Nonocclusive Mesenteric Ischemia Research Articles

Acute Mesenteric Ischemia: Multidetector CT Findings and Endovascular Management.

Acute mesenteric ischemia is a rare life-threatening condition that accounts for approximately one in 1000 hospital admissions. The mortality rate is 50%-69% owing to the absence of specific symptoms and laboratory data, which makes early detection of this condition difficult. If the use of contrast material is possible, biphasic contrast material-enhanced multidetector computed tomography (CT) is the first-line imaging test for early diagnosis of the disease and for differentiation from other causes of acute abdomen. Multidetector CT can depict mesenteric ischemia, its underlying causes, and its severity. Mesenteric ischemia is classified as either acute or chronic. The causes of AMI include arterial embolism, arterial thrombosis, venous thrombosis, and nonocclusive mesenteric ischemia, among which arterial causes are far more common than venous causes. Recently, endovascular procedures such as thrombolysis, thrombectomy, thrombus fragmentation, and stent placement have been successfully and safely performed when the ischemia is reversible. Online DICOM image stacks are available for this article. ©RSNA, 2018.

CHOLESTEROL CRYSTAL EMBOLISM AS THE REASON OF ACUTE NON-OCCLUSIVE MESENTERIC ISCHEMIA AFTER INFRARENAL AORTIC ANEURISM REPAIR

OBJECTIVE. According to the analytical data, the acute non-occlusive mesenteric ischemia after infrarenal aortic aneurism repair occurs in 0.2–1 % of cases. This complication is difficult to diagnose and associated with unfavorable prognosis and high mortality. MATERIAL AND METHODS. The retrospective analysis included 112 case histories of patients with infrarenal aortic aneurism repair in the period from 2007 to 2017. RESULTS. During the early postoperative period, 2 patients (1.8 %) had an acute non-occlusive mesenteric ischemia with lethal outcome. In these cases, the complication developed with safety patency of main mesenteric arteries and was followed by developing early multiorgan failure and thrombocytopenia. The autopsy showed generalized atherosclerosis, infarctions of kidneys, spleen and liver, caused by cholesterol crystal embolism of microvascular bed, which was found after histological research. CONCLUSION. The clinical presentation of acute non-occlusive mesenteric ischemia after infrarenal aortic aneurism repair is low-specific. One of the etiological factors of this complication is cholesterol crystal embolism in microvascular bed of visceral arteries

A Nonsurgical Approach to Mesenteric Vascular Disease.

Mesenteric ischemia is a rare disorder, with considerably high morbidity and mortality rates. It can manifest in several ways, including acute mesenteric ischemia, chronic mesenteric ischemia, nonocclusive mesenteric ischemia, mesenteric venous thrombosis, and colonic ischemia. Of these, acute mesenteric ischemia is the most severe form of intestinal ischemia, with a high mortality rate. The mainstay of therapy for mesenteric ischemia is surgical exploration and resection of infarcted bowel; however, medical therapy can play an important adjunctive role. When diagnosed early, before bowel infarction, endovascular therapy can be used as the primary treatment option. Endovascular therapy includes catheter-based thrombolysis, thromboembolectomy, and stenting. Vasodilators also play an important role in the early management of mesenteric ischemia. Anticoagulation is the main form of therapy in mesenteric venous thrombosis.

Treatment of nonocclusive mesenteric ischemia with type B aortic dissection using intra-arterial catheterization after trauma surgery: case report

BackgroundNonocclusive mesenteric ischemia (NOMI) is a mesenteric arterial spasm and intestinal ischemia. This disease is a highly lethal disease because diagnosis and decision of appropriate treatments are often difficult. Operations cannot resolve the spasms and may worsen the situation. However, the safety and effectiveness of catheterization for NOMI with aortic dissection (AD) have not yet been elucidated. Here, we report a successful case of early diagnosis and treatment of NOMI with type B AD involving the superior mesenteric artery (SMA) using the intra-arterial infusion of a vasodilator via the SMA.Case presentationAn 83-year-old man was admitted to our hospital because of abdominal pain after a motor accident. We performed intestinal resection and splenectomy for intestinal perforation and splenic hemorrhage and treated conservatively for acute AD, liver injury, renal hematoma, and pneumothorax. On postoperative day (POD) 2, the patient had localized abdominal pain. Follow-up computed tomography suggested a smaller superior mesenteric vein sign and segmental lack of enhancement in the intestinal wall and ascites without SMA occlusion. Thus, the patient was diagnosed with NOMI. Although the patient had type B AD including the SMA, we performed selective mesenteric arteriography and transcatheter papaverine infusion via the SMA and prostaglandin via the peripheral vein. Seven days post treatment, mesenteric blood flow improved and intestinal wall enhancement was restored.ConclusionThe intra-arterial infusion of a vasodilator is highly efficient and safety treatment option for NOMI with type B AD. Prompt and accurate management can prevent massive small bowel resection, and this procedure is essential in resolving a spasm independent of whether a necrotic bowel has been resected.

