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      Fulminant Nonocclusive Mesenteric Ischemia Just after Hip Arthroplasty

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          Abstract

          Nonocclusive mesenteric ischemia (NOMI) is not a rare clinical entity in intensive medicine, and it can be a consequence of several clinical or surgical situations. This pathology results from reduced intestinal microvascular blood supply associated with an acute inflammatory process, culminating with bowel necrosis. This is a case on a female patient who developed immediate postsurgical NOMI following hip arthroplasty and died. Since diagnosis of this potentially fatal condition remains a dilemma, NOMI should always be considered an eventual postoperative complication in high-risk surgical patients such as elderly individuals with previous history of nicotine abuse, congestive heart failure, and essential hypertension. The present paper highlights the importance of early diagnosis and prompt adequate treatment of NOMI in subjects with diminished cardiac output and severe abdominal pain.

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          Most cited references16

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          Imaging patients with acute abdominal pain.

          Acute abdominal pain may be caused by a myriad of diagnoses, including acute appendicitis, diverticulitis, and cholecystitis. Imaging plays an important role in the treatment management of patients because clinical evaluation results can be inaccurate. Performing computed tomography (CT) is most important because it facilitates an accurate and reproducible diagnosis in urgent conditions. Also, CT findings have been demonstrated to have a marked effect on the management of acute abdominal pain. The cost-effectiveness of CT in the setting of acute appendicitis was studied, and CT proved to be cost-effective. CT can therefore be considered the primary technique for the diagnosis of acute abdominal pain, except in patients clinically suspected of having acute cholecystitis. In these patients, ultrasonography (US) is the primary imaging technique of choice. When costs and ionizing radiation exposure are primary concerns, a possible strategy is to perform US as the initial technique in all patients with acute abdominal pain, with CT performed in all cases of nondiagnostic US. The use of conventional radiography has been surpassed; this examination has only a possible role in the setting of bowel obstruction. However, CT is more accurate and more informative in this setting as well. In cases of bowel perforation, CT is the most sensitive technique for depicting free intraperitoneal air and is valuable for determining the cause of the perforation. Imaging is less useful in cases of bowel ischemia, although some CT signs are highly specific. Magnetic resonance (MR) imaging is a promising alternative to CT in the evaluation of acute abdominal pain and does not involve the use of ionizing radiation exposure. However, data on the use of MR imaging for this indication are still sparse. http://radiology.rsna.org/content/253/1/31/suppl/DC1.
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            Identification of risk factors for perioperative mortality in acute mesenteric ischemia.

            Acute intestinal ischemia is in most cases a lethal condition with a low survival rate. Risk factors of perioperative mortality are poorly defined. The aim of this study was to define risk factors that predict an adverse outcome of acute mesenteric ischemia (AMI). A total of 132 consecutive patients (73 men, 59 women), mean+/-SD age 71.96+/-13.64 years, who underwent surgery because of AMI in a university tertiary care center were evaluated over a period of 10 years. Clinical features, laboratory findings, etiologic factors, and surgical procedures were recorded and assessed as possible risk factors for perioperative mortality. Of 132 patients, 86 (65.2%) died during the perioperative period as a direct result of AMI. Significant univariate predictors of perioperative mortality were age (P=0.01), cardiopathy (P=0.002), digoxin intake (P=0.015), shock (P=0.01), urea plasma level (P or=2.48 mmol/L (P=0.035); time delay to surgery (P=0.023); colonic involvement (P<0.001); small and large bowel involvement (P<0.001); arterial versus venous ischemia (P=0.007); and intestinal resection (P<0.001). In the multivariate analysis, the variables previous cardiac illness (P=0.045), urea plasma levels (P<0.001), and small and large bowel involvement were identified as independent risk factors of perioperative mortality. Intestinal resection (P<0.001) was a favorable predictor. Age, time delay to surgery, shock, and acidosis significantly increase the risk of mortality due to AMI, whereas intestinal resection has a protective effect. However, only previous cardiac illness, acute renal failure, and large bowel ischemia have a negative effect as independent risk factors of mortality of AMI.
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              Fatal nonocclusive mesenteric ischaemia: population-based incidence and risk factors.

              To estimate the incidence and extension of visceral organ infarction, and to evaluate potential causes, in patients with autopsy-verified nonocclusive mesenteric ischaemia (NOMI) and transmural intestinal infarction. In Malmö, Sweden, the autopsy rate between 1970 and 1982 was 87%, creating possibilities for a population-based study. Amongst 23 446 clinical autopsies, 997 cases were coded for intestinal ischaemia in a database. In addition, 7569 forensic autopsy protocols were analysed. In a nested case-control study within the clinical autopsy cohort, four NOMI-free controls, matched for gender, age at death and year of death, were identified for each fatal NOMI case to evaluate risk factors. The overall incidence of autopsy-verified fatal NOMI was 2.0/100,000 person-years, increasing with age up to 40/100,000 person-years in octogenarians. Patients with stenosis of the superior mesenteric artery (SMA; n = 25) were older (P = 0.002) than those without (n = 37), and had more often a concomitant stenosis of the coeliac trunk (P < 0.001). Synchronous infarction in the liver, spleen or kidney occurred in one-fifth of all patients. Fatal cardiac failure [OR 2.9 (1.7-5.2)], history of atrial fibrillation [OR 2.2 (1.2-4.0)] and recent surgery [OR 3.4 (1.6-6.9)] were risk factors for fatal NOMI. Fatal heart failure was the leading cause of intestinal hypoperfusion, although stenosis of the SMA and coeliac trunk, atrial fibrillation and recent surgery contributed significantly. Collaboration across specialties seems to be of utmost importance to improve the prognosis.
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                Author and article information

                Journal
                Case Report Med
                CRM
                Case Reports in Medicine
                Hindawi Publishing Corporation
                1687-9627
                1687-9635
                2010
                15 March 2010
                : 2010
                : 250436
                Affiliations
                1Divisão de Terapia Intensiva, Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, São Paulo, Brazil
                2Divisão de Proctologia, Departamento de Cirurgia e Anatomia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, São Paulo, Brazil
                3Laboratório de Biomarcadores de Diagnóstico e Monitoração, Instituto René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, MG, Brazil
                Author notes
                *Maria Auxiliadora-Martins: mamartins@ 123456hcrp.usp.br

                Academic Editor: Jonathan P. Garino

                Article
                10.1155/2010/250436
                2840376
                20300426
                9d4c66b4-5fd7-4c07-ba40-9bd2de692c79
                Copyright © 2010 Maria Auxiliadora-Martins et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 28 December 2009
                : 2 February 2010
                : 7 February 2010
                Categories
                Case Report

                Medicine
                Medicine

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