Isquemia mesentérica aguda: un desafío de la medicina. Reporte de un caso

La isquemia intestinal aguda es una emergencia vascular provocada por fenómenos oclusivos y no oclusivos de la circulación mesentérica arterial y venosa, de difícil diagnóstico y pronóstico ominoso. Su incidencia va en aumento paulatino con el decurso de los años, asociada fundamentalmente al envejecimiento de la población. La tasa de mortalidad es elevada a pesar de los avances en el campo de la imagenología. Suele diagnosticarse de forma tardía, cuando está establecido el daño isquémico intestinal de carácter irreversible. El elemento imprescindible e indispensable lo constituye el tiempo que trascurre hasta la cirugía, por lo que su diagnóstico sigue siendo un reto clínico. El tratamiento exige medidas médicas intensivas, al igual que cirugía de revascularización y resección del intestino necrosado. Por desdicha, el examen físico y los hallazgos de laboratorio no son sensibles ni específicos para su diagnóstico. Teniendo en cuenta estos elementos, se presenta el caso de una paciente de 38 años con clínica difusa de vómitos, diarrea y dolor abdominal progresivo, que requirió intervención quirúrgica de urgencia con diagnóstico transoperatorio de isquemia mesentérica aguda. Durante su estancia hospitalaria se relaparotomizó en dos ocasiones, mantuvo soporte ventilatorio e inotrópico por fallo multiorgánico en la Unidad de Cuidados Intensivos, mostrando una adecuada evolución posquirúrgica. El objetivo de esta presentación es enfatizar en la clínica como elemento fundamental para abordar de forma correcta esta entidad en un medio hospitalario de limitados recursos diagnósticos imagenológicos, al abordar conceptos teóricos recientes y facilitar una adecuada actuación en la toma de decisiones.

Acute intestinal ischemia is a vascular emergency caused by occlusive and non-occlusive phenomena of the mesenteric arterial and venous circulation of difficult diagnosis and ominous prognosis. Its incidence is gradually increasing over the years, mainly associated with the ageing of the population. The mortality rate is high despite advances in the field of imaging. It is usually diagnosed late, when irreversible ischemic intestinal damage is established. The essential and indispensable element is the time that elapses until surgery, so its diagnosis continues to be a clinical challenge. Treatment requires intensive medical measures, as well as revascularization surgery and resection of the necrotic intestine. Unfortunately, physical examination and laboratory findings are neither sensitive nor specific for its diagnosis. Taking these elements into account, the authors present the case of a 38-year-old female patient with diffuse symptoms of vomiting, diarrhea and progressive abdominal pain that required emergency surgery with intraoperative diagnosis of acute mesenteric ischemia. During her hospital stay, she underwent re-laparotomy twice, maintained ventilatory and inotropic support due to multi-organ failure in the Intensive Care Unit, showing an adequate post-surgical evolution. The objective of this presentation is to emphasize in the clinic as a fundamental element to correctly address this entity in a hospital environment with limited imaging diagnostic resources by addressing recent theoretical concepts and facilitating adequate action in decision-making.

Open revascularization for chronic mesenteric ischemia in the endovascular era: a quaternary-center experience and management algorithm / Revascularização aberta na isquemia mesentérica crônica durante a era endovascular: experiência de um centro quaternário e um algoritmo de tratamento

Abstract Background Chronic mesenteric ischemia (CMI) is a debilitating disease with a heavy burden on quality of life. Stenting of the superior mesenteric artery (SMA) is the first option for treatment, but there is a lack of consensus defining precise indications for open revascularization (OR). Objectives To describe a series of 4 patients with CMI treated with OR and to present an algorithm for the management of this condition. Methods Three patients presented with typical intestinal angina and weight loss. One patient was subjected to prophylactic revascularization during open abdominal aortic aneurysm repair. Surgical techniques included: 1) Bypass from the infrarenal aorta to the SMA; 2) Bypass from an aorto-bifemoral polyester graft to the SMA; 3) Bypass from the right iliac artery to the SMA; 4) Bypass from the right graft limb of an aorto-biiliac polyester graft to the median colic artery at Riolan's arcade. PTFE was used in all surgeries. All grafts were placed in a retrograde configuration, tunneled under the left renal vein, making a smooth C-loop. A treatment algorithm was constructed based on the institution's experience and a review of recent literature. Results All patients demonstrated resolution of symptoms and recovery of body weight. All grafts are patent after mean follow-up of two years. Conclusions Open revascularization using the C-loop configuration is a valuable technique for CMI and may be considered in selected cases. The algorithm constructed may help decision planning in other quaternary centers.

Resumo Contexto A isquemia mesentérica crônica (IMC) é uma doença debilitante, com grave impacto na qualidade de vida. A literatura recomenda a angioplastia com stent da artéria mesentérica superior (AMS) como primeira opção de tratamento, mas há falta de consenso que defina indicações precisas para a revascularização aberta. Objetivos Descrever uma série de quatro pacientes com IMC, tratados com revascularização aberta, e apresentar um algoritmo para o manejo dessa condição. Métodos Três pacientes apresentaram angina intestinal típica e perda ponderal. Uma paciente foi submetida a reparo aberto de aneurisma da aorta abdominal e apresentava obstrução da AMS, que foi revascularizada profilaticamente. As técnicas cirúrgicas incluíram: 1) enxerto entre a aorta infrarrenal e a AMS; 2) enxerto entre o dácron utilizado em um enxerto aortobifemoral e a AMS; 3) enxerto entre a artéria ilíaca comum direita e a AMS; e 4) enxerto entre o ramo direito do dácron utilizado em um enxerto aorto-biilíaco e a artéria cólica média (ao nível da arcada de Riolan). Todos os enxertos foram feitos utilizando politetrafluoretileno em uma configuração retrógrada, tunelizados abaixo da veia renal esquerda, fazendo uma alça em C. Resultados Todos os pacientes demonstraram resolução dos sintomas e ganho ponderal. Todos os enxertos se mantiveram pérvios durante um seguimento médio de 2 anos. Conclusões A revascularização aberta para IMC utilizando-se a alça em C é uma técnica valiosa e pode ser considerada em pacientes selecionados. O algoritmo proposto pode auxiliar na decisão terapêutica em centros quaternários.