A Case of Non-Occlusive Mesenteric Ischemia During Postoperative Early Enteral Nutrition

A Case of Non-Occlusive Mesenteric Ischemia During Postoperative Early Enteral Nutrition

A Case of Non-occlusive Mesenteric Ischemia Presenting with Hepatic Portal Venous Gas in a 101-year-old Female

A Case of Non-occlusive Mesenteric Ischemia Presenting with Hepatic Portal Venous Gas in a 101-year-old Female

A Case Report of Non-occlusive Mesenteric Ischemia after Thoracoscopic Esophagectomy where Enteral Nutrition Might Etiologically Participate

A Case Report of Non-occlusive Mesenteric Ischemia after Thoracoscopic Esophagectomy where Enteral Nutrition Might Etiologically Participate

A Case of Nonocclusive Mesenteric Ischemia Treated by Continuous Intravenous Administration of Prostaglandin E<sub>1</sub>

A Case of Nonocclusive Mesenteric Ischemia Treated by Continuous Intravenous Administration of Prostaglandin E<sub>1</sub>

Non-occlusive mesenteric ischaemia: CT findings, clinical outcomes and assessment of the diameter of the superior mesenteric artery.

Review of the experience of a tertiary care centre for almost 10 years in the CT diagnosis of non-occlusive mesenteric ischaemia (NOMI). Analysis of CT findings, correlation with clinical outcomes and evaluation of the usefulness of measuring the superior mesenteric artery (SMA) diameter for the diagnosis of NOMI. 106 patients were diagnosed with NOMI in a biphasic CT examination from 2008 to 2017 in our hospital. Clinical outcomes and CT findings were reviewed. In 55 patients, the diameter of the SMA was compared with a previous CT scan where NOMI was not the diagnosis, and statistical analysis using paired t-test was performed. 81 patients (76%) had findings consistent with small bowel ischaemia and the ileum was the segment most commonly involved (47%). Lack of wall enhancement, pneumoperitoneum, pneumatosis intestinalis and portal venous gas were all considered signs of bowel necrosis and surgery was performed promptly. 70 patients had signs of vascular narrowing of the SMA branches and in the 55 cases with a previous CT scan, there were statistically significant differences regarding the SMA diameter with a mean reduction of the artery calibre and standard deviation of 1.93 ± 1.1 mm between the NOMI and non-NOMI scans (p < 0.001). Acknowledgment of characteristic bowel necrosis CT findings is crucial for determining the therapeutic attitude and the use of previous CT scans to compare the SMA diameter may help the radiologist to achieve an early diagnosis of NOMI in an often critically ill patient population. Advances in knowledge: Diagnosis of NOMI can be difficult in cases of partial mural ischaemia, thus objective data (diameter of the SMA) should be useful for the radiologist to include NOMI as the first diagnostic option in the differential diagnosis.

An Interesting Case of Acute Mesenteric Ischemia Secondary to Non-bacterial Thrombotic Endocarditis

Acute mesenteric ischemia is a life-threatening condition that occurs when an abrupt decrease in blood flow results in inadequate supply to the intestines, leading to bowel infarction. Etiologies may include arterial embolus, arterial or venous thrombosis, and nonocclusive mesenteric ischemia. Other causes include vasculitis, traumatic injury, dissection of the aorta and intestinal obstruction. Nonbacterial thrombotic endocarditis (NBTE) is a rare condition that refers to a spectrum of noninfectious lesions of the heart valves. It is often an autopsy finding, found in approximately 1%-1.5% of adults during autopsy. We herein present a case of a 42 year-old male patient with a significant history of smoking presented with a new onset diffuse abdominal pain of 2 days prior to admission. Physical exam was unremarkable. CBC and CMP did not reveal any abnormalities. CT angiography of the abdomen visualized a superior mesenteric artery (SMA) thrombus. The patient underwent an emergent exploratory laparotomy with SMA thrombectomy and endarterectomy and resection of 285 cm of small bowel. Workup for coagulopathy, systemic lupus erythematosus (SLE) and antiphospholipid syndrome was nondiagnostic. Transthoracic echocardiogram showed a small mobile structre attached to the aortic valve, so transesophageal echocardiogram was done and showed a freely mobile pedunculated homogenous mass that is attached to the sub valvular aortic area. Patient underwent thoracotomy and the vegetation was excised. Surgical histopathology was consistent with fibrinous thrombus and no evidence of infective organisms. The patient was started on low molecular weight heparin, then transitioned to rivaroxaban. Acute mesenteric ischemia is a lifethreatening disease, with mortality rates that can approach 90% in the setting of bowel infarction. As such, it is important to establish an early diagnosis before the onset of bowel infarction. Thorough history, physical exam and workup should be done to identify the cause of mesenteric ischemia. Nonbacterial thrombotic endocarditis is characterized by the deposition of sterile platelet thrombi on heart valves, commonly aortic and mitral. It is mostly associated with advanced malignancies (80 percent of cases) and systemic lupus erythematosus (SLE). Although it is rare, it should be kept in mind as an important cause of acute mesenteric ischemia.Figure: CT Scan Showing SMA Occlusion.Figure: Homogeneous Mass Attached To The Subvalvular Aortic Area (Systole).Figure: Homogeneous Mass Attached To The Subvalvular Aortic Area (Diastole).

