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Yuan JJ, Zhang HF, Zhang J, Li JZ. Mesenteric venous thrombosis in a young adult: A case report and review of the literature. World J Radiol 2024; 16:569-578. [PMID: 39494142 PMCID: PMC11525824 DOI: 10.4329/wjr.v16.i10.569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 08/22/2024] [Accepted: 09/06/2024] [Indexed: 10/28/2024] Open
Abstract
BACKGROUND Acute mesenteric vein thrombosis (MVT) accounts for only 2%-10% of all cases of acute mesenteric ischaemia, with an incidence rate of ~0.1% in Europe and the United States. It represents < 10% of mesenteric infarction cases and is seen predominantly in older adults. In younger individuals, MVT is uncommon, with 36% of cases having unidentified mechanisms and causes. CASE SUMMARY A 27-year-old man presented to the emergency department on February 29, 2024, with a chief complaint of intermittent abdominal pain for 3 day. He was previously in good health. As the abdominal pain was not alleviated by conventional treatment, an abdominal computed tomography (CT) scan was performed, which showed increased density in the portal and mesenteric veins. Further imaging, including portal vein ultrasound, mesenteric CT angiography, and enhanced abdominal CT, revealed widespread thrombosis of the portal vein system (including the main portal vein, left and right branches, proximal mesenteric vein, and splenic vein). After 10 day of thrombectomy and anticoagulation therapy, the patient's abdominal pain had improved significantly. Follow-up assessments indicated that portal venous blood flow had largely returned to normal. He was discharged on March 9, 2024. During a follow-up exam 2 months later, repeat abdominal enhanced CT showed that the previously detected thrombi were no longer visible. CONCLUSION Clinicians should remain vigilant for acute MVT in young patients presenting with abdominal pain, to prevent misdiagnosis of this fatal condition.
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Affiliation(s)
- Jiao-Jiao Yuan
- Department of Emergency Medicine, Ninth Hospital of Xi'an, Xi’an 710000, Shaanxi Province, China
| | - Hai-Fu Zhang
- Department of Vascular Intervention, Ninth Hospital of Xi'an, Xi’an 710000, Shaanxi Province, China
| | - Jian Zhang
- Department of Emergency Medicine, Ninth Hospital of Xi'an, Xi’an 710000, Shaanxi Province, China
| | - Jun-Zhi Li
- Department of Emergency Medicine, Ninth Hospital of Xi'an, Xi’an 710000, Shaanxi Province, China
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2
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Quan X, Liang X, Ding Y, Han Y, Li J, Yuan M, Li Y, Yuan Z, Wang R, Zhao Y. Cryo-Shocked Platelet Coupled with ROS-Responsive Nanomedicine for Targeted Treatment of Thromboembolic Disease. ACS NANO 2023; 17:6519-6533. [PMID: 36971410 DOI: 10.1021/acsnano.2c11865] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Thrombolysis with tissue plasminogen activator (tPA) provides the most common therapy for ischemic stroke onset within the past 4.5 h. However, enhanced neutrophil infiltration and secondary blood-brain barrier injury caused by tPA administration have limited its therapeutic application, and tPA treatment is often accompanied by hemorrhagic transformation. To overcome the limitations of thrombolysis by tPA, maximize the therapeutic efficacy, and improve the safety, herein, we report a cryo-shocked platelet-based cell-hitchhiking drug delivery system, which consists of cryo-shocked platelet (CsPLT) and reactive oxygen species (ROS)-responsive liposomes loaded with thrombolytic tPA and anti-inflammation drug aspirin (ASA). CsPLT and liposomes were facilely conjugated via host-guest interactions. Under the guidance of CsPLT, it selectively accumulated in the thrombus site and quickly released the therapeutic payloads in response to the high ROS. tPA subsequently exhibited localized thrombolytic activity to suppress the expansion of thrombus, while ASA assisted in the inactivation of reactive astrogliosis, microglial/macrophage, and obstruction of neutrophil infiltration. This cryo-shocked platelet-hitchhiking tPA/ASA delivery system not only improves the thrombus-targeting efficiency of the two drugs for highly localized thrombolytic effects and anti-inflammation actions and platelets inactivation but also provides insights to the development of targeted drug delivery systems for thromboembolic disease treatment.
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Affiliation(s)
- Xingping Quan
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau, SAR 999078, China
| | - Xiao Liang
- Cancer Center, Faculty of Health Sciences, University of Macau, Taipa, Macau, SAR 999078, China
| | - Yuanfu Ding
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau, SAR 999078, China
| | - Yan Han
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau, SAR 999078, China
| | - Junyan Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau, SAR 999078, China
| | - Mengchen Yuan
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau, SAR 999078, China
| | - Yiyang Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau, SAR 999078, China
| | - Zhen Yuan
- Cancer Center, Faculty of Health Sciences, University of Macau, Taipa, Macau, SAR 999078, China
| | - Ruibing Wang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau, SAR 999078, China
- Department of Pharmaceutical Sciences, Faculty of Health Sciences, University of Macau, Taipa, Macau, SAR 999078, China
| | - Yonghua Zhao
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau, SAR 999078, China
- Department of Pharmaceutical Sciences, Faculty of Health Sciences, University of Macau, Taipa, Macau, SAR 999078, China
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Changsheng L, Heliu D, Zhicheng F, Xianyi Y, Lin C, Hui G. Portal vein gas and pneumatosis intestinalis: A case of intestinal necrosis caused by acute organophosphorus pesticide poisoning? Toxicol Ind Health 2019; 35:482-485. [PMID: 31364505 DOI: 10.1177/0748233719862477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute organophosphorus pesticide poisoning (AOPP) is fairly common in rural areas of Asia. The symptoms of AOPP are mainly caused by acetylcholine accumulation. According to the clinical characteristics, AOPP symptoms can fall into the following three categories: muscarinic, nicotinic, and central. Death from fatal poisoning is caused by respiratory paralysis, and neurological complications are common. However, no case of intestinal necrosis caused by AOPP has been reported. Hepatic portal vein gas and pneumatosis intestinalis are considered typical and early imaging manifestations of intestinal necrosis. In this article, we describe a very rare case of computed tomography imaging-proven intestinal necrosis caused by AOPP.
