due to nonocclusive mesenteric ischemia (NOMI). This research contains all patients diagnosed with congestive heart failure and NOMI between January 2011 to January 2020. The patients who had angiography or CT that showed occlusion of more than 50% in any of the main branches of the mesenteric artery or patients who presented with symptoms in correlation with a total occlusion were excluded from the study. Patients who underwent coronary heart surgery but were not diagnosed with congestive heart failure and those with atrial fibrillation also were excluded from the study. Patients divided into two groups, according to a medical database. A significant difference was found between the surviving and non-survivor groups in minutes, in terms of median time to segmenter intestinal resection (P = 0.042). An early diagnosis and surgical segmental intestinal resection before peritonitis worsens can be the key to better prognosis for NOMI patients.

Mid-term Efficacy of Local Repair Using Modified Altemeier Technique for Stomal Prolapse: A Case Series.

Introduction: Stomal prolapse (SP) is characterized by full-thickness protrusion of the bowel through the stoma site. The surgical procedures for SP include local repair, abdominal wall fixation, and stoma relocation. However, previous reports were mostly case reports or case series with a small number of patients and lacked long-term results. A modified Altemeier technique (MAT) has been used for the local repair of SP in our institution, and this study aimed to evaluate its mid-term efficacy.Methods: We reviewed patients who underwent MAT for SP between August 2013 and December 2020. The variables included patient characteristics, type of stoma, indications of stoma creation, the time interval from stoma creation to prolapse, site of prolapse, reasons for SP surgery, perioperative variables, complications during SP surgery, and length of follow-up. Recurrence of SP was defined as the need for change in stoma care or re-protrusion of the stoma by more than 5 cm in length.Results: Ten patients were included in this study. The median age at the time of SP surgery was 71.5 years. The indications of stoma creation included unresectable or recurrent intra-abdominal malignancies in four patients, diverting ileostomy with rectal cancer surgery in two, transverse colon cancer in one, gastric and rectal cancer in one, rectovaginal fistula in one, and non-occlusive mesenteric ischemia in one. The median interval from stoma creation to prolapse was 2.5 months. Six patients underwent elective SP surgery, and four patients underwent emergency surgery for incarcerated prolapse. The median operative time was 75.5 min. Postoperative complications that included transient mucosal ischemia and subcutaneous abscess occurred in one patient. There were four recurrences (40%), and the median time interval from surgery to recurrence was 4.5 months. Two patients underwent repeated MAT, one of whom underwent stomal reversal with laparotomy for re-recurrence. The median follow-up duration was 19 months.Conclusion: MAT for SP is associated with a high recurrence rate in mid-term follow-up.

Prognostic Factors for Mortality in Acute Mesenteric Ischemia.

Postoperative mortality in patients undergoing surgical and/or interventional treatment for acute mesenteric ischemia (AMI) has remained an unsolved problem in recent decades. Here, we investigated clinical predictors of postoperative mortality in a large European cohort of patients undergoing treatment for AMI. In total, 179 patients who underwent surgical and/or interventional treatment for AMI between 2009 and 2021 at our institution were included in this analysis. Associations between postoperative mortality and various clinical variables were assessed using univariate and multivariable binary logistic regression analysis. Most of the patients were diagnosed with arterial ischemia (AI; n = 104), while venous ischemia (VI; n = 21) and non-occlusive mesenteric ischemia (NOMI; n = 54) were present in a subset of patients. Overall inhouse mortality was 55.9% (100/179). Multivariable analyses identified leukocytes (HR = 1.08; p = 0.008), lactate (HR = 1.25; p = 0.01), bilirubin (HR = 2.05; p = 0.045), creatinine (HR = 1.48; p = 0.039), etiology (AI, VI or NOMI; p = 0.038) and portomesenteric vein gas (PMVG; HR = 23.02; p = 0.012) as independent predictors of postoperative mortality. In a subanalysis excluding patients with fatal prognosis at the first surgical exploration (n = 24), leukocytes (HR = 1.09; p = 0.004), lactate (HR = 1.27; p = 0.003), etiology (AI, VI or NOMI; p = 0.006), PMVG (HR = 17.02; p = 0.018) and intraoperative FFP transfusion (HR = 4.4; p = 0.025) were determined as independent predictors of postoperative mortality. Further, the risk of fatal outcome changed disproportionally with increased preoperative lactate values. The clinical outcome of patients with AMI was determined using a combination of pre- and intraoperative clinical and radiological characteristics. Serum lactate appears to be of major clinical importance as the risk of fatal outcome increases significantly with higher lactate values.

