Veno-occlusive mesenteric ischemia: A case report

Pruthvishree, Vidya Saketharaman*

Emergency Medicine Department, Kauvery Hospital, Chennai, India

Abstract

Small bowel ischemia, also called mesenteric ischemia (AMI), is a potentially “time sensitive” and life-threatening condition that reduces blood flow to the small intestine (duodenum, jejunum, or ileum). Symptoms can range from mild to severe depending on the etiology. In severe cases, loss of blood flow to the intestine can damage intestinal tissue and possibly lead to tissue death – gangrene. Bowel ischemia due to compression of the superior mesenteric vein is less common. Hence, we report a case of veno-occlusive mesenteric ischemia in which timely diagnosis and management achieved salvage of bowel, avoiding resection.

Keywords: Mesenteric vein compression, Bowel gangrene, Acute mesenteric ischemia

Background

Bowel ischemia/gangrene is one of the most challenging surgical emergencies, with high morbidity and mortality all over the world. The causes are diverse. Clinical and radiological manifestations vary according to etiology, the commonest being arterial thrombosis, and less commonly due to veno-occlussion. Early diagnosis, prompt treatment, and good postoperative care are the three important keystones for a successful outcome in a patient with bowel gangrene. They include rapid correction of fluid and electrolyte imbalance, control of sepsis, and urgent and prompt resection of the ischemic bowel. All will be lost once lethal toxins enter the systemic circulation. The technical and judgment errors during diagnosis are the two important factors that can have a high impact on the morbidity and mortality of the patient.

Occasionally a fortunate patient, diagnosed in time, can be salvaged without resection of bowel. This was one such case

Case Presentation

A 60-years-aged gentleman presented to Emergency Department with a three-hour history of severe mid abdominal pain, a tight band-like pain, associated with nausea, one episode of vomiting, and shortness of breath. There was the history of obstipation for one day. He was known to have Type 2 diabetes mellitus and hypertension for which he was on regular medicines. There was no history of previous abdominal surgeries or any episodes of abdominal sepsis.

On clinical assessment

Pulse	BP	RR	SpO2	Temp	GCS
120/min	100/60mmhg	22/min	97%RA	97 F	15/15

Physical examination revealed that he was severely dehydrated, tachypneic, and tachycardic. Abdominal examination revealed tenderness in the umbilical and left the lumbar region with sluggish bowel sounds. ECG showed sinus tachycardia. Initial blood work-up was as follows: ABG in room air revealed severe metabolic acidosis.

pH	7.18
pCO2	25.4
pO2	108
HCO2	9.6
Lactate	10.03
Hb	18.8
WBC	16700
PLT	322
PT	11.8
INR	1.04
Na	139
K	4.3
Urea	25
Creat	1.35
RBS	470

He was immediately rehydrated with IV fluids, and normal saline 2 pints, after which his heart rate settled. Inj. Actrapid 7 units and Inj. Sodium bicarbonate were given.

Urgent CT Abdomen indicates features of focal herniation of the mid descending colon through the mesentery causing compression and occlusion of the jejunal branches of the superior mesenteric vein. There was dilatation of the jejunal branches of the superior mesenteric vein and diffuse circumferential wall thickening of the jejunal loops (Fig. 1) – suggesting ischemic bowel. Partial short segment thrombosis of the anterior segmental branch of the right portal vein with transient hepatic attenuation was seen.

Fig. 1.

Fig. 2. Portal vein thrombosis

He was taken up for emergency laparotomy under general anesthesia. During the immediate opening of the peritoneum, hemorrhagic fluid of about 600 ml was seen and suctioned out. A constricting band was found at the root of the mesentery which was constricting the proximal jejunal loops; the band was then released. A 70 cm proximal jejunum from DJ flexure was found to be ischemic. With sufficient oxygen supply and warm pads, the arterial pulsation both in the root and in the marginal arteries were seen to return, and the bowel gradually regained color. Without resection, the bowel was returned back to the peritoneum. The patient made an uneventful post-operative recovery and was discharged home on the seventh post-operative day.

Discussion

Bowel ischemia can be classified as small intestine ischemia, which is commonly known as mesenteric ischemia, and large intestine ischemia, which is generally referred to as colonic ischemia. Intestinal ischemia occurs when at least a 75% reduction in intestinal blood flow for more than 12 h. Abdominal pain is the most common symptom in patients with intestinal ischemia. This report illustrates an unusual etiology, the evaluation, and management of the consequent bowel ischemia and highlights the role of an integrated and highly professional team in ensuring an optimal clinical outcome for patients with this condition.

Generally, mesenteric ischemia can be, based on the timing of onset, acute or chronic. Common causes of acute intestinal ischemia are mesenteric arterial embolism (50%), intestinal hypoperfusion, or nonocclusive mesenteric ischemia (NOMI) (20 to 30%), mesenteric arterial thrombosis (15 to 25%) and mesenteric venous thrombosis (MVT) (5%).

Usually, mesenteric arterial embolism is seen in patients with cardiovascular disease. Emboli may originate from anywhere from the heart to the origin of SMA, which include mycotic aneurysm, atheromatous plaques in the aorta, or vascular aortic prosthetic grafts. Intestinal hypoperfusion or nonocclusive mesenteric ischemia (NOMI) usually occurs in patients who present with systemic shock, which can be due to cardiac causes, infection, or hypovolemia. Nonocclusive causes account for almost 95% of patients with colonic ischemia. The risk of mesenteric arterial thrombosis is increased in patients with advanced age, peripheral artery disease, traumatic injury, and low cardiac output states. Mesenteric venous thrombosis can happen in patients with acquired and inherited hyper coagulopathy conditions.

Every patient with bowel ischemia should receive emergency diagnosis and treatment. The immediate priority is intravascular fluid replacement to stabilize hemodynamics, as volume displacement to the ischemic portions of the intestines and general endothelial disintegration occur within a few hours. In order to prevent exacerbation of thromboembolic occlusion, immediate anticoagulation should be achieved with 5000 IU heparin IV followed by perfusor-directed administration of an initial dose of 20 000 IU heparin/24 hours. Antibiotic treatment is started concomitantly.

In our patient, the cause for band formation could have been congenital or acquired. This case was unique because of the compression on the veins by the constricting band, which are less commonly reported. The small bowel could be salvaged without bowel resection, due to the timely diagnosis and management.

Conclusion

AMI secondary to veno-occlussion is uncommon, with a non-specific clinical presentation which makes early diagnosis challenging. Despite technical advances in imaging leading to more accurate diagnosis, AMI is often diagnosed late or even missed due to low clinical suspicion; therefore, a high mortality rate result. Although mesenteric ischemia is uncommon, it can be life-threatening, and its recognition is therefore crucial. If treatment is begun more than 6 to 8 h after symptom onset, the mortality rate increases exponentially. Management of intestinal ischemia by restoration of blood flow as soon as possible through medical treatment or surgical management, depending on the etiology.

Acknowledgement

We thank Dr. UP Srinivasan for his guidance in writing this article.

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Veno-occlusive mesenteric ischemia: A case report