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Affiliation(s)
- Li Changsheng
- 1 Department of Emergency, Taihe Hospital, Hubei University of Medicine, Shiyan City, China
| | - Dai Heliu
- 2 Department of Obstetrics and Gynecology, Dong Feng Hospital, Hubei University of Medicine, Shiyan City, China
| | - Fang Zhicheng
- 1 Department of Emergency, Taihe Hospital, Hubei University of Medicine, Shiyan City, China
| | - Yang Xianyi
- 1 Department of Emergency, Taihe Hospital, Hubei University of Medicine, Shiyan City, China
| | - Chai Lin
- 1 Department of Emergency, Taihe Hospital, Hubei University of Medicine, Shiyan City, China
| | - Guo Hui
- 1 Department of Emergency, Taihe Hospital, Hubei University of Medicine, Shiyan City, China
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Henes FO, Pickhardt PJ, Herzyk A, Lee SJ, Motosugi U, Derlin T, Lubner MG, Adam G, Schön G, Bannas P. CT angiography in the setting of suspected acute mesenteric ischemia: prevalence of ischemic and alternative diagnoses. Abdom Radiol (NY) 2017; 42:1152-1161. [PMID: 27885390 DOI: 10.1007/s00261-016-0988-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of the study was to determine the prevalence of ischemic and alternative diagnoses and the diagnostic accuracy of CT angiography (CTA) in the setting of suspected acute mesenteric ischemia (AMI). MATERIAL AND METHODS We included 959 patients undergoing CTA for the evaluation of suspected AMI. The final clinical diagnosis was used to determine the prevalence of ischemic and alternative diagnoses and to calculate the diagnostic accuracy of CTA. Prevalence of diagnoses by age, sex, and admission status was compared using Cochran-Armitage and χ 2 tests. RESULTS Prevalence was 18.8% (180/959) for AMI and 61.2% (587/959) for specific alternative diagnoses. In the remaining 20.0% (192/959), no clear clinical diagnosis was established. The most frequent alternative diagnoses were small-bowel obstruction (10.4%; 61/587), infectious colitis (8.7%; 51/587), pneumonia (6.5%; 38/587), cholecystitis (6.1%; 36/587), and diverticulitis (5.6%; 33/587). Prevalence of specific alternative diagnoses varied significantly according to both age (p < .013) and admissions status (p < 0.001). CTA had a sensitivity and specificity for diagnosing AMI of 89.4%/99.5% and for alternative diagnoses of 86.7%/96.9%, respectively. CONCLUSION In the setting of suspected AMI, the prevalence of ischemic and alternative diagnoses varies significantly by age, sex, and admission status. CTA provides for rapid and non-invasive assessment of ischemic and alternative diagnoses with high diagnostic accuracy.
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Affiliation(s)
- Frank Oliver Henes
- Department of Radiology, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Andrzej Herzyk
- Department of Radiology, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Scott J Lee
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Utaroh Motosugi
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Thorsten Derlin
- Department of Radiology, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Meghan G Lubner
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Gerhard Adam
- Department of Radiology, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bannas
- Department of Radiology, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, USA
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Barrientos Delgado A, Martínez Tirado MP, Martín-Lagos Maldonado A, Palacios Pérez Á, Casado Caballero FJ. [Extensive esophageal stenosis secondary to acute necrotizing esophagitis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 38:327-9. [PMID: 25150722 DOI: 10.1016/j.gastrohep.2014.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 06/23/2014] [Accepted: 06/29/2014] [Indexed: 10/24/2022]
Affiliation(s)
| | | | | | - Ángel Palacios Pérez
- Unidad Clínica de Aparato Digestivo, Hospital Universitario San Cecilio, Granada, España
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Abstract
Ischemic diseases of the gastrointestinal tract are some of the commonly encountered gastrointestinal diseases which are difficult to diagnose and still more difficult to treat. Presentation of colon ischemia is even more subtle, and this review article details about the various presentation patterns of ischemic colitis and their management.
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Byard RW. Acute mesenteric ischaemia and unexpected death. J Forensic Leg Med 2012; 19:185-90. [PMID: 22520368 DOI: 10.1016/j.jflm.2011.12.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 12/27/2011] [Indexed: 12/18/2022]
Abstract
Acute mesenteric ischaemia is a vascular emergency that arises when blood flow to the intestine is compromised leading to tissue necrosis. It is primarily a condition of the elderly associated with significant morbidity and mortality. Causes include arterial thromboembolism, venous thrombosis and splanchnic vasoconstriction (so-called nonocclusive mesenteric ischaemia). Reperfusion injury and breakdown of the intestinal mucosal barrier lead to metabolic derangements, sepsis and death from multiorgan failure. The diagnosis may be difficult to make clinically and numbers of cases are increasing due to ageing of the population. The clinical and pathological features are reviewed with discussion of predisposing conditions. Careful dissection of the mesenteric vasculature is required at autopsy with appropriate histologic sampling and documentation of associated comorbidities. Other organs need to be checked for thrombi and the possibility of testing for inherited thombophilias should be considered. Toxicological evaluation, particularly in younger individuals, may reveal evidence of cocaine use. On occasion no obstructive lesions will be demonstrated, however the confounding effects of post-mortem autolytic and putrefactive changes may mean that nonocclusive mesenteric ischaemia may be difficult to diagnose.
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Affiliation(s)
- Roger W Byard
- Discipline of Anatomy and Pathology, School of Health Sciences, The University of Adelaide, Adelaide, SA 5005, Australia.
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9
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Atherosclerosis in the abdominal aorta and its visceral branches: Associations with other manifestations of atherosclerosis in an autopsy study. Int J Angiol 2011. [DOI: 10.1007/bf02043463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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10
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New aspects in the diagnosis and management of acute mesenteric infarction. Int J Angiol 2011. [DOI: 10.1007/bf02651561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Schnee S, Sass K, Moellmer H, Hohenfellner R, Spanel-Borowski K. Heterogeneity of atherosclerosis in mesenteric arteries and outgrowth remodeling. Cardiovasc Pathol 2009; 19:e195-203. [PMID: 19926495 DOI: 10.1016/j.carpath.2009.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 08/12/2009] [Accepted: 10/07/2009] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In patients with acute mesenteric ischemia by occlusive thrombo-embolism, the superior mesenteric artery (SMA) is more affected than the inferior mesenteric artery (IMA). METHODS This study investigated postmortem mesenteric arteries from aged subjects (n=21). Four atherosclerotic stages were defined by signs of degeneration and inflammation in sections stained with Elastica-van-Gieson and immunohistology, respectively. RESULTS In females and males, Stages 3 and 4 were found in 62% of the SMA and 24% of the IMA. Lumenal areas based on diameter measurements remained essentially unchanged between Stages 1 and 4. Compared to a Stage 1 reference, remodeling was associated with thinning of the media below the plaque base and with pronounced thickening below the shoulder in the IMA. In Stages 3 and 4, the adventitia of the IMA had more vasa vasorum and a higher number of CD45-positive leukocytes than the adventitia of the SMA. During atherosclerotic progression, a stable fraction of leukocytes represented mast cells (6%) and CD117-positive cells as potential progenitor cells (1%). CONCLUSIONS Outgrowth remodeling occurred in both the SMA and the IMA. Less severe atherosclerosis in the IMA than in the SMA was associated with stronger signs of inflammation.
