Shock Bowel Research Articles

The Shock Bowel – “Abdominal shock” presenting as bowel ischaemia

This case illuminates a distinctive clinical challenge: a 67-year-old woman with disseminated ovarian cancer developed severe abdominal pain following gastrojejunal bypass, highlighting the complexity of diagnosing non-occlusive mesenteric ischaemia within the context of septic shock. Despite unremarkable clinical examination and normal biochemical parameters, imaging revealed extensive small bowel pneumatosis and signs of bowel ischaemia. An anastomotic leak from the gastrojejunal bypass was successfully repaired during exploratory laparotomy. However, indocyanine green imaging indicates pneumatosis without clear ischaemic evidence. The patient’s recovery was uneventful. This case underscores the importance of specific imaging features that could help differentiate between surgical cases and those benefitting from conservative management only.

S3518 Shock, Severe Hypothyroidism, and Paralytic Large Bowel Ileus in a Patient With Multiple Neoplasms

S3518 Shock, Severe Hypothyroidism, and Paralytic Large Bowel Ileus in a Patient With Multiple Neoplasms

Signs of post-traumatic hypovolemia on abdominal CT and their clinical importance: A systematic review

PurposeOur aim was to assess the findings of hypovolemia on abdominal CT that are most frequently seen in blunt abdominal trauma patients. When possible, we assessed the correlation of these CT signs with clinical outcome. MethodsMEDLINE, CENTRAL and EMBASE were systematically searched. Two reviewers independently screened and included articles and performed the data-extraction. Primary outcomes of interest were the frequency of each sign and its correlation with mortality. Secondary outcomes were need for intervention, transfusion need, intensive care unit admission rate and length of stay. ResultsA flat inferior vena cava and an inferior vena cava halo, a diminished aortic calibre, shock bowel, altered enhancement of the liver, pancreas, adrenals, kidneys, spleen and gallbladder, peripancreatic fluid and splenic volume changes have been described in the setting of hypovolemic trauma patients to constellate a CT hypovolemic shock complex. It is argued that vascular signs represent the true hypovolemic state and the visceral signs represent hypoperfusion. There is no consensus on the frequency or clinical relevance of these signs, which at least partly can be explained by the heterogeneity in study design, study population, scanning protocols and outcome parameters. Available evidence suggests a good predictive value for occult shock and a higher mortality rate when a flat inferior vena cava is present. Evidence regarding the other signs is scarce. ConclusionsThe hypovolemic shock complex is an entity of both vascular and visceral CT signs that can be seen in blunt trauma patients. It can offer guidance to a swift primary imaging survey in the acute trauma setting, allowing the radiologist to alert the treating physicians to possible pending hypovolemic shock.

Massive Bleeding From Inferior Mesenteric Vein With Hypovolemic Shock: A Rare Complication of Acute Pancreatitis

BackgroundAcute pancreatitis may cause massive intra-abdominal bleeding as vascular complications caused by the erosion of a major pancreatic or peripancreatic vessel. In terms of treatment, the differentiation between arterial bleeding and venous bleeding using abdominal computed tomography (CT) angiography is important. In addition, hypovolemic shock caused by bleeding from the inferior mesenteric vein (IMV) in acute pancreatitis has not been reported. Case ReportA 58-year-old man presented to our emergency department with complaints of abdominal pain of 10 hours’ duration. The pain had an abrupt onset and started with alcohol consumption. After performing initial laboratory tests and an abdominal CT scan, he was diagnosed with acute pancreatitis. However, he complained of severe abdominal pain and was drowsy 2 h later. Follow-up CT angiography revealed acute necrotizing pancreatitis with massive hemoperitoneum and hypovolemic shock. We also found active bleeding from the IMV. We did not consider emergency catheter angiography with embolization; instead, exploratory laparotomy and hematoma evacuation with IMV ligation was performed. He was discharged without complications 14 days later. Why Should an Emergency Physician Be Aware of This?Massive bleeding from the IMV accompanied by shock bowel syndrome is a rare complication of acute pancreatitis that can be confused with arterial bleeding. Emergency physicians should consider this diagnosis in acute pancreatitis as a possible cause of hypovolemic shock and anatomic course of the IMV and prevent fulminant shock by administering appropriate treatment.