Outcomes of Vasoconstrictor-Induced Non-Occlusive Mesenteric Ischemia of Colon: A Systematic Review.

Nonocclusive mesenteric ischemia (NOMI) is due to mesenteric arterial hypoperfusion from several causes, such as hypovolemia, heart failure, shock, vasoconstrictors, and severe liver or renal disease. Vasoconstrictor-induced NOMI is usually iatrogenic or associated with cocaine use. Anecdotal reports suggest that cocaine-induced NOMI has the highest mortality among vasoconstrictors. This review aims to compare the outcomes of colonic NOMI secondary to cocaine versus other vasoconstrictors. We conducted a systematic search of MEDLINE from inception through October 2016 to find articles on colonic NOMI. The study's primary outcomes were mortality and hospital length of stay (LOS), while secondary outcomes included the need for surgery. We reported descriptive statistics as percentages or median and interquartile range (IQR). We compared continuous data with the Mann-Whitney test and categorical data with Fisher's exact test; P < 0.05 was statistically significant. Of the 59 studies, 20 case reports and 3 case series (n= 27 patients) met the inclusion criteria. There was no difference in mortality between cocaine-induced NOMI and non-cocaine NOMI (P=1.0). There were statistically significant differences between cocaine and non-cocaine vasoconstrictor-induced colonic NOMI regarding surgery (60% vs. 5.8%, P=0.03) and median LOS (7 days vs. 4 days, P=0.04). Cocaine-induced NOMI and non-cocaine NOMI both appear to have a relatively high but similar mortality rate, but the former is associated with increased requirement for surgery and LOS; prompt recognition of this clinical entity is required to improve outcomes.

Prognostic factors for the successful conservative management of nonocclusive mesenteric ischemia

BackgroundThe criteria for deciding upon non-operative management for nonocclusive mesenteric ischemia (NOMI) are poorly defined. The aim of this study is to determine the prognostic factors for survival in conservative treatment of NOMI.MethodsPatients with bowel ischemia were identified by searching for “ICD-10 code K550” in the Diagnosis Procedure Combination database between June 2015 and May 2020. A total of 457 patients were extracted and their medical records, including the clinical factors, imaging findings and outcomes, were analyzed retrospectively. Diagnosis of NOMI was confirmed by the presence of specific findings in contrast-enhanced multidetector-row CT. Twenty-six patients with conservative therapy for NOMI, including four cases of explorative laparotomy or laparoscopy, were enrolled.ResultsAmong the 26 cases without surgical intervention, eight patients (31%) survived to discharge. The level of albumin was significantly higher, and the levels of lactate dehydrogenase, total bilirubin, C-reactive protein, and lactate were significantly lower in the survivors than the non-survivors. Sepsis-related Organ Failure Assessment (SOFA) score was significantly lower in the survivors than the non-survivors. The most reliable predictor of survival for NOMI was SOFA score (cutoff value ≤ 3 points), which had the highest AUC value (0.899) with odds ratio of 0.075 (CI: 0.0096–0.58).ConclusionsThe SOFA score and several biological markers are promising predictors to determine a treatment plan for NOMI and to avoid unnecessary laparotomy.

Nonocclusive mesenteric ischemia caused by type B aortic dissection: a case report

BackgroundNonocclusive mesenteric ischemia (NOMI) is defined as acute intestinal ischemia because of decreased blood flow in mesenteric vessels. Only a few cases of NOMI that occur secondary to aortic dissection (AD) have been reported, resulting in the lack of sufficient knowledge of diagnosis and treatment.Case presentationWe aimed to report a case of NOMI caused by type B Aortic Dissection. A 26-year-old male patient was transferred to our hospital with the diagnose of NOMI and aortic dissection in April 2018. The abdominal computed tomography (CT) assists the diagnosis of paralytic intestinal obstruction, intestinal wall pneumatosis, and perforation. Emergency laparotomy revealed that the bowel wall supplied by the superior mesenteric artery (SMA) was pale with the palpable but weak pulsation of the parietal artery. The small intestine was extremely dilated with a paper-thin, fragile wall that was ruptured easily and could not be sutured. In this case, extensive resection and segmental drainage were done. Postoperatively, the digestive tract was reconstructed. However, the patient suffered from iron deficiency anemia and short bowel syndrome eight months later, and unfortunately died from long-term complications.ConclusionAortic dissection leads to continuous decrease in blood pressure and blood flow to the SMA, considering as a predisposing factor for NOMI. During the treatment, extensive resection and segmental drainage are the optimal surgical strategy, which can make benefit in emergencies especially.