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Affiliation(s)
- Siegfried Schnee
- Faculty of Medicine, Institute of Anatomy, University of Leipzig, Leipzig, Germany
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12
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Zou X, Cao J, Yao Y, Liu W, Chen L. Endoscopic findings and clinicopathologic characteristics of ischemic colitis: a report of 85 cases. Dig Dis Sci 2009; 54:2009-15. [PMID: 19089615 DOI: 10.1007/s10620-008-0579-1] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2008] [Accepted: 10/13/2008] [Indexed: 12/12/2022]
Abstract
Ischemic colitis is the most common type of intestinal ischemia and has a clinical spectrum of injury that ranges from mild and transient ischemia to acute fulminant colitis. The aim of this study was to explore endoscopic findings and clinicopathologic characteristics of ischemic colitis and be accurate enough to avoid missed diagnosis or misdiagnosis. A retrospective analysis was undertaken of endoscopy findings and clinicopathologic characteristics of 85 cases of ischemic colitis from March 2005 to April 2008 in the endoscopy center of our hospital. All cases underwent colonoscopy with biopsy within 2 weeks of the onset of symptoms, and all specimens with forceps were stained with hematoxylin-eosin and observed under light microscopy. Of the 85 cases of ischemic colitis (24 men and 61 women, average age 61.36 +/- 14.49 years old, range 29-84), 71 were over 50 years of age. These cases were associated with the basal diseases such as hypertension, cardiovascular disorders, diabetes, and hematological diseases as well as a history of abdominal operation. The clinical features usually presented with sudden onset of abdominal pain, diarrhea, and hematochezia. Ischemic lesions were located mainly in the left colon with segmental form (only descending colon affected 16%, only splenic flexure 14%, and only sigmoid colon 23%). The 85 patients consisted of the non-gangrenous type (82), which were composed of reversible IC (76) and chronic IC (6), and the gangrenous type (3). Endoscopic appearance of the transient ischemic colitis consisted of petechial hemorrhages, edematous and fragile mucosa, segmental erythema, scattered erosion, longitudinal ulcerations, and sharply defined segment of involvement. Ischemic colitis of stricture was characterized by full-thickness mucosa, lumens stricture, and diseased haustrations. The mucosa of gangrenous colitis with cyanotic and pseudopolyps was endoscopically observed as well. Clinicopathologic characteristics showed mucosal inflammation accompanied by erosion, granulation tissue hyperplasia and gland atrophy, lamina propria hemorrhage, and macrophages with hemosiderin pigmentation in submucosa in particular. Although endoscopy findings and clinicopathologic characteristics of ischemic colitis are nonspecific, colonoscopy with biopsy plays a vital role in the early diagnosis of ischemic colitis.
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Affiliation(s)
- Xiaoping Zou
- Department of Gastroenterology, Nanjing Gulou Hospital Affiliated to Medical School of Nanjing University, Nanjing 210008, People's Republic of China
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Jejunal disorders: potentially lethal causes of acute abdomen are still overlooked. Surg Laparosc Endosc Percutan Tech 2009; 19:39-42. [PMID: 19238065 DOI: 10.1097/sle.0b013e3181964758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To highlight the importance of considering jejunal disorders in the differential diagnosis of acute abdomen. Although these conditions are relatively uncommon, we should keep in mind that jejunum still occurs, and deserves consideration. METHOD This study was carried out at King Abdullah University Hospital, Jordan. Medical records of 7 patients with uncommon jejunal disorders that were encountered between 2001 and 2007 were retrospectively evaluated. We had 1 patient with jejunal diverticulitis, 1 with jejunal intussusception, 2 with jejuno-ileal tuberculosis complicated by intestinal obstruction, and 3 with acute mesenteric ischemia. All of these patients presented with acute abdominal pain of nonspecific features. Radiologic workup, along with surgical intervention, was necessary to reach a final diagnosis. RESULTS Only 1 patient matched preoperative diagnosis, in which computed tomography scan revealed the presence of intussusception. The remaining patients were diagnosed intraoperatively. Laparoscopy and/or laparotomy with resection were performed. Morbidity was within acceptable range. There was no mortality. CONCLUSIONS Jejunal disorders are potentially serious, and are underestimated. They are considered important causes of acute abdomen. Although they should not be at the top of a differential diagnostic list, they should always be ruled out when there is no apparent cause.
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ROBERT MARIEE. Inflammatory Disorders of the Small Intestine. SURGICAL PATHOLOGY OF THE GI TRACT, LIVER, BILIARY TRACT, AND PANCREAS 2009:321-354. [DOI: 10.1016/b978-141604059-0.50016-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Abstract
Ischemic colitis is the most common form of intestinal ischemia. It manifests as a spectrum of injury from transient self-limited ischemia involving the mucosa and submucosa to acute fulminant ischemia with transmural infarction that may progress to necrosis and death. Although there are a variety of causes, the most common mechanism is an acute, self-limited compromise in intestinal blood flow. Patients typically have mild abdominal pain and tenderness over the involved segment of bowel. There is usually passage of blood mixed with stool, but hemodynamically significant bleeding is unusual. Although computed tomography may have suggestive findings, colonoscopy is the procedure of choice for diagnosis. Supportive care with intravenous fluids, optimization of hemodynamic status, avoidance of vasoconstrictive drugs, bowel rest, and empiric antibiotics will produce clinical improvement within 1 to 2 days in most patients. Twenty percent of patients will have development of peritonitis or may deteriorate despite conservative management and will require surgery.