Oclusión intestinal por policitemia vera en una anciana / Intestinal occlusion due to polycythemia vera in an old woman

Se describe el caso clínico de una paciente de 67 años de edad con varias comorbilidades, entre ellas la policitemia vera, quien acudió al Cuerpo de Guardia del Hospital Clinicoquirúrgico Universitario Dr. Ambrosio Grillo Portuondo de Santiago de Cuba por presentar síntomas y signos de un síndrome de abdomen agudo oclusivo. Se indicó intervención quirúrgica de urgencia, que permitió confirmar el diagnóstico presuntivo de afección vascular mesentérica de tipo trombótica. La inmediatez del tratamiento quirúrgico, la reversibilidad del daño vascular sin necesidad de procedimiento de resección intestinal y la administración efectiva de anticoagulantes permitieron una evolución favorable y sin complicaciones.

The case report of a 67 years patient with several comorbidities is described, among them polycythemia vera, who went to the emergency room of Ambrosio Grillo Portuondo University Clinical Surgical Hospital in Santiago de Cuba due to symptoms and signs of a syndrome of occlusive acute abdomen. An emergency surgical intervention was indicated, that confirmed the presumptive diagnosis of mesenteric vascular thrombosis. The immediacy of the surgical treatment, the reversibility of the vascular damage without necessity of intestinal resection procedure and the effective use of anticoagulants allowed a favorable clinical course without complications.

Gastrite isquêmica grave por isquemia mesentérica crônica / Severe ischemic gastritis caused by chronic mesenteric ischemia

Resumo A gastrite isquêmica é uma doença rara, podendo ocorrer por insuficiência vascular focal ou sistêmica. Essa condição é raramente vista na prática médica devido à vasta rede colateral arterial do estômago pelo tronco celíaco e mesentérica superior. A apresentação clássica da isquemia crônica é formada pela tríade de dor pós-prandial, perda de peso e sopro abdominal. A intervenção está indicada naqueles pacientes sintomáticos, sendo o tratamento endovascular uma alternativa à cirurgia em pacientes com alta comorbidade, tendo bons resultados. Reportamos um caso de gastrite isquêmica grave com úlceras e sangramento que foi causado por isquemia mesentérica crônica, em uma paciente de 71 anos, com oclusão do tronco celíaco e mesentérica inferior, além de estenose crítica da superior. O diagnóstico foi confirmado por exame de imagem, e a paciente foi submetida a tratamento endovascular. Trata-se de uma condição rara de diagnóstico e tratamento desafiadores, a qual requer uma equipe multidisciplinar para o manejo adequado.

Abstract Ischemic gastritis is a rare illness caused by localized or systemic vascular insufficiency. This condition is rarely seen in medical practice due to the vast arterial collateral blood supply to the stomach through the celiac trunk and superior mesenteric artery and also because other etiologies are much more frequent. The classic presentation of chronic ischemia is comprises the triad of postprandial pain, weight loss, and abdominal bruit. Intervention is indicated in symptomatic patients and endovascular treatment is an alternative to surgery in patients with high comorbidity that offers good results. We report a case of a 71-year-old female patient with severe ischemic gastritis with ulcers and bleeding caused by chronic mesenteric ischemia with occlusion of the celiac trunk and inferior mesenteric artery and critical stenosis of the superior mesenteric artery. The diagnosis was confirmed by imaging, and the patient underwent endovascular treatment. This is a rare condition that is difficult to diagnose and treat and a multidisciplinary team is needed for proper management.

Acute mesenteric ischemia and COVID-19: an integrative review of the literature / Isquemia mesentérica aguda e COVID-19: uma revisão integrativa da literatura

ABSTRACT The novel coronavirus disease 2019 (COVID-19) has spread rapidly around the world after the first cases were reported in December 2019 in China. Despite the prevention of the symptoms presented, extrapulmonary manifestations were identified. In particular, there was an increase in cases of Acute Mesenteric Ischemia (AMI), raising its incidence to 1.9%-3.8% in infected patients. The aim of this study was to investigate the existence of an association between IMA and COVID-19 through the literature. An Integrative Literature Review was carried out. The research question was "mesenteric ischemia in patients with COVID-19: coincidence or association?". After searching the database and applying the inclusion and exclusion criteria, 44 were selected for analysis. COVID-19 was confirmed by RT-PCR and imaging tests, gastrointestinal manifestations, alterations and primarily tomographic imaging findings were identified. Most patients were accelerated to laparotomy. As explanations include direct endothelial and injury by the binding of the ACE-2 virus, between hyperinflammation and hypercoagulability, dysregulation of the renin-angiotensin-aldosterone system and factors associated with the severity of the virus. IMA is an emergency with high associated morbidity and mortality, these cases may be a consequence mainly of the thromboinflammatory mechanism associated with SARS-CoV-2. An early diagnosis, diagnosis and diagnoses are crucial to clinical treatment; an assessment regime should be considered in accordance with current evidence and guidelines.

