Nonocclusive Mesenteric Ischemia Research Articles

A Case of Successful Extracorporeal Membrane Oxygenation Support for Cardiac Arrest Associated with Nonocclusive Mesenteric Ischemia

Background: We report a case of successful extracorporeal membrane oxygenation (ECMO) support for cardiac arrest associated with nonocclusive mesenteric ischemia (NOMI). Case presentation: A 34-year-old previously healthy woman in the sixth week of her second pregnancy was carried to our hospital for abdominal pain and vomiting. She had apparent peritoneal irritation signs with marked hyperglycemia and metabolic acidosis and developed refractory shock. Since portal venous gas and intestinal dilatation without enhancement in contrast-enhanced computed tomography (CT) were observed, a subtotal resection of the small intestine and right hemicolectomy against widespread intestinal necrosis were performed as an emergency operation. The patient returned to the intensive care unit (ICU) with open abdominal management. Severe respiratory failure gradually developed during the operation, and veno-venous (V-V) ECMO was prepared to start in the ICU after the operation. However, cardiac arrest occurred abruptly during the cannulation for ECMO. Therefore, veno-arterial (V-A) ECMO was implemented and hemodynamic status gradually improved. V-A ECMO was switched to V-V ECMO on Day 4 because of persistent respiratory failure. Colostomy was performed on Day 5, abdominal wall was closed on Day 8, and ECMO was successfully weaned off on Day 9. Furthermore, several surgical interventions including gauze packing for retroperitoneal bleeding and operation for intestinal dehiscence, and right lower extremity amputation were needed. She was free from the ICU on Day 78. Finally, closure of the colostomy and anastomosis of the residual duodenum and colon were performed, and the patient was discharged from the hospital without any neurologic impairment on Day 262. Conclusion: Successful surgical interventions and appropriate ECMO support contributed to the patient’s survival.

Usefulness of Endoscopy During Operation to Determine the Resection Range in Patients with Non-occlusive Mesenteric Ischemia：A Case Report

Usefulness of Endoscopy During Operation to Determine the Resection Range in Patients with Non-occlusive Mesenteric Ischemia：A Case Report

Intestinal ischemia in neonates and children.

The article reviews the intestinal ischemia theme on newborn and children. The intestinal ischemia may be either acute - intestinal infarction (by vascular obstruction or by reduced mesenteric blood flow besides the occlusive mechanism), either chronic.In neonates, acute intestinal ischemia may be caused by aortic thrombosis, volvulus or hypoplastic left heart syndrome.In children, acute intestinal ischemia may be caused by fibromuscular dysplasia, volvulus, abdominal compartment syndrome, Burkitt lymphoma, dermatomyositis (by vascular obstruction) or familial dysautonomia, Addison’s disease, situs inversus abdominus (intraoperative), burns, chemotherapy administration (by nonocclusive mesenteric ischemia). Chronic intestinal ischemia is a rare condition in pediatrics and can be seen in abdominal aortic coarctation or hypoplasia, idiopathic infantile arterial calcinosis.

絞扼性イレウスに併発した非閉塞性腸間膜虚血症の1例

絞扼性イレウスに併発した非閉塞性腸間膜虚血症の1例

試験開腹を先行させた選択的動注療法により腸管切除を回避しえた非閉塞性腸間膜虚血症の1例

試験開腹を先行させた選択的動注療法により腸管切除を回避しえた非閉塞性腸間膜虚血症の1例

A Case in which Non-occlusive Mesenteric Ischemia Led to Gradual Narrowing of the Ileal Lumen and the Need for Small Bowel Resection

A Case in which Non-occlusive Mesenteric Ischemia Led to Gradual Narrowing of the Ileal Lumen and the Need for Small Bowel Resection

A Case of Non-Occlusive Mesenteric Ischemia with Hepatic Portal Venous Gas Successfully Treated by Continuous Intra-Arterial Infusion Therapy

A Case of Non-Occlusive Mesenteric Ischemia with Hepatic Portal Venous Gas Successfully Treated by Continuous Intra-Arterial Infusion Therapy

A single preoperative FGF23 measurement is a strong predictor of outcome in patients undergoing elective cardiac surgery: a prospective observational study.