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Affiliation(s)
- Bryan T Green
- Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA.
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Passam FH, Diamantis ID, Perisinaki G, Saridaki Z, Kritikos H, Georgopoulos D, Boumpas DT. Intestinal ischemia as the first manifestation of vasculitis. Semin Arthritis Rheum 2004; 34:431-41. [PMID: 15305242 DOI: 10.1016/j.semarthrit.2003.12.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To summarize current knowledge regarding the diagnosis and management of gastrointestinal vasculitis. METHODS Three cases of gastrointestinal vasculitis with acute abdominal ischemia as their first manifestation are presented. Underlying diseases were microscopic polyangiitis, systemic lupus erythematosus (SLE), and polyarteritis nodosa (PAN). Relevant English-language articles collected from the PubMed database were reviewed. RESULTS Among the angiitides, PAN, SLE, and Henoch-Schönlein are those most commonly accompanied by gastrointestinal complications. Intestinal vasculitis usually occurs when there is evidence of generalized disease activity. Abdominal computerized tomography is a valuable tool for diagnosing intestinal ischemia and suspected vasculitis. CONCLUSIONS In young patients presenting with intestinal ischemia, it is essential to assess the possibility of an underlying systemic disease. With prompt initiation of immunosuppressive treatment, surgery may be avoided. Prognosis is improved when there is minimal delay in surgical intervention.
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Affiliation(s)
- Freda H Passam
- Division of Internal Medicine, University Hospital of Crete, Heraklion, Greece
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Somin M, Korotinski S, Attali M, Franz A, Weinmann EE, Malnick SDH. Three cases of chronic mesenteric ischemia presenting as abdominal pain and Helicobacter pylori-negative gastric ulcer. Dig Dis Sci 2004; 49:1990-1995. [PMID: 15628740 DOI: 10.1007/s10620-004-9607-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Marina Somin
- Department of Internal Medicine C, Kaplan Medical Center, Rehovot 76100, Israel
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Khan AM, Hundal R, Ramaswamy V, Korsten M, Dhuper S. Acute esophageal necrosis and liver pathology, a rare combination. World J Gastroenterol 2004; 10:2457-8. [PMID: 15285044 PMCID: PMC4576312 DOI: 10.3748/wjg.v10.i16.2457] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Acute esophageal necrosis (AEN) or “black esophagus” is a clinical condition found at endoscopy. It is a rare entity the exact etiology of which remains unknown. We describe a case of ‘black esophagus’, first of its kind, in the setting of liver cirrhosis and hepatic encephalopathy.
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Chryssostalis A, Hagège H, Rosa-Hezode I, Cattan P, De Lacroix-Szmania I, Cabanis P, Bayani N, Abd Alsamad I, Chousterman M. [Chronic abdominal pain due to bowel ischemia in a patient with Leiden factor V mutation]. ACTA ACUST UNITED AC 2004; 28:301-3. [PMID: 15094681 DOI: 10.1016/s0399-8320(04)94922-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Leiden Factor V mutation, associated with resistance to activated protein C, is a prothrombotic state found in 20% of the patients with a first episode of deep-vein thrombosis. We report the case of a 30-Year-old woman with a history of intermittent abdominal pain who developed small bowel infarction requiring extensive small bowel resection. Biological search for prothrombotic disorder showed resistance to activated protein C due to homozygosity for the factor V Leiden mutation. Long-term anticoagulant therapy was initiated. Unexplained abdominal pain may be due to venous mesenteric ischemia, which can be associated with factor V Leiden mutation.
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Affiliation(s)
- Ariane Chryssostalis
- Service de Médecine Interne et d'Hépatogastroentérologie, Centre Hospitalier Intercommunal de Créteil, 40, avenue de Verdun, 94010 Créteil
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Bassilios N, Menoyo V, Berger A, Mamzer MF, Daniel F, Cluzel P, Buisson C, Martinez F. Mesenteric ischaemia in haemodialysis patients: a case/control study. Nephrol Dial Transplant 2003; 18:911-7. [PMID: 12686664 DOI: 10.1093/ndt/gfg004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Mesenteric ischaemia is not uncommon in dialysis patients and seems to have been increasing in the last decade. However, the risk factors for mesenteric ischaemia are unclear and prognosis of patients after this type of ischaemic accident is not well defined. METHODS From January 1988 to June 1999, 15 haemodialysis patients (0.3% per patient-year) from a single institution presented with mesenteric ischaemia and the clinical, biological and radiological aspects of the ischaemia were described. To identify risk factors for mesenteric ischaemia, each ischaemic patient (case) was matched with two other haemodialysis patients not having ischaemia (controls). Survival curves were then established for the two groups. RESULTS A marked hypotensive episode was present in seven out of 15 case patients (47%) during dialysis sessions that preceded mesenteric ischaemia. Abdominal pain, guarding, fever and hyperleucocytosis were all present in 13 out of 15 patients (87%). An abdominal computerized tomography scan with opaque enema enabled a rapid diagnosis for six patients. The caecum was the most frequently (47%) affected segment. Twelve patients were surgically treated and the remaining three were given medical support. The two groups (case and control) were not different in cardiovascular risk factors, comorbidity, administered drugs or main haemodialysis characteristics. The median survival of the case group was 600 days, whereas 80% of the control group survived beyond this period (P=0.0132). Eleven case patients survived >3 months after mesenteric ischaemia and had a median survival of 1500 days, which was identical to their matched control patients. CONCLUSIONS Mesenteric ischaemia should be systematically suspected in patients experiencing abdominal pain during or after dialysis sessions. Prompt diagnosis and treatment usually allow for a favourable prognosis.
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Affiliation(s)
- Nader Bassilios
- CHPVR, AURA, Réseau Nephropar, Hopital Necker, 149 rue de Sèvres, F-75743 Paris Cedex 15, France.