Acute Mesenteric Ischaemia Following Cardiac Operations

&lt;p&gt;Acute mesenteric ischaemia (AMI) is an uncommon but sometimes lethal sequel after heart operations. However, no definite diagnostic and therapeutic guidelines have been established so far. It has been reported that AMI occurs on postoperative day six after cardiac operation, with non-occlusive mesenteric ischaemia being the main mechanism leading to AMI. Furthermore, the treatment choices are primarily conservative, including angiography and papaverine infused at 30-60 mg/hour through an angiographic catheter. Others include fluid expansion and antibiotic and anticoagulant treatments. Nevertheless, urgent exploratory laparoscopy or even laparotomy is warranted for patients with peritoneal signs. The surgical principles for treating AMI are bowel resection, embolectomy/thrombectomy and endarterectomy with or without antegrade percutaneous stenting, aiming at restoring blood flow to the superior mesenteric artery. Still, the prognosis is poor, with an overall mortality rate of 71.8%. Therefore, an early suspicion leading to the diagnosis of postoperative AMI is crucial for improving patients&amp;rsquo; outcomes.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Prognostic factors in patients with acute mesenteric ischemia – a novel tool for determining patient outcomes

Abstract Objective Acute mesenteric ischemia (MI) is a devastating disease with poor prognosis. Due to the multitude of underlying factors and broad clinical presentation, prediction of outcomes remains poor. Here, we aimed to identify factors governing survival in MI and develop a novel prognostic tool. Methods The present study is a monocentric retrospective analysis of patients with suspected MI undergoing imaging between January 2014 and December 2019. Primary endpoint was identification of factors influencing survival in patients undergoing surgery for confirmed MI, secondary endpoint was the development of a predictive nomogram to aid in determination of patient prognosis. Results 539 patients underwent CT imaging for suspected MI, 216 of which had radiological indication of MI and 137 of those had subsequently confirmed MI. Factors associated with confirmed ischemia were increasing age, nausea/vomiting, history of peripheral arterial disease and presence of pneumatosis intestinalis and dilated bowel loops. 125 patients underwent surgery, 58 of which survived, and 67 died (median 9 days after diagnosis, IQR: 22). Baseline characteristics, including time from diagnosis to surgery were not different among patients, and outcomes were not affected by the presence of a surgical senior consultant or daytime of the operation. A minimally invasive approach was attempted more often in survivors (25.9% vs. 10.4%, p=0.024), however, in all but 1 patient (1.7%) conversion to open surgery was performed following detection of ischemia. Increasing age and ASA score, type 2 diabetes, decreased haemoglobin and pH, increased creatinine, radiological atherosclerosis, vascular occlusion (versus non-occlusive MI) and affection of the colon (compared to small bowel ischemia only) were independently associated with impaired survival. Based on a multivariate model, we developed a nomogram for survival prediction, which showed adequate power upon internal validation (C-index = 0.738, Figure 1). Conclusion Acute MI remains a condition with high mortality. Here, we identified factors affecting survival after MI, namely colonic involvement, vascular co-morbidities and increasing age. Minimally invasive surgical approaches have not yet gained widespread acceptance in treatment of confirmed MI. Our novel nomogram might prove helpful in outcome prediction of patients with MI.

An Update on Acute Mesenteric Ischemia.