Risk factor analysis for nonocclusive mesenteric ischemia following cardiac surgery: A case-control study.

Although rare, postcardiac surgery nonocclusive mesenteric ischemia (NOMI) is a life-threatening condition. Identifying the risk factors for NOMI during immediate postoperative period may help early detection and intervention, which leads to improved clinical outcomes. The objective of this study was to identify the clinical features and risk factors of NOMI for prognosis identification after cardiac surgery, focusing on immediate postoperative parameters.Among 9445 patients who underwent cardiac surgery over a span of 9 years, 40 NOMI cases (0.4%) requiring surgical interventions were reviewed. Suspected NOMI was diagnosed by sigmoidoscopy or computed tomography. To identify the risk factors, a control group (case: control = 1:3 ratio) was randomly selected and compared using logistic regression models.NOMI was diagnosed after a mean of 8.1 ± 9.6 days following cardiac surgery. Age (odds ratio: 1.16, 95% confidence interval: 1.08–1.25, P < .001), total vasoactive–inotropic score (VIS), and the maximal lactate level at postoperative day 0 (1.003, [1.001–1.005], P = .012), (1.23, [1.04–1.44], P = .011) were shown as risk factors. NOMI cases showed persistent hyperlactatemia without washout during the first 48 hours (P = .04). Thirty-four cases underwent exploratory laparotomy within a median of 10 (2–356) hours after the diagnosis, but only 17 patients (42.5%) survived. Compared with survivors, nonsurvivors showed higher total VIS at diagnosis, higher lactate levels during the first 24 hours postoperatively, and more frequently required extensive bowel resection (P < .05).Old age, postoperative high-dose vasoactive-inotropic use, and persistent high lactate level during the first 24 hours postsurgery were identified as risk factors for NOMI. Lactic acidosis and necrotic-bowel extent at surgical exploration were associated with poor survival.

Effects of complement C5a inhibitor therapy in animal models of non-occlusive mesenteric ischemia

Non-occlusive mesenteric ischemia (NOMI) develops without anatomical causes. Early diagnosis is challenging and treatments are of questionable effectiveness. We investigated the role of complement activation in the pathophysiology of NOMI in animal models through the inhibition of complement C5a. 60-min partial aortic occlusion (PAO; abdominal aorta, proximal to celiac trunk; mean arterial pressure: 30-40 mmHg) was established in Sprague-Dawley rats (n = 28) and 60-min cardiac tamponade in minipigs (n = 19; mean arterial pressure: 40-50 mmHg) to observe short- and long-term circulatory and inflammatory consequences of NOMI. Macro- and microhemodynamics, leukocyte infiltration, plasma levels of inflammatory mediators (endothelin, HMGB-1) were measured. C5a inhibitor (Acetyl-Peptid-A; 4 mg/kg iv) was administered at the 45th min of PAO or tamponade, respectively. Twenty-four hours after PAO systemic inflammatory response increased cardiac output and superior mesenteric artery flow (SMAF). C5a inhibition reduced the elevated cardiac output (203.1 ± 5 vs 269.6 ± 8.1 ml/min/kg) and SMAF and increased ileal microcirculation (833.5 ± 33.8 vs 441.9 ± 22.4 μm/s). In pigs, after the tamponade, C5a inhibition reduced the immediate hemodynamic disturbances, temporarily increased SMAF and permanently the ileal microcirculation. The Acetyl-Peptid-A treatment reduced leukocyte infiltration and plasma levels of inflammatory mediators in both NOMI models. Complement activation plays central role in the macro- and microcirculatory disturbance during NOMI. C5a inhibition reduces the inflammatory activation and influences the hemodynamic consequences of experimental NOMI.