IntroductionSeveral scoring systems have been developed to predict postoperative mortality and complications in patients undergoing cardiac surgery. However, these computer-based calculations are time- and cost-intensive. A simple but highly predictive test for postoperative risk would be of clinical benefit with respect to increasingly scarce hospital resources. We therefore assessed the predictive power of fibroblast growth factor 23 (FGF23) measurement compared with an established scoring system.MethodsWe conducted a prospective interdisciplinary observational study at the Saarland University Medical Centre that included 859 patients undergoing elective cardiac surgery between January 2010 and March 2011 with a median follow-up after discharge of 822 days. We compared a single preoperative measurement of FGF23 as a prognostic tool with the 18 parameters comprising EuroSCORE II with respect to postoperative mortality, acute kidney injury, non-occlusive mesenteric ischemia, clinical course and long-term outcome.ResultsPreoperative FGF23 levels were highly predictive of postoperative outcome and complications. The predictive value of FGF23 for mortality in the receiver operating characteristic curve was greater than the EuroSCORE II (area under the curve: 0.800 versus 0.725). Moreover, preoperative FGF23 independently predicted postoperative acute kidney injury and non-occlusive mesenteric ischemia comparably to the EuroSCORE II. Finally, FGF23 was found to be an independent predictor of clinical course parameters, including duration of surgery, ventilation time and length of stay.ConclusionsIn patients undergoing elective cardiac surgery, a simple preoperative FGF23 measurement is a powerful indicator of surgical mortality, postoperative complications and long-term outcome. Its utility compares to the widely used EuroSCORE II.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0925-6) contains supplementary material, which is available to authorized users.

Complement C5a inhibition improves late hemodynamic and inflammatory changes in a rat model of nonocclusive mesenteric ischemia

Nonocclusive mesenteric ischemia (NOMI) can evolve in a variety of low-flow states. Although the mechanisms leading to NOMI-related intestinal necrosis are largely unknown, circumstantial evidence suggests that excessive vasoconstriction and complement activation both play important roles in this process. Because targeting of the circulatory malfunction of the splanchnic area could be of therapeutic relevance, we set out to investigate the long-term effects of treatment with a complement C5a antagonist in a rat model of partial aortic occlusion (PAO)-induced transient mesenteric hypoperfusion. The mean arterial pressure of the splanchnic area was kept between 30 and 40 mm Hg by 60 minutes of PAO in anesthetized male Sprague-Dawley rats. C5a inhibitor acetyl-peptide-A (AcPepA; 4 mg kg(-1) intravenously) or vehicle administration was initiated at the 45th minute of PAO. After 24 hours, the animals were reanesthetized to record the macrohemodynamics and ileal microcirculation, and plasma and tissue samples were taken for determination of high-mobility group box protein-1 (HMGB-1), endothelin-1, tumor necrosis factor (TNF)-α levels, and small intestinal leukocyte infiltration. Epithelial structural changes were visualized by in vivo confocal laser scanning endomicroscopy. At 24 hours after PAO, mean arterial pressure, heart rate, and cardiac output were significantly greater, the intestinal intramural microcirculation was significantly impaired, and plasma HMGB-1, endothelin-1, TNF-α levels, the degree of epithelial damage and leukocyte infiltration was increased. The AcPepA treatment moderated the hemodynamic and microcirculatory changes, and decreased inflammatory activation and histologic signs of mucosal damage. C5a inhibition ameliorated the potentially harmful local mesenteric hypoperfusion and global long-term inflammatory consequences of PAO. This approach is of promise for use in NOMI-associated situations.