Clinical Evaluation of "Shock Bowel" Using Intestinal Fatty Acid Binding Protein.

"Shock bowel" is one of the computed tomographic (CT) signs of hypotension, yet its clinical implications remain poorly understood. We evaluated how shock bowel affects clinical outcomes and the extent of intestinal epithelial damage in trauma patients by measuring the level of intestinal fatty acid binding protein (I-FABP). We reviewed the initial CT scans, taken in the emergency room, of 92 patients with severe blunt torso trauma who were consecutively admitted during a 24-month period. The data collected included CT signs of hypotension, I-FABP, feeding intolerance, and other clinical outcomes. Demographic and clinical outcomes were compared in patients with and without hemodynamic shock and shock bowel. Shock bowel was found in 16 patients (17.4%); of them 7 patients (43.8%) did not have hemodynamic shock. Certain CT signs of hypotension, namely free peritoneal fluid, contrast extravasation, small-caliber aorta, and shock bowel, were significantly more common in patients with hemodynamic shock than in patients without (P < 0.05). Injury severity score and the rate of consciousness disturbance were significantly higher in patients with shock bowel than in patients without (P < 0.05). The rate of feeding intolerance and median plasma I-FABP levels were significantly higher in patients with shock bowel than in patients without (75.0% vs. 22.4%, P < 0.001 and 17.0 ng/mL vs. 3.7 ng/mL, P < 0.001, respectively). There was no difference in mortality. In conclusion, shock bowel is not always due to hemodynamic shock. It does, however, indicate severe intestinal mucosal damages and may predict feeding intolerance.

A snapshot of circulation failure following acute traumatic injury: The expansion of computed tomography beyond injury diagnosis.

CT scans with a flat Inferior Vena Cava (IVC) suggest hypovolemia, and the presence of shock bowel implies hypoperfusion. The purpose of this study is to correlate injury severity, resuscitation needs, and clinical outcomes with CT indices of hypovolemia and hypoperfusion. Retrospective cohort study. Level II trauma centre in Central California. Adult patients imaged with abdominal and pelvic CT scans, from January 2010-January 2011. None. Circulatory derangements on CT scans were defined as an IVC (AP) diameter measurement of <9 mm, flat IVC (FIVC), hypovolemia. The presence of small intestine hypoperfusion was shock bowel (SB). The absence of these findings was a normal CT scan (NCT). Comparisons of acid-base status, fluids, morbidity and mortality were made based on CT findings. Subgroups were: FIVC (n=20), FIVC+SB (n=19), SB (n=4) only versus normal CT scans, NCT (n=47). Overall ISS was 19 (SD) 14. The lowest ISS was in NCT 14 (SD) 10 and there was an incremental increase in ISS based on circulatory derangements, p=0.001. ICU admission was lowest in NCT and highest in the presence of hyovolemia and hypoperfusion, p=0.03. Similarly ED crystalloid requirements and the activation of a massive transfusion protocol (MTP), was lowest in NCT group and gradually increased significantly as hypovolemia and hypoperfusion was demonstrated on CT scans. Additional parameters such as metabolic acidosis, nosocomial infections and mortality were associated with acute CT findings of circulatory failure. Hypovolemia and hypoperfusion, markers of abnormal circulation, were demonstrated on CT scans for trauma evaluation. The presence of these findings alone or in combination showed strong correlation with high injury severity, and the need for aggressive resuscitation.