Reverse takotsubo cardiomyopathy presenting as abdominal pain: An atypical presentation

Reverse takotsubo cardiomyopathy is the rarest variant of takotsubo cardiomyopathy. We present a case of reverse takotsubo cardiomyopathy presenting as abdominal pain likely due to non-occlusive mesenteric ischemia. A 58-year-old female presented with abdominal pain, nausea, vomiting, and diarrhea for 2 days. Upon presentation, she was normotensive but tachycardic. Her lactic acid level was 2.8 mmol/L and troponin-T was 0.62 ng/ml. The electrocardiogram showed non-specific ST changes. CT scan of abdomen revealed bowel wall thickening in transverse colon and splenic flexure. Patient was started on aggressive intravenous fluid therapy for possible infectious colitis.The next day, patient started becoming progressively more dyspneic, hypoxic, and hypotensive. A chest X-ray at that time showed signs of severe congestive heart failure. Echocardiogram revealed left ventricular ejection fraction of 20% with akinesis of proximal and mid-ventricular walls. Patient was intubated for hypoxic respiratory failure and started on milrinone infusion for acutely depressed cardiac function. Inotropes were weaned off the next day, and she was successfully extubated on day 4. Subsequently, gastrointestinal symptoms resolved. Cardiac catheterization was performed later during the hospitalization that showed normal coronary arteries. Repeat echocardiogram done 3 months later showed return of cardiac function to normal.

Occurrence and severity of non-occlusive mesenteric ischemia (NOMI) after cardiovascular surgery correlate with preoperatively assessed FGF-23 levels.

PurposeTo evaluate the value of preoperatively assessed fibroblast growth factor 23 (FGF-23) levels and to correlate FGF-23 with angiographic findings in non-occlusive mesenteric (NOMI) ischemia using a standardized scoring system.Materials and methodsBetween 2/2011 and 3/2012 a total of 865 patients (median age: 67 years) underwent cardiovascular surgery during this ethics committee approved, prospective study. 65 of these patients had clinical suspicion of NOMI and consequently underwent catheter angiography of the superior mesenteric artery. Images were assessed using a standardized reporting system (Homburg-NOMI-Score). These data were correlated to following preoperative parameters of kidney function: cystatin C, creatinine, FGF-23 and estimated glomerular filtration rate (eGFR), and outcome data (death, acute renal failure) using linear and logistic regressions, as well as nonparametric tests.ResultsSignificant correlations were found between FGF-23 and the angiographic appearance of NOMI (p = 0.03). Linear regression analysis showed no significant correlation to the severity of NOMI with creatinine (p = 0.273), cystatin C (p = 0.484), cystatin C eGFR (p = 0.914) and creatinine eGFR (p = 0.380). Logistic regression revealed a significant correlation between death and the Homburg-NOMI-Score (p<0.001), but not between development of NOMI and acute renal failure (p = 0.122). The ROC Analysis yielded an area under the curve of 0.695 (95% CI: 0.627–0.763) with a sensitivity of 0.672 and specificity of 0.658.ConclusionsFGF-23 significantly correlates with the severity of NOMI, which is in contrast to other renal function parameters. The applied scoring system allows to predict mortality in NOMI patients.

Intestinal fatty acid-binding protein level as a predictor of 28-day mortality and bowel ischemia in patients with septic shock: A preliminary study

PurposeWe sought to evaluate the levels of intestinal fatty acid-binding protein (I-FABP), a biomarker of enterocyte injury, as a predictor of 28-day mortality and bowel ischemia in septic shock patients. Material and methodsIn this preliminary prospective observational study, 57 adult septic shock patients under mechanical ventilation were enrolled. Serum I-FABP levels and prognostic biomarkers were recorded upon intensive care unit (ICU) admission. ResultsThe overall 28-day mortality rate of participants was 23% (13/57). Non-survivors displayed significantly higher lactate (p=0.009), I-FABP (p=0.012), and N-terminal pro-B-type natriuretic peptide (p=0.039) levels compared to survivors. Only I-FABP was associated with 28-day mortality (odds ratio, 1.036; 95% confidence interval, 1.003–1.069; p=0.031) in a multiple logistic regression analysis adjusted for the Acute Physiology and Chronic Health Evaluation II score. When divided into low and high I-FABP groups based on the optimum cut-off value of 19.0ng/mL for predicting 28-day mortality, high-I-FABP patients had a significantly higher incidence of non-occlusive mesenteric ischemia (NOMI) (2% [1/43] vs 29% [4/14]; p=0.011). ConclusionsI-FABP level at ICU admission can serve as a predictor of 28-day mortality in septic shock patients and is associated with the incidence of NOMI.