RESUMO A doença do novo coronavírus 2019 (COVID-19) disseminou-se rapidamente pelo mundo após os primeiros casos serem relatados em dezembro de 2019 na China. Apesar da prevalência dos sintomas respiratórios, manifestações extrapulmonares foram sendo identificadas. Particularmente, houve um aumento de casos de Isquemia Mesentérica Aguda (IMA), elevando sua incidência para 1,9%-3,8% em pacientes infectados. O objetivo deste estudo foi investigar a existência de uma associação entre IMA e a COVID-19 através da literatura. Realizou-se uma Revisão Integrativa da Literatura. A pergunta de pesquisa foi "isquemia mesentérica em pacientes com COVID-19: coincidência ou associação?". Após a busca na base de dados e aplicação dos critérios de inclusão e exclusão, elegeu-se 44 estudos para análise. A COVID-19 foi confirmada por RT-PCR e exames de imagem, foram identificadas manifestações gastrointestinais, alterações laboratoriais e achados de imagem primordialmente tomográfica. A maioria dos pacientes foi submetida à laparotomia. As explicações incluem lesão endotelial direta pela ligação do vírus ao receptor ECA-2, correlação entre hiperinflamação e hipercoagulabilidade, desregulação do sistema renina-angiotensina-aldosterona e fatores associados à gravidade do quadro. A IMA é uma emergência de alta morbimortalidade associada, nesses casos pode ser consequência principalmente do mecanismo tromboinflamatório associado ao SARS-CoV-2. Um alto nível de suspeita clínica, diagnóstico e tratamento precoces são cruciais diante dessa complicação; um regime de anticoagulação deve ser considerado conforme as evidências e diretrizes vigentes..

Post-COVID-19 superior mesenteric artery and jejunal branches thromboembolism / Tromboembolismo de la arteria mesentérica superior y de las ramas yeyunales post-COVID-19

Abstract The World Health Organization has declared the novel coronavirus disease 2019 (COVID-19) a global public health emergency. Despite the predominating respiratory symptoms occurring in COVID-19, thrombosis can occur in some patients, with morbidity and mortality increase due to the respiratory worsening. This article reports the case of a 62-year-old man with a flu-like illness that was diagnosed as CO VID-19 by RT-PCR of SARS-CoV-2. After three weeks, he subsequently developed abdominal pain in addition to bloating, nausea, and vomiting. He underwent exploratory laparotomy after imaging tests suggested mesenteric ischemia. Intestinal ischemia was evident, due to the absence of flow in the superior mesenteric artery and jejunal branches. Embolectomy and enterectomy were performed and they resulted in a favorable outcome, with clinical improvement. This case adds data to the limited literature on extrapulmonary complications of COVID-19, notably those related to thromboembolic events.

Resumen La Organización Mundial de la Salud ha declarado la enfermedad del nuevo coronavirus 2019 (COVID-19) una emergencia de salud pública mundial. A pesar de los síntomas respiratorios predominantes en COVID-19, la trombosis puede ocurrir en algunos pacientes, con un aumento de la morbimortalidad debido al empeoramiento respiratorio. Presentamos el caso de un hombre de 62 años con enfermedad similar a la gripe que fue diagnosticada como COVID-19 por RT-PCR de SARS-CoV-2. Después de tres semanas, de sarrolló dolor abdominal además de hinchazón, náuseas y vómitos. Fue sometido a laparotomía exploradora luego de que las pruebas de imagen sugirieran isquemia mesentérica. Se evidenció isquemia intestinal por ausencia de flujo en la arteria mesentérica superior y ramas yeyunales. Se realizó embolectomía y enterec tomía con evolución favorable, con mejoría clínica. Este caso añade datos a la limitada literatura sobre las complicaciones extrapulmonares del COVID-19, en particular las relacionadas con eventos tromboembólicos.

Isquemia mesentérica aguda asociada a Covid-19: serie de casos

Introducción: Los pacientes con Covid-19 pueden presentar complicaciones serias como: tromboembolia pulmonar y la isquemia mesentérica aguda (IMA). Estos eventos trombóticos son más frecuentes en el contexto de la pandemia debido al estado de hiperinflamación e hipercoagulabilidad transitoria con la que cursan los pacientes. Reporte de casos: Se describe de casos de Covid-19 que cursaron con IMA en el norte de Perú. Son dos pacientes hombres de 48 y 67 años, con una evolución subaguda cursaban con síntomas respiratorios sin embargo en días posteriores sus cuadros empeoraron cursando con dolor abdominal, niveles elevados de dímero D y alteraciones de la coagulación. Ambos presentaron IMA sin embargo, no se sospechó de dicho diagnóstico sino hasta ser intervenidos quirúrgicamente. Pese a que el segundo paciente uso enoxaparina y se le intervino dentro de las 24horas su desenlace fue fatal. Conclusión: Ante un paciente con Covid-19 y síntomas gastrointestinales atípicos, se debe considerar esta enfermedad en el diagnóstico. Es importante saber reconocerlo tempranamente