Severe accidental colchicine poisoning by the autumn crocus: A case of successful treatment

The common garden plant autumn crocus contains colchicine and its derivatives. Colchicine poisoning causes abdominal cramps and diarrhea within hours. Several days later, multiorgan failure, pancytopenia, and cardiovascular collapse occur. 1 , 2 Severe colchicine poisoning is associated with high mortality. A 63-year-old woman who accidentally ingested an autumn crocus, which contained ∼0.38 mg colchicine, had severe vomiting and was taken to an emergency center. She presented with symptoms of gastroenterocolitis within 1 hour of ingestion, and bone marrow hypoplasia with pancytopenia developed on the 3 rd day after ingestion. We continued administration of granulocyte colony-stimulating factor (300 μg) for 5 days until we confirmed that the patient's white blood cell count was increasing. Also, there was focal and segmental intestinal ischemia and some cakes of charcoal remained in the intestinal tract. Therefore, we presumed that nonocclusive mesenteric ischemia was caused by hypotension with severe dehydration, although pseudo-obstruction due to the activated charcoal may have been a contributing factor. We were able to promptly intervene to treat paralytic ileus and gastrointestinal edema before anticipated worsening of abdominal compartment syndrome, by conducting open peritoneal drainage. Despite severe poisoning, our patient survived with intensive care. Conclusion: Colchicine intoxication may lead to a sudden and extreme critical course. Therefore, as there is no means to predict prognosis from initial severity of symptoms at onset, we suggest that all patients suspected of colchicine intoxication should be managed in hospital with continuous vital sign monitoring and frequent laboratory testing for at least a few days after ingestion.

Letter to the editor: spontaneous renal haemorrhage in end-stage renal disease.

Letter to the editor: spontaneous renal haemorrhage in end-stage renal disease.

Pathogenic mechanisms of intestinal pneumatosis and portal venous gas: should patients with these conditions be operated immediately?

We aimed to histologically observe portal venous gas (PVG)-causing intestinal pneumatosis (IP) and evaluate pathogenic mechanisms and therapeutic strategies, including decisions on whether emergency surgery should be performed. Autopsy was performed in two cases of nonocclusive mesenteric ischemia (NOMI). We directly histologically observed the pathogenic mechanisms of IP caused by gas-producing bacteria and IP considered to be caused by mechanical damage to the intestinal mucosa. IP can be classified hypothetically into the following types according to pathogenesis: (1) infection, (2) rupture (damage) of the intestinal mucosa + increased intestinal intraluminal pressure, and (3) mixed type. In cases of IP caused by gas-producing bacteria or IP associated with intestinal wall damage extending beyond the mucosa to the deep muscular layer, emergency surgery should be considered. However, it is highly possible that patients who test negative for infection with gas-producing bacteria whose intestinal wall damage remains only in the mucosa can be conservatively treated.

A Case Report of Non-Occlusive Mesenteric Ischemia in a Patient with Multiple Risk Factors

Non-occlusive mesenteric ischemia (NOMI) refers to all types of mesenteric ischemia without any organic blockage of blood vessels. It is usually seen in elderly age group with risk factors of previous myocardial infarction, congestive cardiac failure, aortic insufficiency, renal or liver impairment and post-cardiac surgery. Amongst all the cases of acute mesenteric ischemia, NOMI constitutes 20-30%. The mortality is generally high, at least 50% because it usually presents late and the bowel is already gangrenous. Common presentations include nausea, vomiting and acute abdominal pain. Selective angiography is the gold standard to exclude obstructive mesenteric ischemia, for which the diagnosis of NOMI could be made, but one can use other non-invasive modalities such as CT, MRI or ultrasound. Colonoscopy, lactate, arterial blood gas can be used to investigate for bowel ischemia. In the early stages, there is no need for surgery. Surgical intervention is generally limited unless there is a need to excise away the gangrenous bowel. The only effective treatment is by administering intra-arterial vasodilator therapy and it should be done as early as possible to improve prognosis. We describe a case of large bowel ischemia likely secondary to non-occlusive mesenteric ischemia.

Non-occlusive Mesenteric Ischemia Complicated by Intramural Hematomas: A Case Report

