Nonocclusive Mesenteric Ischemia Research Articles

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.

Classification of Nonocclusive Mesenteric Ischemia Based on the Trigger for the Disease

Classification of Nonocclusive Mesenteric Ischemia Based on the Trigger for the Disease

An investigation of bedside laparoscopy in the ICU for cases of non-occlusive mesenteric ischemia

BackgroundAcute mesenteric ischemia is a rare affection with high related mortality. NOMI presents the most important diagnostic problems and is related with the higher risk of white laparotomy. This study wants to give a contribution for the validation of laparoscopic approach in case of NOMI.MethodsThirty-two consecutive patients were admitted in last 10 years in ICU of Paolo Giaccone University Hospital of Palermo for AMI. Diagnosis was obtained by multislice CT and selective angiography was done if clinical conditions were permissive. If necrosis was already present or suspected, surgical approach was done. Endovascular or surgical embolectomy was performed when necessary. Twenty NOMI patients underwent medical treatment performing laparoscopy 24 h later to verify the evolution of AMI. A three-port technique was used. In all patients we performed a bed side procedure 48–72 h later in both non-resected and resected group.ResultsIn 14 up 20 case of NOMI the disease was extended throughout the splanchnic district, in 6 patients it involved the ileum and the colon; after a first look, only 6 patients underwent resection. One patient died 35 h after diagnosis of NOMI. The second look, 48 h later, demonstrated 4 infarction recurrences in the group of resected patients and onset signs of necrosis in 5 patients of non-resected group. A total of 15 resections were performed on 11 patients. Mortality rate was 6/20–30% but it was much higher in resected group (5/11–45,5%). Non-therapeutic laparotomy was avoided in 9/20 patients and in this group mortality rate was 1/9–11%. No morbidity was recorded related to laparoscopic procedure.ConclusionsLaparoscopy could be a feasible and safety surgical approach for management of patient with NOMI. Our retrospective study demonstrates that laparoscopy don’t increase morbidity, reduce mortality avoiding non-therapeutic laparotomy.

Non-occlusive mesenteric ischaemia in out of hospital cardiac arrest survivors.

Non-occlusive mesenteric ischaemia (NOMI) is characterised by hypoperfusion of the intestines without evidence of mechanical obstruction, potentially leading to extensive ischaemia and necrosis. Low cardiac output appears to be a major risk factor. Cardiopulmonary resuscitation aims at restoring blood flow after cardiac arrest. However, post restoration of spontaneous circulation, myocardial stunning limits immediate recovery of sufficient cardiac function. Since after successful cardiopulmonary resuscitation patients are often ventilated and sedated, NOMI might be underdiagnosed and potentially life-saving treatment delayed. A prospectively maintained multi-purpose cohort of out of hospital cardiac arrest survivors, who had successful restoration of spontaneous circulation, was used for this retrospective database analysis. Patients' charts were screened for clinical, radiological or pathological evidence of NOMI and clinical data were collected. Between 2000 and 2014, 1780 patients who were successfully resuscitated after out of hospital cardiac arrest were screened for NOMI. Twelve patients (0.68 %) suffered from NOMI and six of those died (50 %). Patients suffering from NOMI tended to have a longer duration until restoration of spontaneous circulation (27 vs. 20 min, p=0.128) and had significantly higher lactate (14 mmol/l vs. 8 mmol/l, p=0.002) and base deficit levels at admission (-17 vs. -10, p=0.012). Median leukocyte counts in NOMI patients peaked at the day of diagnosis. NOMI is a rare but life-threatening and potentially curable complication following successful cardiopulmonary resuscitation. Lactate and base deficit at admission could help to identify patients at risk for developing NOMI who might benefit from increased clinical attention.