Introduction: Patients with Covid-19 may present most serious complications, pulmonary thromboembolism and acute mesenteric ischemia (AMI) have been described. These thrombotic events are now more common in the context of the Covid-19 pandemic, because patients have to state of hyperinflammation and transient hypercoagulability. Case of Report: AMI manifestation are abdominal pain and other atypical gastrointestinal symptoms. Patients with severe and critical symptoms of Covid-19, have elevated levels of D-dimer and coagulation disorders. The paper described a fatal outcome of to two patients of Covid-19 that presented with mesenteric ischemia. The objective of this report is to emphasize the importance of early recognition of this complication, which has high mortality rates. The first series of Covid-19 cases that attended IMA in northern Peru is described. Two male patients, 48 and 67 years old, with a subacute course presented respiratory symptoms. However in subsequent days, their symptoms worsened presenting, with abdominal pain, high levels of D-dimer, and coagulation disorders. Both presented AMI, however, this diagnosis was not suspected until they were operated. Conclusion: The patients with Covid-19 who present atypical gastrointestinal symptoms, this disease should be considered in the diagnosis. It is important to know how to recognize it early

Morbilidad y mortalidad por isquemia mesentérica aguda en el Hospital Universitario "Arnaldo Milián Castro" / Mobility and Mortality for Acute Mesenteric Ischemia in "Arnaldo Milián Castro" University Hospital

Introducción: La isquemia mesentérica aguda es la condición clínica que aparece cuando el flujo sanguíneo del territorio mesentérico resulta insuficiente para satisfacer los requerimientos del intestino. Objetivo: Caracterizar la morbilidad y mortalidad de los pacientes con isquemia mesentérica aguda. Métodos: Se realizó un estudio observacional, descriptivo, transversal, en el Servicio de cirugía del Hospital Universitario "Arnaldo Milián Castro" de Santa Clara, Villa Clara desde enero del 2016 hasta diciembre del 2020. La muestra quedó constituida por 119 pacientes que cumplieron los criterios de inclusión y exclusión. Resultados: De los 119 pacientes que presentaron isquemia mesentérica aguda, predominaron pacientes con factores de riesgo mayores de 65 años 97 (81,5 por ciento), femeninos 61 (51,3 por ciento), fumadores 52 (43,7 por ciento), con hipertensión arterial 84 (70,6 por ciento), cardiopatía isquémica 57 (47,9 por ciento), diabetes mellitus 31 (26,1 por ciento) y enfermedad arterial periférica 20 (16,8 por ciento). Predominó el tratamiento quirúrgico: la laparotomía exploratoria y cierre 55 (46,3 por ciento). Las complicaciones más frecuentes encontradas: el fallo múltiple de órganos 25 (25,7 por ciento) en los pacientes fallecidos. En los hallazgos necrológicos predominó la trombosis arterioesclerótica de la arteria mesentérica superior. Conclusiones: La isquemia mesentérica resulta frecuente en pacientes con factores de riesgo como son la edad mayor de 65 años, el sexo femenino, el hábito tóxico del tabaquismo y las enfermedades crónicas no transmisibles tales como la hipertensión arterial, cardiopatía isquémica y la diabetes mellitus. El tratamiento más realizado es el quirúrgico (la laparotomía y el cierre). En la mayoría de las necropsias realizadas la trombosis de la arteria mesentérica superior es el mayor hallazgo en los informes necrológicos(AU)

Introduction: Acute mesenteric ischemia is the clinical condition that appears when the blood flow of the mesenteric area becomes insufficient to meet intestinal requirements. Objective: To characterize the morbidity and mortality of patients with acute mesenteric ischemia. Methods: An observational, descriptive and cross-sectional study was carried out in the surgery service of Arnaldo Milián Castro University Hospital of Santa Clara City, Villa Clara Province, Cuba, from January 2016 to December 2020. The sample consisted of 119 patients who met the inclusion and exclusion criteria. Results: Of the 119 patients who presented acute mesenteric ischemia, patients with risk factors predominated: older than 65 years (97; 81.5 percent), female (61; 51.3 percent), smokers (52; 43.7 percent), with arterial hypertension (84; 70.6 percent), ischemic heart disease (57; 47.9 percent), diabetes mellitus (31; 26.1 percent), and peripheral arterial disease (20; 16.8 percent). Surgical management predominated: exploratory laparotomy and closure (55; 46.3 percent). The most frequent complications were multiple organ failure (25; 25.7 percent) in the deceased patients. Among the necropsy findings, arteriosclerotic thrombosis of the superior mesenteric artery predominated. Conclusions: Mesenteric ischemia is frequent in patients with risk factors such as age over 65 years, the female sex, the toxic habit of smoking; as well as chronic noncommunicable diseases such as arterial hypertension, ischemic heart disease and diabetes mellitus. The most commonly performed procedure is surgery (laparotomy and closure). In most of the performed necropsies, thrombosis of the superior mesenteric artery is the main finding according to the necrology reports(AU)

Trombosis mesénterica asociada a infección por Sars-Cov-2 / Mesenteric thrombosis associated with Sars-Cov-2 infection