Shock Bowel Caused by Neurogenic Shock: Computed Tomography Findings

Shock Bowel Caused by Neurogenic Shock: Computed Tomography Findings

Small Bowel Angioedema Associated with Angiotensin Converting Enzyme Inhibitor Use

A 45-year-old African American female presented with a four-day history of nausea, vomiting, abdominal pain and diarrhea. She had recently been started on an angiotensin converting enzyme inhibitor (ACE-I) - lisinopril, for hypertension. On examination, she had diffuse abdominal tenderness but no swelling of the lips or tongue. Laboratory tests showed mild leucocytosis and lactic acidosis. A computed tomography (CT) scan of the abdomen and pelvis showed circumferential small bowel wall edema and fold thickening with hyperenhancing mucosa and edematous submucosa resulting in mural stratification (solid arrows, Fig. 1a), intraluminal fluid accumulation (dotted arrow, Fig. 1b) as well as mesenteric vascular engorgement and ascites (dashed arrow, Fig. 1b). Lisinopril was discontinued with complete resolution of symptoms within next 48 hours. Figure 1 a: Axial images from CT scan of the abdomen and pelvis with oral and IV contrast shows circumferential duodenal and small-bowel wall and fold thickening (solid arrows) with hyperenhancing mucosa and edematous submucosa resulting in mural stratification. ... A follow-up CT scan obtained four days later, showed complete resolution of bowel wall thickening, and the associated peri-enteric inflammatory changes and ascites. ACE-I have been reported to cause peripheral angioedema in 0.1% to 0.2% of patients, with visceral angioedema reported to occur even less commonly1. The differential diagnosis of bowel wall thickening includes ischemic bowel, shock bowel, vasculitis (e.g. Henoch–Schonlein purpura), intramural hematoma (e.g. trauma or anticoagulation therapy), infectious enteritis, medications (esp ACE-I) and inflammatory bowel disease2. Usually angioedema presents as swelling of tongue, lips or upper airways. It can present with GI symptoms without involvement of upper airway, as in this patient3. Having a high index of suspicion can help make the diagnosis of angioedema secondary to ACE-I and avoid the cost and morbidity associated with unnecessary interventions4.

Answer to Case of the Month #155: Shock Bowel

Answer to Case of the Month #155: Shock Bowel

CT Hypotension Complex (Shock Bowel) Is Not Always Due to Traumatic Hypovolemic Shock

The purpose of our study was to review the clinical and CT findings in a substantial series of 41 patients with the shock bowel sign to determine if there is an association between shock bowel (and other CT signs of hypotension) and conditions other than post-traumatic hypovolemic shock. The shock bowel sign and the CT hypotension complex are frequently associated with hypotension from causes other than trauma-induced hypovolemic shock, such as severe head or spine injury, cardiac arrest, septic shock, bacterial endocarditis, and diabetic ketoacidosis. Other elements of the CT hypotension complex such as flattening of the inferior vena cava and aorta, abnormal pancreatic enhancement and peripancreatic fluid, and hypoperfusion of the spleen and liver are variably associated with shock bowel whether due to posttraumatic hypovolemia or other causes of hypotension. The CT hypotension complex (shock bowel) has important prognostic and therapeutic implications and can probably be distinguished from bowel trauma and other forms of bowel injury in most cases.

Shocking abdominal trauma: Review of an uncommon disorder of small intestine perfusion

'Shock bowel' is a rare disorder of gastrointestinal physiology with characteristic radiological features. It usually occurs in the setting of blunt abdominal trauma and hypovolaemia, with complete reversibility of these findings following resuscitation. We present a case demonstrating the classic features of this complex of imaging findings thought to be caused by end-organ hypoperfusion.

Interleukin-1 Receptor Antagonists and Other Markers in Colorectal Cancer Patients

Background: Although the interleukin-1 receptor antagonist (IL-lra) has been suggested as a potentially valuable therapeutic agent and has been shown to improve outcome in various animal models of arthritis, septic shock, and inflammatory bowel disease, there is little information available about its level in the circulation in patients with cancer. Methods: Serum levels of IL-lra, soluble interleukin-2 receptor (sIL-2r), soluble intercellular adhesion molecule-1 (sICAM-1), and Cortisol were measured in normal controls and patients with colorectal cancer. Results: The data showed that serum IL-lra levels in patients were significantly lower than those of healthy controls (P < 0.05). In contrast, serum sIL-2r and Cortisol levels in patients were significantly higher than those of normal controls (P < 0.01). Serum sICAM-1 levels in patients were the same as in normal controls. Conclusions: These results suggested that a reduced level of IL-lra exists in colorectal cancer patients relative to normal controls, indicating that cancer patients have an immunologic disorder and that exogenous IL-lra administration might be a future alternative for cancer treatment.