A Case Report of Successful Treatment of Nonocclusive Mesenteric Ischemia after Aortic Dissection Repair

A Case Report of Successful Treatment of Nonocclusive Mesenteric Ischemia after Aortic Dissection Repair

消化管アミロイドーシスに非閉塞性腸管虚血を併発した1例

消化管アミロイドーシスに非閉塞性腸管虚血を併発した1例

非閉塞性腸管虚血症様血管攣縮を呈しプロスタグランディンE1大量投与が奏効した上腸間膜動脈塞栓症の1例

症例は脳梗塞治療中の69歳の男性で，突然の腹痛で当院を受診した．造影CTにて小腸壁の造影不良と上腸間膜動脈（superior mesenteric artery；以下，SMAと略記）の閉塞を認め，血管造影検査にてSMA塞栓症と診断した．さらに，血管攣縮を認め非閉塞性腸管虚血症（non-occlusive mesenteric ischemia；以下，NOMIと略記）様の病態を合併していた．検査中に腹膜刺激症状が出現したため緊急手術を施行した．壊死腸管を切除後，一期的に吻合し手術を終えた．術中からプロスタグランディンE1（prostaglandin E1；以下，PGE1と略記）の静脈内持続投与を開始し，術後は動脈内持続投与に切り替え，縫合不全を合併することなく救命しえた．腸間膜動脈閉塞症に対しても，PGE1を早期に投与することにより，併存するNOMI様の病態や潜在的な血管攣縮による腸管虚血発症のリスクを下げ，結果的に急性腸間膜血行不全症全体の予後改善に寄与しうると考えられた．

非閉塞性腸管虚血症を伴った食道裂孔ヘルニア嵌頓の1例

非閉塞性腸管虚血症を伴った食道裂孔ヘルニア嵌頓の1例

S状結腸虚血性腸炎に続発した右側結腸非閉塞性腸管虚血症の1例

S状結腸虚血性腸炎に続発した右側結腸非閉塞性腸管虚血症の1例

Nonocclusive mesenteric infarction after cardiac surgery: potential biomarkers

BackgroundNonocclusive mesenteric ischemia can cause intestinal infarction but the diagnosis is challenging. This prospective study evaluated three plasma biomarkers of intestinal infarction after cardiac surgery. Materials and methodsPatients were recruited after cardiac surgery if they required laparotomy (with or without intestinal resection) for suspected nonocclusive mesenteric ischemia. Plasma levels of D-lactate, intestinal fatty acid–binding protein (i-FABP), and smooth muscle actin (SMA) before laparotomy were measured. ResultsTwenty patients were recruited (68 ± 9 y, EuroSCORE: 8.7 ± 2.8, mortality 70%). A positive laparotomy (n = 13) was associated with no change in D-lactate (P = 0.95), decreased i-FABP (P = 0.007), and increased SMA (P = 0.01). All patients with high SMA had a positive laparotomy. A subgroup analysis was undertaken in the eight patients who required multiple laparotomies. D-lactate increased between the two laparotomies in nonsurvivors (n = 4). Plasma i-FABP (P = 0.008) and SMA (P = 0.036) significantly decreased after the bowel resection, regardless of survival outcome. ConclusionsNone of the biomarkers were accurate enough to reliably diagnose intestinal infarction. However, all patients with high values of SMA developed intestinal infarction, thus warranting further investigation. An increasing D-lactate after intestinal resection suggests impending death.

Intraoperative Indocyanine Green Fluorescence Angiography for Diagnosis of Nonocclusive Mesenteric Ischemia: A Case Report

Nonocclusive mesenteric ischemia (NOMI) has a very poor prognosis. It is often difficult to determine the extent to which the necrotic intestine should be resected. We herein report a case in which indocyanine green (ICG) fluorescence angiography was found to be a useful method for diagnosis of NOMI and determination of the extent to which the necrotic intestinal tissue should be resected. A 65-year-old man underwent a second-look operation followed by surgical repair of strangulation of the ileum. A noncontinuous segmental ischemic lesion was detected in the remnant small intestine and cecum. Whether necrotic changes had occurred in the small intestine was difficult to discern. Thus, intraoperative ICG fluorescence angiography was performed with a near-infrared camera system to visualize the blood flow in the intestines and mesentery. ICG fluorescence angiography revealed insufficient blood flow in some parts of the intestine. Based on these findings, ileocecal resection and enterectomy were carried out. Histopathologic examination revealed necrotic changes in all layers of the resected specimens, but no thrombi in the associated blood vessels. The patient received a diagnosis of NOMI based on the findings of intraoperative ICG fluorescence angiography and subsequent histopathologic examination. Intraoperative ICG angiography appears to have the potential to be one of the convenient and useful modalities for the diagnosis and treatment of NOMI.