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Ben Soussan E, Savoye G, Hochain P, Hervé S, Antonietti M, Lemoine F, Ducrotté P. Acute esophageal necrosis: a 1-year prospective study. Gastrointest Endosc 2002; 56:213-7. [PMID: 12145599 DOI: 10.1016/s0016-5107(02)70180-6] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A prospective 1-year study was conducted to assess the frequency, clinical spectrum, histologic description, and follow-up of acute esophageal necrosis unrelated to ingestion of caustic or corrosive agents. METHODS The diagnosis of acute esophageal necrosis was based on a diffusely black esophagus at endoscopy and typical histologic features of diffuse mucosal and submucosal necrosis. Ingestion of caustic and corrosive agents was excluded in all patients. Medical history, associated diseases, and clinical symptoms were recorded for each patient. Nutritional status was evaluated based on clinical and biochemical parameters. Treatment included short-term parenteral nutrition and intravenous administration of a pump proton inhibitor. A second endoscopy was performed when possible at 2 weeks after presentation to assess regression of acute esophageal necrosis. RESULTS Among 3900 patients who underwent EGD, 8 (0.2%) with acute esophageal necrosis were identified. Nutritional status was poor for 6 patients. Complete resolution of acute esophageal necrosis without further recurrence was observed in 4. No esophageal strictures appeared during follow-up. Four patients died, but no death was directly related to acute esophageal necrosis. CONCLUSION Acute esophageal necrosis is not as infrequent an endoscopic finding as has been reported. Acute esophageal necrosis appears to be associated with poor general health status and is not a purely local phenomenon.
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Affiliation(s)
- Emmanuel Ben Soussan
- Digestive Tract Research Group and Department of Pathology, Rouen University Hospital, Rouen Cedex, France
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22
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Klotz S, Vestring T, Rötker J, Schmidt C, Scheld HH, Schmid C. Diagnosis and treatment of nonocclusive mesenteric ischemia after open heart surgery. Ann Thorac Surg 2001; 72:1583-6. [PMID: 11722048 DOI: 10.1016/s0003-4975(01)03179-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute nonocclusive mesenteric ischemia (NOMI) is a rare but often fatal event after cardiac surgery. METHODS Twenty patients with ongoing ileus after cardiac surgery despite maximal laxative treatment underwent selective mesenteric angiography. In cases of pathological radiographic findings, papaverine was continuously administered via an intraarterial perfusion catheter. RESULTS Severe NOMI was confirmed in seven patients (mean lactate: 6.9 +/- 8.3 mg/dL), mild to moderate findings in another seven (mean lactate: 1.4 +/- 1.1 mg/dL). One patient had thromboembolic occlusion of the superior mesenteric artery; five patients demonstrated normal imaging findings. In nine of fourteen patients (64%) treated with papaverine, symptoms improved within hours (defecation occurred after 4-29 hours, mean 13 +/- 8.1 hours). No side effects or complications occurred in connection with the papaverine treatment. The clinical condition of five patients deteriorated. Four patients underwent laparotomy with creation of an ileostomy or colostomy, two of whom presented with severe intestinal ischemia and later died. One patient died prior to laparotomy. CONCLUSIONS Selective mesenteric angiography with continuous papaverine administration is a simple, fast, and effective diagnostic and therapeutic tool to reduce the need for laparotomy for symptoms of ileus after open-heart surgery.
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Affiliation(s)
- S Klotz
- Department of Cardiothoracic Surgery, University Hospital of Münster, Germany
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 25-2001. A 71-year-old man with gastric ulcers and ileocecal thickening eight years after renal transplantation. N Engl J Med 2001; 345:526-32. [PMID: 11519508 DOI: 10.1056/nejmcpc010025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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24
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 16-2001. A 17-year-old girl with worsening abdominal pain, fever, and diarrhea after a recent cesarean section. N Engl J Med 2001; 344:1622-7. [PMID: 11372015 DOI: 10.1056/nejm200105243442109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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25
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Abstract
BACKGROUND Dialysis patients develop nonocclusive mesenteric ischemia (NOMI) at an increased rate. Previous studies have associated atherosclerosis and hemodialysis-induced hypotension as inciting factors for NOMI development. A retrospective review of 29 of 1,370 longterm hemodialysis patients who developed NOMI from January 1992 to December 1997 was performed. The NOMI patients were compared with a similar profile of hemodialysis patients to identify risk factors for the development of NOMI and for outcomes assessment. STUDY DESIGN All NOMI patients had hypotensive episodes during hemodialysis the week before the development of abdominal symptoms, and additional risk factors of hypertension (83%), diabetes (55%), and atherosclerosis (38%). The majority of patients (83%) experienced abdominal pain more than 24 hours before admission. Sixty-six percent of patients had leukocytosis on admission laboratory data. RESULTS Sixteen patients (55%) had ischemia of the small bowel, all underwent laparotomy, and nine (56%) died. Thirteen patients (45%) had ischemia of the colon and were managed nonoperatively; four (31%) of them died. Overall mortality rate for NOMI was 45%. CONCLUSIONS NOMI occurs at an increased rate in hemodialysis patients. Identification of patients at high risk for NOMI and dose monitoring of filtration rates may impact on the high mortality of this disease.
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Affiliation(s)
- A S John
- Medical College of Pennsylvania-Hahnemann University School of Medicine, Philadelphia, USA
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27
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Srivastava DN, Gulati MS, Tandon RK. Colonic infarction in acute pancreatitis: an unusual cause of gastrointestinal hemorrhage. Am J Gastroenterol 1998; 93:1186-7. [PMID: 9672366 DOI: 10.1111/j.1572-0241.1998.01186.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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28
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Klempnauer J, Grothues F, Bektas H, Pichlmayr R. Results of portal thrombectomy and splanchnic thrombolysis for the surgical management of acute mesentericoportal thrombosis. Br J Surg 1997. [DOI: 10.1046/j.1365-2168.1997.d01-1083.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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29
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Klempnauer J, Grothues F, Bektas H, Pichlmayr R. Results of portal thrombectomy and splanchnic thrombolysis for the surgical management of acute mesentericoportal thrombosis. Br J Surg 1997. [DOI: 10.1002/bjs.1800840146] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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30
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Järvinen O, Sisto T, Laurikka J, Tarkka M. Intimal thickening and fragmentation of the internal elastic lamina in the mesenteric arteries. APMIS 1996; 104:395-400. [PMID: 8703447 DOI: 10.1111/j.1699-0463.1996.tb00733.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
To evaluate the intimal thickness and continuity of the internal elastic lamina (IEL) in the mesenteric arteries, proximal segments of the coeliac artery (CA), superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) were studied light microscopically in 123 consecutive postmortem examinations. The mean age of the subjects was 62 years. Arterial segments were fixed in formalin, embedded in paraffin blocks, sectioned, and stained with Masson's trichrome. Fifty-one per cent of the samples examined showed at least minimal intimal thickening. The occurrence of significant luminal narrowing increased with age. We found a positive correlation between defects in the IEL and thickness of the intima in the mesenteric arteries, which is in harmony with previous observations showing marked fragmentation of the IEL in atherogenesis.