La enfermedad COVID-19 se caracteriza principalmente por manifestaciones clínicas respiratorias, que pueden ser leves hasta muy severas, sin embargo, hay un grupo de pacientes que pueden cursar con eventos tromboembólicos en cualquier parte del cuerpo. Se realizó una búsqueda de información científica en tres bases de datos PubMed, Scopus y Web of Science, con el objetivo de describir y analizar las potenciales causas de la trombosis mesentérica asociada a la infección por SARS-CoV-2, así como los resultados clínicos, de los pacientes que presentaron y fueron tratados por trombosis mesentérica durante el curso de la enfermedad. Se han reportado diferentes mecanismos fisiopatológicos de eventos tromboembólicos asociados a la COVID-19, dentro de ellos se mencionan el estado de hipercoagulabilidad, una mayor producción de factor Von Willebrand, la expresión de la enzima convertidora de angiotensina 2 en los enterocitos del intestino delgado, que como respuesta a la infección pueden liberar mediadores inflamatorios y el estado de shock presente en las dos terceras partes de los pacientes críticos. Los pacientes con la COVID-19 y sobre todo aquellos que cursan con estadios graves pueden tener diferentes mecanismos que confluyen o exacerban un estado de hipercoagulación, que puede puede afectar cualquier parte del cuerpo como los vasos mesentéricos y llevar a una isquemia gastrointestinal que comprometa su viabilidad y termine en una resección intestinal por necrosis(AU)

COVID-19 disease is mainly characterized by respiratory clinical manifestations, which can be light to very severe; however, there is a group of patients who can present with thromboembolic events in any part of the body. A search of scientific information in three databases, PubMed, Scopus and Web of Science, was carried out with the aim of describing and analyzing the potential causes of mesenteric thrombosis associated with SARS-CoV-2 infection, as well as the clinical outcomes of patients who presented and were treated for mesenteric thrombosis during the course of the disease. Different pathophysiological mechanisms of thromboembolic events associated with COVID-19 have been reported, among them the hyper-coagulable state, an increased production of Von Willebrand factor, the expression of angiotensin-converting enzyme 2 in small intestinal enterocytes, which in response to infection can release inflammatory mediators, and the state of shock present in two thirds of critically ill patients. Patients with COVID-19 and especially those with severe stages may have different mechanisms that converge or exacerbate a state of hyper-coagulation, which can affect any part of the body such as the mesenteric vessels and lead to gastrointestinal ischemia that compromises its viability and ends in intestinal resection due to necrosis(AU)

Gastritis enfisematosa como manifestación de isquemia mesentérica no oclusiva tras coartectomía / Emphysematous gastritis as a manifestation of non-occlusive mesenteric ischemia after coartectomy

Resumen Las intervenciones mayores en cirugía cardiovascular de pacientes con patología aórtica pueden traer como consecuencia el compromiso de la perfusión de órganos distantes al sitio de la cirugía, siendo el tracto gastrointestinal uno de los más sensibles a los cambios hemodinámicos, en especial en grupos extremos de edad con un alto riesgo de morbimortalidad. Se reporta el caso de una lactante con antecedente de síndrome de Turner, quien es llevada a corrección de coartación de aorta más hipoplasia del arco, presentando como complicación posoperatoria un cuadro de gastritis enfisematosa con compromiso sistémico, proceso que fue favorecido por bajo gasto cardiaco posterior a bomba y presencia de urosepsis temprana, todo lo cual fue interpretado como parte del espectro del síndrome de isquemia mesentérica no oclusiva. Su diagnóstico precoz hizo posible una pronta intervención, consistente en soporte nutricional parenteral, freno ácido, antibioticoterapia de amplio espectro y seguimiento radiológico estricto, logrando la resolución completa de su sintomatología, sin complicaciones a corto plazo. Este caso demuestra que la identificación de factores de riesgo de isquemia esplácnica, una alta sospecha clínica y un cuidadoso manejo médico permiten un desenlace favorable para una patología con una alta tasa de mortalidad y muy pocos casos reportados en población pediátrica.

Abstract Major interventions in cardiovascular surgery of patients with aortic pathology can result in the compromise of perfusion of organs distant from the surgery site, the gastrointestinal tract being one of the most sensitive to hemodynamic changes, especially in extreme age groups with a high risk of morbidity and mortality. The case of a young infant is reported, with a history of Turner syndrome, who is led to correction of aortic coarctation plus arch hypoplasia, presenting as a postoperative complication a picture of emphysematous gastritis with systemic compromise, a process that was favored by low cardiac output post-pump and the presence of early urosepsis, all of which was interpreted as part of the spectrum of non-occlusive mesenteric ischemia syndrome. Its early diagnosis made possible a prompt intervention consisting of parenteral nutritional support, acid brake, broad-spectrum antibiotic therapy and strict radiological follow-up, achieving complete resolution of her symptoms, without short-term complications. This case demonstrated that the identification of risk factors for splanchnic ischemia, a high clinical suspicion and careful medical management, allowed a favorable outcome for a disease with a high mortality rate and very few cases reported in the pediatric population.

Isquemia mesentérica: manejo endovascular

La isquemia mesentérica es una condición que puede volverse muy grave y ser letal, más aún en los casos agudos. Un tratamiento precoz es muy importante. Se presentaron cuatro casos consecutivos tratados por nuestro equipo con trombosis, o disección o aneurismas de arterias mesentérica superior y tronco celíaco, se revisaron las indicaciones y se evaluaron los tratamientos llevados a cabo. Se utilizaron procedimientos endovasculares en todos, técnicamente en forma exitosa, evitando que progrese a un desenlace peligroso. Hubo diversidad de técnicas endovasculares adaptándolas a cada caso. En ningún paciente se requirió un acceso quirúrgico abierto para completar el tratamiento realizando las intervenciones prontas. El manejo endovascular de las lesiones mesentéricas es factible y replicable, y en nuestros casos podría haber prevenido una necrosis intestinal así como la necesidad de cirugías resectivas.