Imaging gastrointestinal perforation in pediatric blunt abdominal trauma.

To assess the role of imaging, in particular CT, in the early detection of GI perforation. In a 10-year period, 43 patients with surgically confirmed GI perforation were identified from hospital records; 22 of these had preoperative CT evaluation. Medical records and radiology were retrospectively reviewed and CT studies were particularly assessed for extraluminal air, free intraperitoneal fluid, bowel wall thickening, bowel wall enhancement, and bowel dilatation. During the study period an additional 12 trauma patients were identified who had CT studies demonstrating the above findings, but who had hypovolemic shock bowel or nondisrupting bowel injury without perforation evident. Extraluminal air was demonstrated in 47 % of the imaged perforations. There was one false-positive extraluminal air. Perforation was confirmed in patients who had all five of the above CT findings, but this was the case for only 18 % of patients with perforation. One or more of the five specified CT findings were present in all CT studies reviewed. No false-negative CT study was performed in the study period. Separating nondisrupting bowel injury from perforation is diagnostically difficult; however, CT remains a good modality for assessing GI perforation in pediatric blunt trauma, but it cannot replace diligent and repeated clinical evaluation of all potential perforation victims.

Diffuse small-bowel ischemia in hypotensive adults after blunt trauma (shock bowel): CT findings and clinical significance.

The purpose of this study is to describe CT findings of shock bowel (diffuse abnormality of the small bowel observed in hypotensive or hypoperfused patients after blunt abdominal trauma) and to determine the clinical significance of CT-diagnosed shock bowel. A data base search of a radiology data registry indicated 13 patients had CT scans obtained at admission that showed diffuse abnormalities of the small bowel and a corresponding medical history of profound clinical shock preceding CT study. All patients sustained blunt abdominal trauma: nine were involved in motor vehicle collisions, three were struck by motor vehicles, and one had a crushing injury. Vehicular impacts were typically high speed, inducing multisystem injury. Admission and follow-up CT studies were reviewed to characterize and assess the evolution of the abdominal CT findings that occur with shock bowel. Medical records were reviewed to determine blood pressure at the accident scene or on admission, surgical findings, and patient outcome. All patients were severely hypotensive in the field or on admission; three were in cardiac arrest at the scene of the accident. CT scans showed diffuse thickening of the small-bowel wall in all patients, ranging from 7 mm to 15 mm (mean, 11 mm); fluid-filled, dilated small bowel in nine patients; subjectively increased contrast enhancement of the small-bowel wall in six patients; and a flattened inferior vena cava (< 9 mm anteroposterior diameter at renal veins) in 10 patients. The colon appeared normal in all cases. Celiotomy in eight patients revealed normal-appearing small bowel by inspection in two and localized bowel injuries, with the remaining bowel appearing normal in six. Three patients, including one who had celiotomy, had normal-appearing small bowel on repeat CT scans obtained within 5 days of admission, and three had no clinical evidence of small-bowel disease. Three patients died of causes unrelated to bowel pathology. In trauma patients with hypotension, early abdominal CT may show diffuse abnormalities of the small bowel due to prolonged hypoperfusion--shock bowel--with a normal appearing colon. In this study, the CT findings of shock bowel were reversible and were not associated with clinical symptoms.

Therapeutic Applications of Anti-TNF Monoclonal Antibodies

Tumour necrosis factor α (TNF) is a major product of activated macrophages which has a wide range of biological actions that have been implicated in a rumber of human diseases. This review presents the evidence that has been generated in animal models which suggests that TNF plays an important role in the pathology of septic shock, rheumatoid arthritis and inflammatory bowel diseases (Crohn's disease and ulcerative colitis). Anti-TNF antibodies either reduce or block the onset of symptoms in these models which suggests that this class of antibody may have useful therapeutic effects. Recent results of human clinical trials with a mouse antibody, BAYX 1351, and two recombinant antibodies, cA2 and CDP571, are discussed which indicate that the promising results in animals may be duplicated in man.