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Affiliation(s)
- O Järvinen
- Department of Thoracic and Cardiovascular Surgery, Tampere University Hospital, Finland
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31
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Klein HM, Klosterhalfen B, Kinzel S, Jansen A, Seggewiss C, Weghaus P, Kamp M, Töns C, Günther RW. CT and MRI of experimentally induced mesenteric ischemia in a porcine model. J Comput Assist Tomogr 1996; 20:254-61. [PMID: 8606233 DOI: 10.1097/00004728-199603000-00016] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Our goal was to assess the value of CT and MRI for the detection of bowel wall changes in experimentally induced mesenteric ischemia. METHODS in 18 female pigs, a percutaneous embolization of the superior mesenteric artery was performed with buthyl-2-cyanoacrylate and Lipiodol (1:1) (experimental group). In six animals, only diagnostic imaging and histologic evaluation were performed (control group). CT was carried out 3, 6, and 12 h after occlusion. Incremental CT (1 s scan time, 5 mm slice thickness, 7 mm increment, 120 kV/290 mAs) and spiral CT (slice thickness 5 mm, pitch 1.5, 120 kV/165 mA) were performed pre and post contrast injection (Somatom Plus/Siemens). Serial CT was carried out after intravenous contrast injection (1 ml/kg, 2 ml/s). MRI (Magnetom 1.5 T; Siemens) was performed with T1 (pre and post 0.01 mmol/kg Gd-DTPA; Magnevist; Schering, Germany), T2, and proton density images in axial orientation. Slice thickness was 3 mm and slice gap 1 mm. Additionally, a T1-weighted GE sequence (multislice FLASH 2D) was obtained in dynamic technique (before and 30, 60, and 90 s after contrast agent injection) with a slice thickness of 5 mm. Biometrical monitoring included blood pressure, heart frequency, blood cell count, electrolyte status, blood gas analysis, and determination of serum lactate. Image evaluation included morphological analysis and determination of the enhancement pattern. Histological specimens were obtained and analyzed according to the Chiu classification. RESULTS The histologic workup of the specimen 3, 6, and 12 h after vascular occlusion revealed an average Chiu state 3, 4, and 5. On CT, the bowel wall had a thickness of 4.7 mm on average in the ischemic segments. There was a significant difference from the control group (average 3 mm). Free intraperitoneal fluid and intramural gas were seen after 12 h of ischemia in 80%. In ischemic bowel segments, no mural enhancement was seen. Normal segments and the bowel of the control animals showed an enhancement of 34 HU on average (SD = 3.1 HU; p.<0.01). In MRI, S/N and C/N differed significantly between experimental and control groups in T1 and proton density images. In ischemic segments of all phases, the bowel wall did not show contrast enhancement. Healthy segments and bowel of control animals showed a significant enhancement (p<0.01). CONCLUSION Cross-sectional imaging has a high sensitivity for delineation of ischemic bowel wall segments. The enhancement pattern of the bowel wall enables detection of location, extent, and cause of a acute arterial mesenteric ischemia with high accuracy in an early phase.
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Affiliation(s)
- H M Klein
- Department of Diagnostic Radiology, University of Technology, Aachen, Germany
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32
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Abu-Laban RB, Ho K, Walls RM. Acute mesenteric ischemia in a middle-aged patient: case report and discussion. J Emerg Med 1995; 13:857-61. [PMID: 8747645 DOI: 10.1016/0736-4679(95)02024-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Mesenteric ischemia usually occurs in elderly patients, especially those with predisposing factors. It has also been described in young patients using oral contraceptive pills or illicit drugs. We present a case of a middle-aged woman who developed acute focal ischemia of the small intestine without predisposing factors. The unusual presentation of this patient, combined with her relative youth, obscured the diagnosis, which was ultimately made at laparotomy. The diagnosis of mesenteric ischemia should be considered in patients of any age presenting with recurrent or severe abdominal pain, particularly when no alternative cause is apparent. The definitive study to diagnose mesenteric ischemia is angiography. Unless identified early in its course, the condition may progress to frank infarction with a significant increase in morbidity and mortality. Because of this, an aggressive approach to the diagnosis and therapy of mesenteric ischemia is essential.
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Affiliation(s)
- R B Abu-Laban
- Emergency Medicine Residency Training Program, University of British Columbia, Vancouver, Canada
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33
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 9-1995. A 60-year-old man with hypertrophic cardiomyopathy and ischemic colitis. N Engl J Med 1995; 332:804-10. [PMID: 7862185 DOI: 10.1056/nejm199503233321208] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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34
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Bleichner G, Thomas O, Sollet J. Diarrhea in intensive care: diagnosis and treatment. Int J Antimicrob Agents 1993; 3:33-48. [DOI: 10.1016/0924-8579(93)90004-o] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/1993] [Indexed: 10/27/2022]
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35
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Rahmouni A, Mathieu D, Golli M, Douek P, Anglade MC, Caillet H, Vasile N. Value of CT and sonography in the conservative management of acute splenoportal and superior mesenteric venous thrombosis. GASTROINTESTINAL RADIOLOGY 1992; 17:135-40. [PMID: 1551509 DOI: 10.1007/bf01888529] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Acute splenoportal and superior mesenteric venous thrombosis were diagnosed on sonography and computed tomography (CT) in six patients. Sonography demonstrated the presence of echoic material filling the involved vessels in all patients. Precontrast CT scans demonstrated an increased, intra luminal density of the clots in four patients with splenoportal thrombosis. However, in two cases of superior mesenteric venous thrombosis, no hyperdensity was observed within the lumens. Nevertheless, the clots were always visualized as low-density regions in the vessel lumens after bolus injection. Intravenous anticoagulant therapy was started immediately after the diagnosis. All patients were evaluated twice a week with sonography and/or CT until recanalization occurred. The patency of the previously involved vessels was assessed from 6 days to 4 weeks after the acute episode (average time of recanalization: 17 days) without development of collateral pathways. It is concluded that, in the absence of clinical signs of a life-threatening process, a conservative management of acute splanchnic thrombosis can be successfully achieved by (1) early diagnosis, (2) efficacious intravenous anticoagulant therapy, (3) careful imaging follow-up of these patients by sonography and/or CT during the acute phase and, finally, (4) by an extensive search for a hypercoagulable state.