Introduction: Acute mesenteric ischemia (AMI) often mimics coagulopathy related intestinal intramural hematomas because their similar clinical settings and imaging features. However, their managements are difference. We report a case of non-occlusive mesenteric ischemia (NOMI) complicated by transmural hematoma. Case Presentation: A 49-year-old woman was admitted to the intensive care unit because of septic shock. She had an underlying diseases of undifferentiated connective tissue disease and severe pulmonary hypertension. She presented with fever, hypotension, respiratory failure and acute kidney injury. She received ventilator support, renal dialysis and a high dose intravenous of the combination of norepinephrine and adrenaline for maintaining her hemodynamic condition. Three days after admission, she developed abdominal distension and mucous bloody stool. Physical examination showed fever, marked abdominal distension, and absence bowel sound. Laboratory results showed platelet count 5,000/uL, prolong prothrombin time with INR at 1.58, and prolonged activated partial thromboplastin time 51.3 sec (control 26 sec). Stool examination demonstrated WBC 20-30 cell/mm3, RBC 10-20/mm3, negative C. difficile toxin test, and negative culture for bacterial pathogen. A computed tomography of abdomen demonstrated dilated and thickened bowel wall at the ileum and ascending colon with intramural hematomas. Pneumatosis intestinalis and ascites were demonstrated. (Figure 1) The vascular structures (SMA, SMV, IMA and IMV) were patent. Therefore, NOMI complicating bowel infarction with spontaneous intramural hematomas was diagnosed. She underwent an emergency surgery. The operation showed a gangrenous colon and distal ileum. The remaining bowel was non-gangrenous ischemia. Total colectomy with end ileostomy was successfully performed. Pathology revealed transmural hemorrhagic necrosis of the colon, appendix, and terminal ileum. (Figure 2) Unfortunately, she died from multiple organ failure a week later.Figure 1Figure 2Discussion: This patient initially presented with septic shock requiring inotropic drugs. With poor perfusion status, she was susceptible to AMI. While her condition had been worsening; she developed disseminated intravascular coagulation (DIC) on top of NOMI. As AMI progressed, an element of intramural hemorrhage could be seen. A combination of medical history, physical examination, and laboratory values are all important in establishing the correct diagnosis and activating the prompt treatment. AMI may necessitate emergency intervention to restore blood flow whereas coagulopathy related intramural hematoma requires medical management to correct coagulopathy.

Acute mesenteric ischemia

Acute vascular occlusion within the mesenteric circulation leads to ischemic damage of the corresponding bowel segment, which starts on the mucosal level and progresses transmurally. Report on pathogenesis, clinical picture and treatment of various forms of intestinal ischemia. Analysis of the available literature taking into consideration our own experience. Frequently, predisposing diseases and risk factors are present (e.g., cardiac diseases, hypercoagulability, status post cardiac surgery, circulatory failure, or administration of vasoconstrictive drugs). Acute small bowel ischemia-caused by either mesenteric embolism, mesenteric artery thrombosis, nonocclusive mesenteric ischemia (NOMI) or mesenteric venous thrombosis-represents an acute emergency. If this condition is suspected clinically, the diagnosis must be established immediately by computed tomography of the abdomen with intravenous administration of contrast medium in order to prevent irreversible damage to the small bowel. Medical treatment is supportive. If possible, occluded vessels may be re-opened either by radiologic intervention or surgically. Irreversibly damaged bowel segments must be surgically removed. Ischemic colitis has a benign course in most cases if limited to reversible mucosal damage. The diagnosis is based mainly on colonoscopy and computed tomography findings, and treatment is symptom oriented. Rarely, severe manifestations with a worse prognosis due to considerable comorbidities occur. In such cases, surgical removal of the ischemic bowel is frequently required. Even today, acute mesenteric ischemia is associated with a poor prognosis. To improve survival and to reduce long-term morbidity, a rapid and systematic diagnostic workup is mandatory.

Renal Outcome After Open Surgery and Fenestrated Endovascular Aneurysm Repair of Juxta-renal Aneurysms