Mesenteric Ischemia

Acute mesenteric ischemia is interruption of intestinal blood flow by embolism, thrombosis, or a low-flow state. Bowel infarction is the end result of a process initiated by mediator release and inflammation. On clinical assessment, the early hallmark is severe abdominal pain but minimal physical findings. The abdomen remains soft, with little or no tenderness. Mild tachycardia may be present. Early diagnosis is difficult, but selective mesenteric angiography and computed tomographic angiography have the most sensitivity; other imaging studies and serum markers can show abnormalities but lack sensitivity and specificity early in the course of the disease, when diagnosis is most critical. Treatment is by embolectomy, anticoagulation, revascularization of viable segments, or resection; sometimes vasodilator therapy is successful. If diagnosis and treatment take place before infarction occurs, mortality is low; after intestinal infarction, mortality approaches 30 to 70%. For this reason, in the emergency department, clinical diagnosis should supersede diagnostic tests, which may delay treatment. This review contains 6 highly rendered figures, 4 tables, and 33 references. Key words: acute mesenteric ischemia; bowel necrosis; chronic mesenteric ischemia; mesenteric occlusive disease; mesenteric venous thrombosis; nonocclusive mesenteric ischemia; postprandial abdominal pain; superior mesenteric artery thromboembolism

Diagnosis of non-occlusive acute mesenteric ischemia in the intensive care unit.

BackgroundNon-occlusive mesenteric ischemia (NOMI) is a common complication and accounts for a major cause of death in critically ill patients. The diagnosis of NOMI with respect to the eventual indications for surgical treatment is challenging. We addressed the performance of the diagnostic strategy of NOMI in the intensive care unit, with emphasis on contrast-enhanced abdominal CT-scan.MethodsThis was a retrospective monocenter study. Patients with clinically suspected acute mesenteric ischemia were included if a comprehensive diagnostic workup was carried out including surgical and/or endoscopic digestive explorations. Patients with evidence of occlusive mesenteric ischemia were excluded. A definite diagnosis of NOMI only relied on surgical or endoscopic findings. Abdominal CT-scans were reviewed by two radiologists blinded from the final diagnosis.ResultsA diagnosis of NOMI could be definitely confirmed or ruled out through surgical or endoscopic explorations of the digestive tract in 147 patients. With respect to their clinical characteristics, only a history of atrial fibrillation was an independent predictor of NOMI (odds ratio 8.3, 95% confidence interval 2.0–35.2, p = 0.004). Among them, 114 patients (75 with and 39 without NOMI) had previously been subjected to contrast-enhanced abdominal CT-scan. Portal venous gas, pneumatosis intestinalis and, to a lesser extent, abnormal contrast-induced bowel wall enhancement were poorly sensitive, but exhibited good specificities of 95, 85 and 71%, respectively. Nineteen out of 75 patients (25.3%) without any suggestive radiological signs finally exhibited mesenteric ischemia, including ten with intestinal necrosis.ConclusionsThe performance of abdominal CT-scan for the diagnosis of NOMI is limited. Radiological signs of advanced-stage ischemia are good predictors of definite mesenteric ischemia, while their absence should not be considered sufficient to rule out the diagnosis.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0213-x) contains supplementary material, which is available to authorized users.

Mesenteric Ischemia

Acute mesenteric ischemia is interruption of intestinal blood flow by embolism, thrombosis, or a low-flow state. Bowel infarction is the end result of a process initiated by mediator release and inflammation. On clinical assessment, the early hallmark is severe abdominal pain but minimal physical findings. The abdomen remains soft, with little or no tenderness. Mild tachycardia may be present. Early diagnosis is difficult, but selective mesenteric angiography and computed tomographic angiography have the most sensitivity; other imaging studies and serum markers can show abnormalities but lack sensitivity and specificity early in the course of the disease, when diagnosis is most critical. Treatment is by embolectomy, anticoagulation, revascularization of viable segments, or resection; sometimes vasodilator therapy is successful. If diagnosis and treatment take place before infarction occurs, mortality is low; after intestinal infarction, mortality approaches 30 to 70%. For this reason, in the emergency department, clinical diagnosis should supersede diagnostic tests, which may delay treatment. Key words: acute mesenteric ischemia; bowel necrosis; chronic mesenteric ischemia; mesenteric occlusive disease; mesenteric venous thrombosis; nonocclusive mesenteric ischemia; postprandial abdominal pain; superior mesenteric artery thromboembolism