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Affiliation(s)
- A Rahmouni
- Department of Radiology, Henri Mondor Hospital, Creteil, France
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36
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37
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Bakal CW, Sprayregen S, Wolf EL. Radiology in intestinal ischemia. Angiographic diagnosis and management. Surg Clin North Am 1992; 72:125-41. [PMID: 1731380 DOI: 10.1016/s0039-6109(16)45631-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Angiography is an essential component of the diagnosis and treatment of patients with acute and chronic intestinal ischemia. Aortography and selective angiography permit identification of the cause and precise anatomy of intestinal ischemic syndromes, and also help plan their potential correction. Direct intra-arterial infusion of pharmacologic agents into splanchnic vessels has now become part of the therapy of these conditions. This article reviews angiographic techniques and their applications in the management of intestinal ischemic syndromes.
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Affiliation(s)
- C W Bakal
- Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
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38
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Fried MW, Murthy UK, Hassig SR, Woo J, Oates RP. Creatine kinase isoenzymes in the diagnosis of intestinal infarction. Dig Dis Sci 1991; 36:1589-93. [PMID: 1935497 DOI: 10.1007/bf01296402] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Total creatine kinase and its isoenzymes CK-MB and CK-BB were measured in the serum of patients admitted with acute abdominal pain or signs suggestive of an intraabdominal catastrophe. Total creatine kinase was measured by automated spectrophotometry, CK-MB by chemiluminescent assay, and CK-BB by radioimmunoassay. Patients were grouped according to their final diagnosis: intestinal infarction (N = 8); all other diagnoses (N = 22); controls (N = 20). CK-BB in the infarction group (22.3 +/- 5.3 ng/ml, mean +/- SE) was significantly greater (P less than 0.01) than in the noninfarction or the control groups (11.0 +/- 0.8 ng/ml and 5.8 +/- 0.7 ng/ml, respectively). There were no differences in total creatine kinase and CK-MB in the three groups. Stepwise deletion multiple regression analysis of 26 independent regressors showed that among a cluster of six significant variables (R2 = 0.92, P less than 0.005), CK-BB greater than 20 ng/ml was the best predictor of intestinal infarction. Results of this study indicate that CK-BB isoenzyme measurement may be useful in the diagnosis of intestinal infarction in man.
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Affiliation(s)
- M W Fried
- Department of Medicine, State University of New York Health Sciences Center, New York
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39
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Klein P, Bruckschlegel M, Schweiger H. [Significance of revascularization in arterially-induced mesenteric infarct]. LANGENBECKS ARCHIV FUR CHIRURGIE 1990; 375:220-4. [PMID: 2395389 DOI: 10.1007/bf00187442] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Until 1957 the only treatment of occlusion of mesenteric arteries was resection of the ischemic part of the bowel. A reduction of the extremely high mortality can be reached by the combination of mesenteric revasularisation with an optional resection of the necrotic parts of the bowel. Based on the experience with 57 patients operated on between 1970 and 1987, the survival rate (greater than 60 days after operation) could be improved by performing this regime. Reasons for this improvement are both the salvage of bowel length and the avoidance of the leak of bowel anastomosis. The latter was observed only in patients treated by bowel resection alone without revascularisation leading to death in three out of four cases.
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Affiliation(s)
- P Klein
- Gefässchirurgische Abteilung, Chirurgischen Universitätsklinik, Erlangen
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40
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Valentine RJ, Whelan TV, Meyers HF. Nonocclusive mesenteric ischemia in renal patients: recognition and prevention of intestinal gangrene. Am J Kidney Dis 1990; 15:598-600. [PMID: 2368700 DOI: 10.1016/s0272-6386(12)80533-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Nonocclusive mesenteric ischemia (NOMI) is a disorder with an extremely high mortality. Salvage of affected patients requires early recognition and aggressive intervention to prevent intestinal gangrene. Dialysis patients represent a group at particularly high risk for this condition. Clinicians should develop a high index of suspicion for NOMI in dialysis patients to lessen the risk of death. A high interventional posture must be maintained due to the notoriously unreliable signs and symptoms of this disorder.
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Affiliation(s)
- R J Valentine
- Division of Vascular Surgery, Bethesda Naval Hospital, MD
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41
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Hallett JW, James ME, Ahlquist DA, Larson MV, McAfee MK, Cherry KJ. Recent trends in the diagnosis and management of chronic intestinal ischemia. Ann Vasc Surg 1990; 4:126-32. [PMID: 2178662 DOI: 10.1007/bf02001366] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This paper reviews the operative management over the past 27 years of 102 patients with chronic mesenteric ischemia, and summarizes recent clinical trends and ongoing research in this area. The most important trends in the diagnosis and management of chronic intestinal ischemia include: (1) increasing use of duplex ultrasound scanning in the initial evaluation of patients with possible intestinal angina; (2) rapidly evolving noninvasive clinical tests to assess mucosal perfusion (reflectance spectrophotometry, laser Doppler flow analysis, and tonometry); and (3) preferential use of antegrade mesenteric grafts or transaortic endarterectomy for mesenteric atherosclerotic occlusive disease. Surgical revascularization continues to provide excellent early relief of symptoms (93%) and a low late recurrence rate (10%). New noninvasive diagnostic tests for chronic intestinal ischemia and excellent results of surgical revascularization support a continued aggressive approach to the early recognition and treatment of patients with chronic intestinal angina. With the aging population, we anticipate that the number of patients with chronic intestinal ischemia will increase.
