Surgery for acute exacerbation of chronic mesenteric ischemia: a case report

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Abstract

Background

Chronic mesenteric ischemia (CMI) is a rare disease; however, symptomatic CMI has a risk of acute exacerbation without timely revascularization.

Case presentation

A 54-year-old man who had had postprandial pain for 6 months was admitted to our hospital because of vomiting and diarrhea. Although the celiac and superior mesenteric arteries were occluded at the proximal portion, contrast enhancement of the bowel wall was good in contrast-enhanced computed tomography (CECT). Endoscopic examination revealed only a healed gastric ulcer and slight mucosal erosions in the colon. He was diagnosed as having acute enteritis or inflammatory digestive disease and observed with conservative therapy, which improved his acute symptoms. On hospitalization day 42, he suddenly complained of lower back pain. CECT showed abdominal free air, which indicated gastrointestinal perforation. Emergency surgery was performed for jejunum resection. Two days later, a second operation was performed for a leak in the anastomotic site of the jejunum. Necrotic change in the small intestinal serosa was also observed and required broad resection of the small intestine. He was diagnosed with acute exacerbation of CMI, and we performed surgical retrograde bypass to the gastroduodenal artery using a saphenous vein graft as the third operation. After the surgery, he was free from digestive symptoms and was discharged.

Conclusions

When patients complain of chronic and gradual digestive symptoms, we should always consider symptomatic CMI. Timely mesenteric revascularization is important for symptomatic CMI before severe complications occur.

Related collections

Most cited references 16

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Contemporary management of acute mesenteric ischemia: Factors associated with survival.

William S. Harmsen, Whitney Panneton, Peter Gloviczki … (2002)

Acute mesenteric ischemia (AMI) is a morbid condition with a difficult diagnosis and a high rate of complications, which is associated with a high mortality rate. For the evaluation of the results of current management and the examination of factors associated with survival, we reviewed our experience. The clinical data of all the patients who underwent operation for AMI between January 1, 1990, and December 31, 1999, were retrospectively reviewed, clinical outcome was recorded, and factors associated with survival rate were analyzed. Fifty-eight patients (22 men and 36 women; mean age, 67 years; age range, 35 to 96 years) underwent study. The cause of AMI was embolism in 16 patients (28%), thrombosis in 37 patients (64%), and nonocclusive mesenteric ischemia (NMI) in five patients (8.6%). Abdominal pain was the most frequent presenting symptom (95%). Twenty-five patients (43%) had previous symptoms of chronic mesenteric ischemia. All the patients underwent abdominal exploration, preceded with arteriography in 47 (81%) and with endovascular treatment in eight. Open mesenteric revascularization was performed in 43 patients (bypass grafting, n = 22; thromboembolectomy, n = 19; patch angioplasty, n = 11; endarterectomy, n = 5; reimplantation, n = 2). Thirty-one patients (53%) needed bowel resection at the first operation. Twenty-three patients underwent second-look procedures, 11 patients underwent bowel resections (repeat resection, n = 9), and three patients underwent exploration only. The 30-day mortality rate was 32%. The rate was 31% in patients with embolism, 32% in patients with thrombosis, and 80% in patients with NMI. Multiorgan failure (n = 18 patients) was the most frequent cause of death. The cumulative survival rates at 90 days, at 1 year, and at 3 years were 59%, 43%, and 32%, respectively, which was lower than the rate of a Midwestern white control population (P <.001). Six of the 16 late deaths (38%) occurred because of complications of mesenteric ischemia. Age less than 60 years (P <.003) and bowel resection (P =.03) were associated with improved survival rates. The contemporary management of AMI with revascularization with open surgical techniques, resection of nonviable bowel, and liberal use of second-look procedures results in the early survival of two thirds of the patients with embolism and thrombosis. Older patients, those who did not undergo bowel resection, and those with NMI have the highest mortality rates. The long-term survival rate remains dismal. Timely revascularization in patients who are symptomatic with chronic mesenteric ischemia should be considered to decrease the high mortality rate of AMI.

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Acute mesenteric ischemia: the challenge of gastroenterology.