SUMMARY Mesenteric ischaemia is a condition that may be very severe and potentially lethal particularly in the acute presentation. Early treatment is crucial. We present four consecutive cases managed by our team with thrombosis or dissection or aneurysm of the superior mesenteric artery and the celiac trunk reviewing indications and treatment implemented. Multiple successful endovascular procedures were used in all cases avoiding progression to lethal consequences. None of the patients required an open surgical procedure. Therefore, endovascular procedures are feasible in these patients avoiding intestinal necrosis as well as the need for open surgeries.

Factores diferenciales entre las etapas evolutivas de la isquemia mesentérica aguda / Differential factors between the acute mesenteric ischemia evolutive stages

RESUMEN Fundamento: la isquemia mesentérica aguda tiene una elevada letalidad debido a la rápida evolución de su etapa temprana a la tardía, la larvada sintomatología en su fase inicial y por la complejidad del tratamiento. Objetivo: determinar las diferencias clínicas, de laboratorio, imagenológicas y evolutivas entre las etapas de la isquemia mesentérica aguda. Métodos: se realizó un estudio observacional, analítico transversal que incluyó un universo de 32 pacientes con isquemia mesentérica aguda, desde diciembre de 2015 a marzo de 2018, en el Hospital General Universitario Vladimir Ilich Lenin. Resultados: la reacción peritoneal se asoció de forma muy significativa a la etapa avanzada. La mayor parte de los pacientes con isquemia intestinal no presentaron niveles hidroaéreos, al contrario de los diagnosticados con necrosis. Todos los afectados con fibrilación auricular se encontraron en la etapa tardía. El valor medio del pH fue mayor en la etapa inicial, mientras que el valor del lactato en la fase tardía duplicó el valor medio de los casos isquémicos. La diferencia de medias de estos valores entre ambas fases de la enfermedad fue estadísticamente muy significativa. Fallecieron todos los casos con necrosis intestinal y más de dos tercios de los afectados con isquemia intestinal. Conclusiones: el retardo en el diagnóstico se asoció a una elevada mortalidad. La sospecha clínica temprana de abdomen agudo, la valoración de parámetros hemodinámicos y la identificación de factores de riesgo como la fibrilación auricular, favorecen el tratamiento oportuno en etapa isquémica y la posibilidad de supervivencia.

ABSTRACT Background: the acute mesenteric ischemia is a highly lethal disease, mainly due to the rapid evolution from its premature stage to the late one, the symptomatology in its start-up period and for the complexity of its management. Objective: to determine the clinical, laboratory, imagenological and evolutionary differences between the stages of the disease. Methods: an analytical transversal study was carried out. The universe was composed by 32 patients with acute mesenteric ischemia positive diagnosis in the period from December 2015 to March 2018, in Vladimir Ilich Lenin General Hospital. Results: peritoneal reaction is linked to the advanced stage in a highly significant way. There were no air-fluid levels in most of the ischemic patients, unlike the nechrosis stage, where levels were present in most of the patients. The difference between the pH and lactate average values in both of disease phases were statistically highly significant. All the cases with atrial fibrillation were dianosed in the late stage. All the patients with intestinal necrosis and more than 2/3 of the affected with intestinal ischemia perished. Conclusions: the delay in diagnosis was associated with high mortality. The early clinical suspicion of an acute abdomen, the assessment of hemodynamic parameters and the identification of risk factors such as atrial fibrillation, favor timely treatment in the ischemic stage and the possibility of survival.

Late mesenteric ischemia after Sars-Cov-2 infection: case report / Isquemia mesentérica tardia após infecção por Sars-Cov-2: relato de caso

Abstract The purpose of this article is to report the case of a 53-year-old black man, with no previous comorbidities, who presented 48 days after a confirmed diagnosis of COVID-19, complaining of an initially insidious epigastric pain that had progressed to severe pain radiating to the interscapular vertebral region, with hyporexia and episodes of projectile vomiting, with no nausea or fever. Laboratory tests revealed no signs of acute infection or pancreatic injury. Abdominal computed tomography showed dilated, fluid-filled small bowel loops with thickened walls. After clinical treatment, the patient developed persistent abdominal pain. An exploratory laparotomy was performed, finding two sites of small bowel stenosis, with no extrinsic cause, and signs of local ischemia and considerable distension of jejunal and ileal loops. After enterectomy and side-to-side enteroanastomosis, the patient recovered satisfactorily and was discharged with a prescription for oral anticoagulants for outpatient use.

Resumo O objetivo deste artigo é relatar o caso de um homem de 53 anos de idade, negro, sem comorbidades prévias, com diagnóstico confirmado de COVID-19 há 48 dias anteriores ao início do quadro de dor epigástrica insidiosa, que evoluiu para dor de forte intensidade que irradiava para região interescapulovertebral, associada a hiporexia e episódios de vômitos em jato, sem náuseas ou febre. Os exames laboratoriais não apresentavam sinais de infecção aguda ou lesão pancreática. A tomografia computadorizada do abdome mostrou alças do intestino delgado dilatadas, cheias de líquido e com paredes espessas. Após terapia de suporte, o paciente evoluiu com dor abdominal persistente. Foi realizada laparotomia exploratória, na qual foram encontrados dois sítios de estenose no intestino delgado sem causa extrínseca, ao lado de sinais de isquemia local e distensão importante das alças jejunais e ileais. Após enterectomia e enteroanastomose primária látero-lateral, o paciente evoluiu de forma satisfatória e recebeu alta hospitalar com prescrição de anticoagulantes orais para uso ambulatorial.