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Affiliation(s)
- J W Hallett
- Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905
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42
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43
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Nemcek AA. CT of Acute Gastrointestinal Disorders. Radiol Clin North Am 1989. [DOI: 10.1016/s0033-8389(22)02161-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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44
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45
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Rose SC, Meyers WC, Saeed M, Feldman JM. Limitations of angiography for mesenteric ischemia caused by midgut carcinoid tumors. Cardiovasc Intervent Radiol 1989; 12:131-5. [PMID: 2507147 DOI: 10.1007/bf02577376] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Mesenteric ischemia associated with carcinoid tumors often presents with nonspecific abdominal pain and is usually due to mesenteric branch artery occlusion caused by elastic vascular sclerosis. Mesenteric ischemia was defined by the operative findings of cyanosis or infarction. Eleven patients with intraabdominal metastatic carcinoid tumor were evaluated by angiography. Angiographic narrowing and occlusion of multiple peripheral jejunal and ileal intramesenteric branch arteries was present in 3 patients with mesenteric ischemia, but also occurred in 5 of 8 patients without mesenteric ischemia. Other angiographic abnormalities included staining of the primary tumor (5) or metastases (6), tenting of small mesenteric vessels (5), and occlusion of draining mesenteric veins (2). We conclude that in patients with midgut carcinoid tumors, angiographic narrowing and occlusion of peripheral mesenteric arteries most likely represents elastic vascular sclerosis, is indicative of mesenteric invasion of tumor, but correlates poorly with the presence of ischemia in the subtended bowel. Alternatively, a normal selective arteriogram should exclude mesenteric ischemia as the cause of abnormal pain.
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Affiliation(s)
- S C Rose
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
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46
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Abstract
The clinical features, the treatment given, the factors governing treatment selection, and the result of such treatment were analyzed in all patients aged 65 years and over in whom a tissue diagnosis of acute mesenteric infarction was made at a major teaching hospital. Thirty-two such patients, of mean age 78.5 years, were identified during the 8-year study period. Expected clinical features of bowel infarction were commonly absent; for example, there was no abdominal pain and no abdominal tenderness in 29% and 26% of patients, respectively. A sizeable minority of patients (29%) were acutely confused at presentation. All patients not undergoing surgery died shortly after admission to hospital. For those 20 patients (63%) who underwent abdominal surgery, half were discharged alive from hospital. Whether or not the patient survived was associated with the ward to which they were originally admitted. Those admitted to a surgical ward tended to be younger and had a more typical clinical presentation than their counterparts admitted to a medical ward. In particular they were more likely to have abdominal pain and distention and less likely to be confused. Surgical intervention was undertaken more often and earlier in those admitted to surgical wards and this may have accounted for the better outcome. It should be emphasized that acute mesenteric ischemia is a potentially correctable surgical condition even in very elderly people. A realization that the presentation is often atypical should increase the likelihood of early recognition and lead to improved patient survival.
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Affiliation(s)
- P M Finucane
- University of Wales College of Medicine, Cardiff, United Kingdom
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47
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Abstract
Superior mesenteric artery embolism or thrombosis and nonocclusive ischemia are the most frequent causes of mesenteric ischemia. Symptoms out of proportion to the physical findings, leucocytosis, and metabolic acidosis suggest the diagnosis. A high index of suspicion, aggressive resuscitation and correction of metabolic derangements, early angiography, and operative intervention are necessary if the current high mortality rates are to be reduced.
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Affiliation(s)
- G C Hunter
- University of Arizona Health Sciences Center, College of Medicine, Tucson
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48
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Shaff MI, Tarr RW, Partain CL, James AE. Computed tomography and magnetic resonance imaging of the acute abdomen. Surg Clin North Am 1988; 68:233-54. [PMID: 3279544 DOI: 10.1016/s0039-6109(16)44475-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
CT is a noninvasive investigation that in many instances is more sensitive in elucidating intra-abdominal and retroperitoneal disease than is conventional radiography. With modern scanners, the procedure is rapid and efficient and suitable for the most severely ill and infirm. The scans are easily interpretable, and the anatomic and morphologic depiction of disease is readily understood by those with surgical training. Information regarding the state of the bowel wall, mesentery, and intraperitoneal and retroperitoneal structures is displayed in greater detail than by any other diagnostic imaging modality. The use of intravenous contrast medium is rarely essential. The concentration of iodinated contrast needed for opacification of the bowel is no greater than 2 per cent to 5 per cent and will not complicate bowel surgery, as would standard upper gastrointestinal or barium enema studies. Abscess, free air, calcium, and intraperitoneal fluid are very sensitively detected. CT is extremely useful in aiding surgical decision making in the acute abdomen and is complementary to or has replaced conventional studies.
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Affiliation(s)
- M I Shaff
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
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49
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Abstract
Ninety-eight patients with documented mesenteric infarction during a 19-year period were reviewed. In 13 patients infarction was due to a mesenteric venous thrombosis (MVT). Patients with MVT distinguished themselves from those having another aetiology by: (1) longer history of pain before admission (median 8 days, P less than 0.0001); (2) typical appearance of the bowel at laparotomy (10/13); (3) a localized segment of ischaemic jejunum or ileum of less than 120 cm in length (12/13) allowing better operability at the first laparotomy (P = 0.006). In hospital the mortality was lower for venous mesenteric infarction (5/13, 38 per cent) than for mesenteric infarction of other aetiologies (70/85, 82 per cent) (P = 0.002). Patients with primary venous mesenteric infarction showed a better survival rate (one death in eight patients) than patients with associated diseases such as liver cirrhosis, sepsis or previous operation who had a poor prognosis with a mortality comparable to other aetiologies of acute bowel ischaemia (four deaths in five patients). Since the high recurrence rate of this disease in the early postoperative period was due to residual venous thrombosis and to a hypercoagulable state, a wide bowel resection is recommended followed by early and long-term anticoagulation. Thrombectomy is probably inefficient since it removes only centrally located thrombi and leaves peripheral occlusion, which is responsible for the recurrence.
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Affiliation(s)
- P A Clavien
- Department of Surgery, University Hospital, Basle, Switzerland
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50
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Abstract
Eighty-one cases of mesenteric infarction documented by angiography, laparotomy or autopsy were reviewed to assess the cause of the persistently high mortality. Thirty-seven patients (46 per cent) were felt to have inoperable lesions and were treated by supportive care only, while forty-four (54 per cent) underwent bowel resection and/or revascularization. Of these 44 patients 20 (45 per cent) survived, 14 (32 per cent) died of an early recurrence of infarction and 10 (23 per cent) died of an unrelated cause. In view of the high recurrence rate in the early postoperative period, treatment must prevent the causes of persistent or recurrent ischaemia such as vasoconstriction and reperfusion tissue damage. On the basis of recent clinical and experimental research we suggest that treatment should include routine angiography with selective perfusion of vasodilators through the superior mesenteric artery, pharmacological prevention of ischaemic and reperfusion tissue damage before surgery, and postoperative anticoagulation.
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