Nonocclusive Mesenteric Ischaemia Induced by Diltiazem Overdose: A Case Report

Acute mesenteric ischaemia is a rare complication of calcium channel blocker (CCB) overdose. A previous study reported a case of mesenteric ischaemia induced by poisoning with CCBs other than diltiazem. We present a case of nonocclusive mesenteric ischaemia (NOMI) induced by diltiazem poisoning. Through this case report, we wish to emphasize that the clinicians should keep the possibility of intestinal ischaemia in mind from the early phase of calcium channel blocker poisoning. In addition, close monitoring and intense abdominal examination including the abdominal computed tomography scan should be done if CCBs poisoning patients complained of an abdominal pain.

非閉塞性腸管虚血（NOMI）の治療戦略：パパベリン塩酸塩動注療法とダメージコントロール手術を行い救命できた1例

非閉塞性腸管虚血（NOMI）の治療戦略：パパベリン塩酸塩動注療法とダメージコントロール手術を行い救命できた1例

Tu1333 - Jejunostomy Feeding Associated with Non-Occlusive Mesenteric Ischemia after Major Upper Gatrointestinal Surgery

Tu1333 - Jejunostomy Feeding Associated with Non-Occlusive Mesenteric Ischemia after Major Upper Gatrointestinal Surgery

Iloprost Use in Patients with Persistent Intestinal Ischemia Unsuitable for Revascularization

Persistent or chronic intestinal ischemic injury (i3) can lead to severe malnutrition and acute mesenteric ischemia. Although recommended, revascularization of splanchnic arteries is sometimes unrealizable. We report a case series of iloprost use in consecutive stable patients with persistent i3 unsuitable for revascularization followed in a tertiary care center. The feasibility of revascularization was discussed and ruled out by a multidisciplinary team, and informed consent was obtained prior to consideration of a vasoactive therapy. Therapeutic response was defined at 6months by a decrease in the use of analgesic and parenteral nutrition, and no need for intestinal resection. Between 2006 and 2015, 6 patients (mean age: 51) were included. Splanchnic vascular insufficiency was due to superior mesenteric artery (SMA) thrombosis (n=4), dissection of the celiac trunk and SMA (n=1), or repeated vasospasm resulting in chronic nonocclusive mesenteric ischemia (n=1). Iloprost was delivered via continuous intravenous perfusion at a maximum dosage of 2ng/kg/min for 6hours/day on 4 consecutive days, without severe adverse events. Therapeutic response was observed in 4 patients, 3 of which completely stopped parenteral nutrition and analgesic with no need for intestinal resection. Our results are consistent with findings of a favorable effect of iloprost in patients with persistent splanchnic ischemia that should be confirmed in prospective trials.

Acute Mesenteric Ischemia Among Postcardiac Surgery Patients Presenting with Multiple Organ Failure.

Acute mesenteric ischemia (AMI) is a rare but severe complication after cardiac surgery. However, AMI is likely to be more frequent in the subgroup of patients presenting with multiple organ failure after a cardiac surgery. The primary objective of this study was to identify AMI risk factors among patients requiring intensive care unit (ICU) admission after cardiac surgery. Retrospective observational study of all the patients requiring admission to two ICUs in a large university hospital after a cardiac surgery procedure. AMI confirmation was based on abdominal computed tomography scan, digestive endoscopy, laparotomy, or postmortem examination. Univariate and multivariate analyses were done to compare pre- and in-ICU characteristics between patients with or without AMI. Between 2007 and 2013, a cardiac surgery was performed in 4,948 patients, of whom 320 patients (6%) required ICU admission for multiple organ failure. AMI was confirmed in 10% of the patients admitted to the ICU for multiple organ failure (33/320). The prognosis of these patients was extremely poor with 28- and 90-day mortality rates of 64% and 83%, respectively. Nonocclusive mesenteric ischemia (NOMI) was the main mechanism involved in 83% of the patients. Coronary artery bypass graft, need for blood transfusion during cardiopulmonary bypass, aspartate aminotransferase at least 100 UI/L, and Simplified Acute Physiology Score II at least 50 at ICU admission were independently associated with AMI. An AMI risk score based upon these four risk factors was able to identify three classes of risk: low risk (<1%), intermediate risk (9%), and high risk (29%). AMI is a frequent condition among patients presenting with multiple organ failure after cardiac surgery, occurring in 10% of them. The prognosis of AMI is extremely poor. The main mechanism of AMI is NOMI, occurring in approximately 80% of patients. Further progress should be performed on prevention and earlier diagnosis.