Tromboembolismo de la arteria mesentérica inferior con necrosis del territorio de la arteria rectal superior / Thromboembolism of the inferior mesenteric artery with necrosis of the territory of the superior rectal artery

RESUMEN Fundamento: la elevada mortalidad de la isquemia intestinal obliga a llevar a cabo un esfuerzo de coordinación a todos los niveles al actuar con celeridad. Las isquemias segmentarias son menos comunes y lo son, aún más, las del territorio de la arteria mesentérica inferior. Objetivo: exponer un caso poco frecuente de isquemia de la unión rectosigmoidea, provocado por un embolismo de la arteria mesentérica inferior y subsiguiente necrosis del territorio de la rectal superior. Presentación de caso: paciente femenina 76 años de edad ingresada desde hacía 31 días con diagnóstico de enfermedad cerebrovascular tipo infarto cerebral, que el día que se decide su egreso presenta un cuadro sincopal, presentando luego; dolor, distensión y contractura abdominal en cuadrante inferior izquierdo por lo que es intervenida quirúrgicamente, se encontró una necrosis del recto superior y sigmoides bajo (unión rectosigmoidea). Conclusiones: el embolismo de la arteria mesentérica inferior con necrosis segmentaria es una presentación muy rara de esta afección, en la literatura los casos reportados son escasos, esto se debe a las consideraciones anatómicas de las arterias y venas mesentéricas, cuando ocurre la oclusión de las arteria mesentérica inferior suele ser lenta y progresiva con revascularización o si es de forma abrupta la arteria mesentérica superior suple las necesidades de este territorio mediante la arteria de Drummont, lo cual ocurrió en esta paciente pero no con su arteria terminal (punto crítico de Sudeck) necrosándose el rectosigmoides.

ABSTRACT Background: the high mortality of intestinal ischemia requires an effort of coordination at all levels, requiring prompt action. Segmental ischemias are less common and, more so, those of the territory of the inferior mesenteric artery. Objective: to present a rare case of ischemia of the rectosigmoid junction, caused by an embolism of the inferior mesenteric artery and subsequent necrosis of the upper rectal territory. Case presentation: 76-year-old female patient admitted for 31 days with a diagnosis of cerebral infarction-type cerebrovascular disease, which on the day her discharge is decided presents a syncopal picture, presenting later; pain, abdominal distension and contracture in the lower left quadrant, so she undergoes a surgery finding a necrosis of the upper rectum and low sigmoid (recto-sigmoid union). Conclusions: the embolism of the inferior mesenteric artery with segmental necrosis is a very rare presentation of this affection, in the literature the cases reported are scarce, this is due to the anatomical considerations of the mesenteric arteries and veins, when occlusion of the inferior mesenteric artery occurs is usually slow and progressive with revascularization or if abruptly the superior mesenteric artery supplies the needs of this territory through the Drummont artery, which occurred in this patient but not with her terminal artery (Sudeck's critical point) recto-sigmoid necrosis.

Isquemia mesentérica aguda: a propósito de un caso / Acute mesenteric ischemia: a purpose of a case

La isquemia mesentérica aguda (IMA) es consecuencia de la oclusión de la arteria mesentérica superior (AMS) por trombosis o embolia, y es considerada la más letal del síndrome de abdomen agudo. Se presenta el caso de paciente femenina de 69 años con clínica difusa y confirmación diagnóstica radiológica, El objetivo de este caso clínico es proporcionar una revisión bibliográfica actual del tema y facilitar la adecuada actuación ante este problema de salud de amplio compromiso sistémico, y de aparición no tan infrecuente. (AU)

Acute mesenteric ischemia (IMA) is a consequence of occlusion of the superior mesenteric artery (AMS) by thrombosis or embolism; and it is considered the most lethal of acute abdomen syndrome. The case of a 69 years old female patient with diffuse clinic and radiological diagnostic confirmation is presented. The objective of this clinical case is to provide a current bibliographic review of the topic and facilitate adequate action in the face of this health problem with a broad systemic commitment, and with no appearance so infrequent. (AU)

Unidad de Medicina Fetal Hospital Regional "Rio Gallegos" Santa Cruz Argentina. Experiencia de trabajo Estadística Febrero/Diciembre 2019 / FETAL UNIT. HOSPITAL REGIONAL "RIO GALLEGOS". SANTA CRUZ ARGENTINA. EXPERIENCIA DE TRABAJO ESTADÍSTICA FEBRERO/DICIEMBRE 2019

La isquemia mesentérica aguda (IMA) es consecuencia de la oclusión de la arteria mesentérica superior (AMS) por trombosis o embolia, es considerada como la más letal del síndrome de abdomen agudo. Se presenta el caso de paciente femenina de 69 años con clínica difusa y confirmación diagnóstica radiológica, El objetivo de este caso clínico es proporcionar una revisión bibliográfica actual del tema y facilitar la adecuada actuación ante este problema de salud de amplio compromiso sistémico, de aparición no tan infrecuente.

Acute mesenteric ischemia (IMA) is a consequence of occlusion of the superior mesenteric artery (AMS) by thrombosis or embolism, it is considered the most lethal of acute abdomen syndrome. The case of a 69-year-old female patient with diffuse clinic and radiological diagnostic confirmation is presented. The objective of this clinical case is to provide a current bibliographic review of the topic and facilitate adequate action in the face of this health problem with a broad systemic commitment, with no appearance. so infrequent.