H. Yasuhara (2004)

Intestinal ischemia has been classified into three major categories based on its clinical features, namely, acute mesenteric ischemia (AMI), chronic mesenteric ischemia (intestinal angina), and colonic ischemia (ischemic colitis). Acute mesenteric ischemia is not an isolated clinical entity, but a complex of diseases, including acute mesenteric arterial embolus and thrombus, mesenteric venous thrombus, and nonocclusive mesenteric ischemia (NOMI). These diseases have common clinical features caused by impaired blood perfusion to the intestine, bacterial translocation, and systemic inflammatory response syndrome. Reperfusion injury, which exacerbates the ischemic damage of the intestinal microcirculation, is another important feature of AMI. There is substantial evidence that the mortality associated with AMI varies according to its cause. Nonocclusive mesenteric ischemia is the most lethal form of AMI because of the poor understanding of its pathophysiology and its mild and nonspecific symptoms, which often delay its diagnosis. Mesenteric venous thrombosis is much less lethal than acute thromboembolism of the superior mesenteric artery and NOMI. We present an overview of the current understanding of AMI based on reported evidence. Although AMI is still lethal and in-hospital mortality rates have remained high over the last few decades, accumulated knowledge on this condition is expected to improve its prognosis.

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Mesenteric ischemia: Pathogenesis and challenging diagnostic and therapeutic modalities.

Stavroula Touloumi, Aikaterini Mastoraki, Sotiria Mastoraki … (2016)

Mesenteric ischemia (MI) is an uncommon medical condition with high mortality rates. ΜΙ includes inadequate blood supply, inflammatory injury and eventually necrosis of the bowel wall. The disease can be divided into acute and chronic MI (CMI), with the first being subdivided into four categories. Therefore, acute MI (AMI) can occur as a result of arterial embolism, arterial thrombosis, mesenteric venous thrombosis and non-occlusive causes. Bowel damage is in proportion to the mesenteric blood flow decrease and may vary from minimum lesions, due to reversible ischemia, to transmural injury, with subsequent necrosis and perforation. CMI is associated to diffuse atherosclerotic disease in more than 95% of cases, with all major mesenteric arteries presenting stenosis or occlusion. Because of a lack of specific signs or due to its sometime quiet presentation, this condition is frequently diagnosed only at an advanced stage. Computed tomography (CT) imaging and CT angiography contribute to differential diagnosis and management of AMI. Angiography is also the criterion standard for CMI, with mesenteric duplex ultrasonography and magnetic resonance angiography also being of great importance. Therapeutic approach of MI includes both medical and surgical treatment. Surgical procedures include restoration of the blood flow with arteriotomy, endarterectomy or anterograde bypass, while resection of necrotic bowel is always implemented. The aim of this review was to evaluate the results of surgical treatment for MI and to present the recent literature in order to provide an update on the current concepts of surgical management of the disease. Mesh words selected include MI, diagnostic approach and therapeutic management.

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Author and article information

Contributors

Shinji Abe:

ORCID: http://orcid.org/0000-0003-0237-6047

+81-11-782-9111 , shinabe_mail@yahoo.co.jp

Journal

Journal ID (nlm-ta): Surg Case Rep

Journal ID (iso-abbrev): Surg Case Rep

Title: Surgical Case Reports

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Electronic): 2198-7793

Publication date (Electronic): 5 December 2016

Publication date PMC-release: 5 December 2016

Publication date Collection: December 2016

Volume: 2

Electronic Location Identifier: 146

Affiliations

[1 ]Department of Cardiovascular Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505 Japan

[2 ]Department of Surgery, Kin-i-kyou Central Hospital, 5-1-9-1 Higashinaebo, Higashi-ku, Sapporo, 007-8505 Japan

[3 ]Department of Cardiovascular and Thoracic Surgery, Hokkaido University Hospital, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638 Japan

Author information

Shinji Abe http://orcid.org/0000-0003-0237-6047

Article

Publisher ID: 272

DOI: 10.1186/s40792-016-0272-0

PMC ID: 5138179

PubMed ID: 27921277

SO-VID: 2823fe6a-d283-40ef-bc8f-24d06701f23d

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.