Topical intraperitoneal papaverine to minimize non-viable bowel resection from non-occlusive bowel ischemia in neonatal segmental volvulus: A case report

Abstract Arrest in the embryologic intestinal rotation around the superior mesenteric artery prevents proper mesenteric attachment and subjects the gut to volvulus and ischemia which may lead to bowel resection. The length of non-viable resected bowel has been shown by Teitelbaum et al. to be an independent predictor of survival in patients with postoperative short bowel syndrome ( RR = 5.74, P = .003). Non-occlusive mesenteric ischemia (NOMI) is a feed-forward loop of vasoconstriction that aggravates the primary ischemic injury. It is an initially reversible process and a potential point of intervention for preservation of viable bowel. The Boley et al. algorithm for management of adult NOMI utilizes intravascular papaverine infusion to increase intracellular cAMP, decreasing calcium concentration and halting vasospasm. We present a modified version of this approach using topical papaverine in the setting of neonatal post-ischemic NOMI, with the goal of minimizing bowel resection.

Surgical intervention and perioperative risk factors of retroperitoneal teratomas in children: a single institution experience.

Retroperitoneal teratomas (RTs) are rare among germ cell tumors and predominantly occur in infants. RTs are often difficult to manage by perioperative management. In this study, we retrospectively reviewed our series of RTs. Seventy patients with germ cell tumors were treated from 1989 to 2015 in our institution. Fourteen patients had RTs (3 boys and 11 girls). The median age at diagnosis was 5.5months (range 0-64), and three were antenatally diagnosed. All except one patient underwent total tumor excision. They exhibited dense adhesions with major vessels, and ligation of the splenic and gastroduodenal arteries was required in two patients. Injuries of PV and renal artery occurred in two patients. IVC injury in a neonate with a giant mass caused circulatory failure and brain death occurred postoperatively. Other major complications included injury of the diaphragm and bile duct. An infant whose tumor compressed the superior mesenteric artery developed enteritis while waiting for surgery and non-occlusive mesenteric ischemia, resulting in massive intestinal necrosis. The perioperative complication rate was 50%. Surgery for RTs remains challenging, and a preoperative evaluation of the vascular anatomy is crucial due to the high complication rate. Moreover, pre- and intraoperative fluid management is important to avoid any unexpected fatalities.

Point-of-Care Ultrasound in Necrotizing Acute Pancreatitis Complicated by Perforated Ileum Due to Nonocclusive Mesenteric Ischemia

Necrotizing acute pancreatitis is the most severe form of pancreatitis, and it is a potentially life-threatening condition. Its diagnosis and severity are based on radiological signs. Although computed tomography is the most used imaging tool, ultrasound can be a quick and useful technique in emergency and intensive care scenarios. The use of abdominal ultrasound is generally limited to ruling out cholecystitis. Bowel gas can limit the accuracy of pancreatic imaging. When the pancreas is visualized, ultrasound can reveal pancreatic enlargement, echotextural changes, and peripancreatic fluid. We present a patient with necrotizing pancreatitis who developed peritonitis due to ileal perforation, where the use of ultrasound as a bedside imaging technique was very useful.