function. 1 New onset of renal insufficiency was detected in 26.5% of the open surgery group and 8.5% of the endovascular group, which was persistent in 11.8% and 5.7%, respectively.Three per cent of the patients in each group required dialysis in the longer term.The rate of renal failure after open repair and after FEVAR in a recent systematic review were 13.9% and 11.4%, respectively, with no difference in the rate of permanent dialysis between the groups (2.8% and 1.9%, respectively). 2 In a propensity-matched comparison, the rates of perioperative renal insufficiency were 2.7% after open repair and 7.1% after FEVAR (p ¼ .1); the FEVAR group were initially considered to be high risk for open surgery. 3 Despite the transient nature of postoperative renal dysfunction, in most cases it remains a significant predictor of mortality in these patients. Serum creatinine is the most commonly reported marker of renal function, but estimated glomerular filtration rate (eGFR) can offer greater functional sensitivity. 4 Renal volume has been assessed in various urological studies as a predictor of graft function in living donor renal transplantation. It can be calculated from computed tomography (CT) data and has been shown in the context of endovascular aneurysm repair to be an early marker of renal dysfunction and to correlate well with eGFR. 5 Renal impairment in FEVAR is related to the nephrotoxicity of the contrast medium, micro- and macro-embolisation into the renal arteries during device manipulation in the aorta, and the inflammatory response associated with the procedure. Carbon dioxide has been used as a contrast medium in patients with renal failure, but it is associated with a high complication rate including right heart strain and fatal nonocclusive mesenteric ischaemia. 6 The repositionability of the Cook and Anaconda stent-grafts is intended to allow better alignment between the device and the renal artery ostia but it may also cause embolisation of athero-embolic material into the renal arteries. Other endovascular considerations include the design of the bridging stents, the amount of flaring of the proximal end, and the anatomy of the renal artery. Aortic cross-clamping during open surgical repair results in renal hypoperfusion and every additional 5 minutes of renal ischaemia time has been shown to double the risk of postoperative renal dysfunction. 7 Clamp placement above both renal arteries, and manipulation of the aorta and renal arteries results in embolisation of material and this effect is compounded by ischaemia-reperfusion injury. Division of the left renal vein increases the risk of renal dysfunction by six times. 7 Perfusion of the renal arteries with cold crystalloid solution may preserve renal function during thoracoabdominal aneurysm repair but is not widely used in juxtarenal aneurysm repair. Imaging surveillance is mandatory after FEVAR but repeated CT angiography exposes the patient to nephrotoxic iodinated contrast agent. Studies investigating the effect of different CT contrast agents on renal kinetics and renal oxygenation have shown that low osmolar compared with iso-osmolar contrast agents have a superior profile regarding rapid excretion, short-term renal exposure, and renal oxygenation. 8 Surveillance is currently changing from repeated CT angiography to immediate post-EVAR cone-beam CT in the hybrid room with ultrasound performed prior to hospital discharge. 9 CT angiograms are then performed at years 1 and 3 in the presence of good renal function with ultrasound performed annually. Ultrasound provides a hemodynamic evaluation of the bridging stents and target vessels, and the CT images are used to verify device integrity and positioning. Contrast-enhanced ultrasound has been shown to be as accurate as CT scan in detecting endoleaks and in assessing both target vessel patency and aortic diameter after fenestrated endovascular repair. 10 Future work should be directed towards investigation of potential biomarkers to predict risk, prognosis, and therapeutic response in patients with acute kidney injury. Renal impairment should be assessed with eGFR, which is a sensitive and reliable measure of renal function. Definite evidence of a difference between open surgical repair and FEVAR would require a randomised controlled trial and long term followup of 5e10 years.

非閉塞性腸管虚血（non-occlusive mesenteric ischemia: NOMI）の診断と治療

非閉塞性腸管虚血（non-occlusive mesenteric ischemia: NOMI）の診断と治療

簡便かつ機能的なopen abdominal management

簡便かつ機能的なopen abdominal management

Delayed intestinal stricture following non-resectional treatment for non-occlusive mesenteric ischemia associated with hepatic portal venous gas: a case report