Acute mesenteric ischemia (AMI) is an uncommon yet highly lethal cause of acute abdomen in the emergency setting. Computed tomography (CT) imaging, in particular a biphasic protocol consisting of angiographic and venous phase scans, is widely used to corroborate non-specific clinical findings when suspicions of AMI are high. Techniques such as low kilovoltage peak scanning, dual energy acquisition, or a combined arterial/enteric phase can improve iodine conspicuity and evaluation of bowel enhancement. Biphasic CT with CT angiography is mandatory to directly assess for the 3 primary etiologies of AMI-arterial, venous, and non-occlusive mesenteric ischemia (NOMI), and the CT angiographic findings may be the first visible in the disease. In addition, numerous non-vascular CT findings have also been reported. Bowel wall thickening, mesenteric stranding, and ascites are common but non-specific findings that correlate poorly with disease severity. Pneumatosis intestinalis and portomesenteric venous gas, while not pathognomonic for ischemia, are highly specific in cases of high clinical suspicion. Bowel wall hypoenhancement is an early and specific sign but requires a protocol optimizing iodine conspicuity to confidently identify. Finally, intraperitoneal free air and solid organ infarcts are also highly specific ancillary findings in AMI. AMI occurs as a complication in 10% of small bowel obstruction (SBO) patients, and understanding imaging findings of ischemia in the context of SBO is necessary to aid in treatment planning and reduce over- and under-diagnosis of strangulation. Familiarity with the imaging features of ischemia by radiologists is vital to establish an early diagnosis before irreversible necrosis occurs.

Methamphetamine-Induced Bowel Ischemia in a 50-Year-Old Male

Methamphetamine intoxication is a known risk factor for nonocclusive mesenteric ischemia (NOMI). We describe a case of a 50-year-old male with a history of polysubstance abuse who presented to the Emergency Department with severe abdominal pain and coffee-ground emesis. Computed tomographic (CT) imaging demonstrated portal venous gas and diffuse colonic wall thickening concerning for ischemic colitis. The patient underwent exploratory laparotomy with resection of the ascending colon as well as a necrotic section of the jejunum. Further embolic workup was negative with a subjective history of amphetamine use prior to presentation. NOMI has a high fatality rate, and we recommend providers include drug-induced bowel infarction on their differential when presented with findings of ischemic bowel of unclear etiology.

Predictors of response to intra-arterial vasodilatory therapy of non-occlusive mesenteric ischemia in patients with severe shock: results from a prospective observational study

BackgroundNon-occlusive mesenteric ischemia (NOMI) is a life-threatening condition occurring in patients with shock and is characterized by vasoconstriction of the mesenteric arteries leading to intestinal ischemia and multi-organ failure. Although minimal invasive local intra-arterial infusion of vasodilators into the mesenteric circulation has been suggested as a therapeutic option in NOMI, current knowledge is based on retrospective case series and it remains unclear which patients might benefit. Here, we prospectively analyzed predictors of response to intra-arterial therapy in patients with NOMI.MethodsThis is a prospective single-center observational study to analyze improvement of ischemia (indicated by reduction of blood lactate > 2 mmol/l from baseline after 24 h, primary endpoint) and 28-day mortality (key secondary endpoint) in patients with NOMI undergoing intra-arterial vasodilatory therapy. Predictors of response to therapy concerning primary and key secondary endpoint were identified using a) clinical parameters as well as b) data from 2D-perfusion angiography and c) experimental biomarkers of intestinal injury.ResultsA total of 42 patients were included into this study. At inclusion patients had severe shock, indicated by high doses of norepinephrine (NE) (median (interquartile range (IQR)) 0.37 (0.21–0.60) μg/kg/min), elevated lactate concentrations (9.2 (5.2–13) mmol/l) and multi-organ failure. Patients showed a continuous reduction of lactate following intra-arterial prostaglandin infusion (baseline: (9.2 (5.2–13) mmol/l vs. 24 h: 4.4 (2.5–9.1) mmol/l, p < 0.001) with 22 patients (52.4%) reaching a lactate reduction > 2 mmol/l at 24 h following intervention. Initial higher lactate concentrations and lower NE doses at baseline were independent predictors of an improvement of ischemia. 28-day mortality was 59% in patients with a reduction of lactate > 2 mmol/l 24 h after inclusion, while it was 85% in all other patients (hazard ratio 0.409; 95% CI, 0.14–0.631, p = 0.005).ConclusionsA reduction of lactate concentrations was observed following implementation of intra-arterial therapy, and lactate reduction was associated with better survival. Our findings concerning outcome predictors in NOMI patients undergoing intra-arterial prostaglandin therapy might help designing a randomized controlled trial to further investigate this therapeutic approach.Trial registration Retrospectively registered on January 22, 2020, at clinicaltrials.gov (REPERFUSE, NCT04235634), https://clinicaltrials.gov/ct2/show/NCT04235634?cond=NOMI&draw=2&rank=1.