Trombosis porto-mesentérica aislada secundaria a trauma abdominal cerrado / Isolated porto-mesenteric thrombosis secondary to blunt abdominal trauma

En este artículo se revisan los aspectos más importantes de la epidemiología, fisiopatología, abordaje diagnóstico y terapéutico de la trombosis del sistema venoso portal y mesentérico, para finalizar discutiendo la experiencia clínica de un caso a la luz de la literatura relevante. Esta complicación es usualmente relacionada con afecciones sistémicas y hepáticas, pero rara vez se presenta aislada y relacionada con el trauma. En ausencia de tratamiento adecuado durante la etapa aguda, la trombosis puede evolucionar hacia el infarto intestinal y la muerte del paciente. En casos crónicos, se ha asociado con la degeneración del sistema venoso portal hacia cambios por hipertensión portal crónica

This article reviews the epidemiology, pathophysiology, diagnostic and therapeutic approach of the portal and mesenteric venous system thrombosis, with a clinical case discussion considering the relevant literature. This complication is usually related to systemic and hepatic conditions, but rarely occurs isolated and related to trauma. In the absence of adequate treatment during the acute stage, thrombosis can progress to intestinal infarction and death. In chronic cases, it has been associated with degeneration of the portal venous system into changes due to chronic portal hypertension

Protein C and S deficiency as a cause of mesenteric thrombosis: Differential diagnosis of systemic vasculitis / Deficiencia de proteínas C y S como causa de trombosis mesentérica: diagnóstico diferencial de las vasculitis sistémicas

ABSTRACT Acute mesenteric ischemia is a medical emergency that accounts for less than 1/1000 hospital admissions. The disease affects adults older than 50 years predominantly with cardiac compromise, in whom the presence of acute abdominal pain is the cardinal manifestation, and should make the clinician suspect this entity. Its presentation in adolescents is unusual; therefore, in these cases, the possibility of an underlying thrombophilia should be part of the differential diagnosis. The case is presented here of a young female with a protein C and S deficiency as the cause of mesenteric thrombosis.

RESUMEN La isquemia mesentérica aguda es una urgencia médica que se presenta en menos de 1/1.000 ingresos hospitalarios. Es una entidad clínica infrecuente, predominante en adultos mayores de 50 arios con afectación cardíaca, en quienes la presencia de dolor abdominal agudo es la manifestación cardinal y debería hacer sospechar dicho diagnóstico. La presentación en adolescentes es inusual, por lo que, en estos casos, la posibilidad de una trombofilia subyacente debe formar parte del diagnóstico diferencial. Presentamos el caso de una paciente joven con deficiencia de proteínas C y S como agente causal de trombosis mesentérica.

Enterocolitis necrotizante del adulto, ¿una presentación atípica de la isquemia mesentérica? / Adult necrotizing enterocolitis, an atypical presentation of mesenteric ischemia?

La enterocolitis necrosante en adultos (ECNA) es una enfermedad de etiología incierta, muy infrecuente, con apenas casos descritos en la literatura y con elevada mortalidad. Existe una fuerte correlación entre eventos vasculares e infecciosos implicados en la patogenia de necrosis intestinal masiva en esta entidad.

Necrotizing enterocolitis in adults (ECNA) is a disease of uncertain etiology, very rare, with very few cases described in the literature and with high mortality. There is a strong correlation between vascular and infectious events involved in the pathogenesis of massive intestinal necrosis in this entity.

Isquemia de ciego como hallazgo no esperado / Cecum blind ischemia as an unexpected finding

RESUMEN Las patologías isquémicas a nivel de colon tienen una clínica poco característica, por ello, son de difícil diagnóstico. Se reporta a un paciente, con antecedente de hipertensión arterial, que presenta dolor abdominal de 12 horas de evolución, localizado en fosa iliaca derecha sin irradiación, tipo cólico, de moderada intensidad, sin síntomas acompañantes. Al examen físico presenta abdomen depresible, doloroso a palpación profunda, signos de Mc Burney, Rovsing y Blumberg positivos. El hemograma reporta leucocitosis 12.900/mm3 con neutrofilia 82,9%. Se diagnostica apendicitis aguda y se planea apendicetomía, pero el cirujano constata apéndice cecal grado II, base apendicular en buen estado, asas intestinales distendidas e isquemia en la cara anterior del ciego, siendo este hallazgo importante para cambiar la conducta de la cirugía a una ileostomía de urgencia. Se considera que es de importancia conocer los patrones evolutivos de la isquemia de colon y los factores que predicen su curso desfavorable y mortalidad.

ABSTRACT The colon ischemic pathologies have scare clinical features and are difficult to diagnose. We report a case of a with history of arterial hypertension, who presents with abdominal pain of 12 hours in the right iliac fossa without radiation, colic type, of moderate intensity, without other accompanying symptoms. On physical examination the abdomen was soft depressible, painful to deep palpation, signs of Mc Burney, Rovsing and Blumberg were positives. The hemogram reported leukocytosis 12900 with neutrophilia 82.9%. It is diagnosed as acute appendicitis and was planned an appendectomy. The surgeon reported an cecal appendix grade II, good appendicular base, distended bowel loops and ischemia on the anterior face of the cecum, being the cast finding an important one to change the planned surgery to an ileostomy urgent. We consider an important to fact know the evolution patterns of colon ischemia and factors that predict its unfavorable course and mortality.