BackgroundHepatic portal venous gas associated with non-occlusive mesenteric ischemia is indicative of a serious pathology that leads to bowel necrosis and it has a high mortality rate. Although non-occlusive mesenteric ischemia is acknowledged as a condition that requires early surgical treatment, it has been reported that bowel necrosis and surgical resection of the gangrenous lesion may be avoided if the condition is identified quickly and the cause is detected at an early phase. However, no reports or guidelines have been published that describe the management of patients in whom bowel necrosis and surgical treatment were avoided. We report the case of a patient who presented with non-occlusive mesenteric ischemia who was managed with non-resectional treatment at an early phase and had a delayed small-bowel stricture.Case presentationA 24-year-old man presented to the hospital with fever, abdominal pain, and vomiting. Abdominal computed tomography confirmed a diffuse gaseous distention with small-bowel pneumatosis and hepatic portal venous gas. An urgent laparotomy was performed, because septic shock associated with diffuse peritonitis and bowel necrosis was strongly suspected. Although we found purulent ascites and a perforated appendix at the time of surgery, gangrenous and transmural ischemic changes were not evident in the small bowel and colon. We performed an appendectomy without a bowel resection, and the patient was discharged on an oral diet. However, he was re-admitted to hospital, because 4 days after discharge he developed postoperative paralytic ileus. Non-operative management was chosen, but his symptoms did not improve. We decided to perform a laparotomy 40 days after the initial operation, and a considerable adhesion was detected. Therefore, only a synechotomy was performed. On day 57, he experienced symptoms that were associated with bowel obstruction once again. On day 59, a partial resection of the jejunum was performed. Severe luminal strictures were apparent within the jejunum, and marked structural changes were evident.ConclusionWhile non-surgical management can be chosen for selected patients with non-occlusive mesenteric ischemia, continuous observation to evaluate the development of delayed strictures that lead to bowel obstructions is required in patients who undergo non-resectional treatment.

Invited Commentary

Mesenteric ischemia after cardiac surgical procedures is a catastrophic event. Despite the expedient execution of appropriate therapeutic measures immediately after the diagnosis has been established, mortality remains exceedingly high. Surviving patients usually face a prolonged period of recovery under extended stays in the intensive care unit. Whereas the patient’s comorbidity, which may contribute considerably to the cause of mesenteric ischemia, is not subject to intervention, clinical experience suggests that the time delay between the onset of mesenteric ischemia and its diagnosis is a crucial factor for the patient’s prognosis and that it may be shortened by improved means of detection. In the past, various studies have identified several of risk factors for mesenteric ischemia; however, their significance is mostly academic because their predictive value is too low to hasten the process of diagnosis. More recently, elevated levels of procalcitonin (PCT) have been associated with various forms of mesenteric ischemia. It is the great merit of this excellent report by Klingele and colleagues [1Klingele M. Bomberg H. Poppleton A. et al.Elevated procalcitonin in patients after cardiac surgery: a hint to nonocclusive mesenteric ischemia.Ann Thorac Surg. 2015; 99: 1306-1313Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar] that they investigated the correlation between postoperatively elevated PCT levels and the occurrence of nonocclusive mesenteric ischemia (NOMI) in an observational cohort study with a comprehensive statistical approach. The authors found for the postoperative PCT level in receiver operating characteristic analyses an area under the curve of 0.94, which is much better than what we deal with when we apply the current risk scores to our patient population. Even after adjustment for a multitude of risk factors such as age, gender, EuroSCORE 2, pulmonary hypertension, chronic obstructive pulmonary disease, previous stroke, insulin-dependent diabetes, duration of operation, and six additional risk factors, the risk of developing NOMI remained 28-fold higher in patients with a postoperative PCT level above 6.6 ng/mL. Although Klingele and colleagues focused on NOMI in their study, corroborating evidence from other studies indicates that the findings just mentioned could perhaps apply to obstructive mesenteric ischemia just as well, which requires further investigation. However, the ultimate test remains to be taken. Further studies need to clarify whether early detection of NOMI by elevated PCT levels is actually early enough to improve outcome and lower mortality. Without this confirmation of clinical significance, highly elevated PCT levels after cardiac operations may end up being just another marker. In the mean time, as long as these confirmative studies are missing, clinicians are encouraged to consider an elevated PCT level as a strong indicator of NOMI, which may, in conjunction with other specific clinical findings, justify appropriate therapeutic measures in selected cases. Elevated Procalcitonin in Patients After Cardiac Surgery: A Hint to Nonocclusive Mesenteric IschemiaThe Annals of Thoracic SurgeryVol. 99Issue 4PreviewNonocclusive mesenteric ischemia (NOMI) can occur after cardiac surgery, commonly in conjunction with use of cardiopulmonary bypass. Some evidence suggests that serum procalcitonin (PCT) levels are increased in patients with mesenteric ischemia; however, an association between PCT and NOMI has not yet been studied. The current study investigates whether elevated serum PCT levels are found in patients exhibiting NOMI. Full-Text PDF