Vasopressin as Therapy During Nonocclusive Mesenteric Ischemia

Vasopressin is used as an adjunct to norepinephrine to support blood pressure in vasodilatory shock after cardiopulmonary bypass (CPB). In this study, we report our observation of vasopressin treatment in 11 patients with nonocclusive mesenteric ischemia (NOMI). In an observational cohort study, 78 patients were studied after having been treated for NOMI with intraarterial iloprost infusion after elective cardiac operation. All patients received norepinephrine as vasopressor for marked vasodilation. In 11 patients mean arterial pressure could not be maintained with norepinephrine alone (≤0.4 μg · kg(-1) · min(-1)), and vasopressin was given in addition to norepinephrine as a rescue therapy. The 11 patients (Vaso) and the remaining 67 patients (Nor) were analyzed for clinical improvement after initiation of NOMI treatment, on the following days 1 and 2, and for hospital survival. Intestinal perfusion was controlled by mesenteric angiography. Before initiation of NOMI treatment Vaso patients had significantly higher doses of norepinephrine than the Nor patients (Vaso, 0.65 ± 0.20 μg · kg(-1) · min(-1); Nor, 0.20 ± 0.13 μg · kg(-1) · min(-1); p < 0.001), and their diagnostic score of the angiography was higher (Vaso, 5.4 ± 1.1 points; Nor, 3.5 ± 2.1 points; p= 0.004). After 2 days of NOMI treatment, Vaso patients had improved intestinal perfusion in the control angiography (Vaso, 3.8 ± 1.5 points) and significantly lower doses of norepinephrine than the Nor patients (Vaso, 0.28 ± 0.12 μg · kg(-1) · min(-1); Nor, 0.53 ± 0.34 μg · kg(-1) · min(-1); p= 0.002). All patients survived in the Vaso group; in the Nor group, 17 of 67 patients died in the hospital. Vasopressin administration during NOMI treatment after CPB seems to improve small intestine perfusion and appears be to associated with improved hospital survival.

Reperfusion in non-occlusive mesenteric ischaemia (NOMI): effectiveness of CT in an emergency setting.

To investigate the CT features of reperfusion (presence/absence) in non-occlusive mesenteric ischaemia (NOMI) and their prognostic value in an emergency setting. A revision was undertaken of imaging from 20 patients (16 males/4 females) with a dismissal summary of NOMI. All patients had previously undergone a minimum of one multidetector CT examination, and consequently underwent surgery (n = 8), autopsy (n = 2), angiography (n = 1) or endoscopy (n = 9). An evaluation of the CT scans was conducted to determine vessels, mesentery, bowel and peritoneal cavity features. The superior mesenteric artery (SMA) average diameter of NOMI cases were compared with 30 controlled cases. Kappa, Kolmogorov-Smirnov (K-S) and Fisher's exact tests were used for statistical analysis. A mean SMA diameter significantly smaller than that of the controlled cases was found for patients with NOMI (K-S test: D = 0.75, p = 3.7 × 10-08). Fisher's exact tests showed a strong connection between the presence of reperfusion and mesenteric fat stranding (p = 0.026), bowel wall thickening (p = 3.2 × 10-05) and a high attenuation of the bowel wall on unenhanced CT images (p = 2.8 × 10-04). A reduction in mortality was significantly linked to the combination of normal mesenteric vessels and wall thickening (p = 0.034). Analysis of not only vessels findings but also mesentery and bowel CT features will support the identification of NOMI with or without a reperfusion event in an emergency setting. A strong correlation between some CT features and lower mortality exists. CT features of NOMI with or without reperfusion are demonstrated. Correctly assessing the presence of reperfusion in NOMI, may allow better management of these conditions in the emergency setting.

Non-occlusive Mesenteric Ischemia with Diabetic Ketoacidosis and Lactic Acidosis Following the Administration of a Sodium Glucose Co-transporter 2 Inhibitor

We herein describe a patient with non-occlusive mesenteric ischemia (NOMI) potentially associated with the administration of a sodium glucose co-transporter 2 (SGLT2) inhibitor. A 60-year-old man with type 1 diabetes was transferred to our hospital due to vomiting and respiratory distress. He was treated with insulin, metformin and a SGLT2 inhibitor, which had recently been added. He was diagnosed with intestinal ischemia complicated by diabetic ketoacidosis and lactic acidosis. Urgent exploratory surgery was performed, and the gangrenous bowel was resected. Histological findings confirmed the diagnosis of NOMI. The administration of SGLT2 inhibitors therefore requires certain exceptions for type 1 diabetes and cautious monitoring for the occurrence of these possible adverse effects.