Establishment of an acute arterial mesenteric ischaemia model in canines with an endovascular approach.

Purpose: This study aimed to evaluate the feasibility of establishing an arterial acute mesenteric ischemia (AMI) model in canines using transcatheter autologous thrombus administration. Materials and methods: Ten canines were divided into the experimental group (Group A, n = 5) and the sham group (Group B, n = 5). The canines in Group A received thrombus administration to the superior mesenteric artery (SMA) through a guiding catheter, while the canines in Group B received normal saline administration. Blood samples were collected and tested at baseline and 2 h after modelling. Canines in Group A underwent manual thromboaspiration after blood and intestine samples were collected. Ischaemic grades of intestinal mucosa were evaluated under light microscopes. Results: The AMI models were successfully conducted in all canines without procedure-related vessel injury or death. At the 2-h follow-up, the high-sensitivity C-reactive protein and D-dimer in Group A were significantly higher than in Group B (5.72 ± 1.8 mg/L vs. 2.82 ± 1.5 mg/L, p = 0.024; 2.25 ± 0.8 µg/mL vs. 0.27 ± 0.10 µg/mL, p = 0.005; respectively). The mean histopathologic intestinal ischaemic grade in Group A was significantly higher than in Group B (2.4 ± 0.5 vs. 0.8 ± 0.4, p < 0.001). After a median of 2 times of thromboaspiration, 80% (4/5) of the canines achieved complete SMA revascularisation. Conclusion: This experimental study demonstrated that establishing an arterial model in canines using endovascular approaches was feasible. The present model may play an important role in the investigation of endovascular techniques in the treatment of arterial AMI.

Quain Hernia Masquerading as Mesenteric Ischemia.

The case describes a rare instance of Quain hernia, a specific type of internal hernia where the bowel protrudes through a defect in the broad ligament. Broad ligament defects can either be congenital or acquired. Quain hernias are uncommon and difficult to diagnose due to nonspecific symptoms. We report a case of a Quain hernia initially diagnosed as mesenteric ischemia with small bowel gangrene. If a Quain hernia is suspected, immediate diagnostic laparoscopy is recommended, as it is an effective diagnostic tool and definitive management method, regardless of the specific type. During the laparoscopic procedure, it is crucial to thoroughly assess the contralateral broad ligament to identify any defects, which should be repaired prophylactically if found. Understanding their rare presentation and distinctive radiological features is vital for prompt diagnosis and appropriate management, highlighting the need to consider uncommon etiologies in acute abdominal cases to optimize patient outcomes.

Optimizing Outcomes for Acute Mesenteric Ischemia in the Context of Hypogammaglobulinemia: A Detailed Analysis of Surgical and Medical Strategies.

Acute mesenteric ischemia is a critical condition marked by a sudden loss of blood supply to the intestines, often leading to rapid tissue necrosis and severe clinical outcomes if untreated. In the context of hypogammaglobulinemia, an immunodeficiency characterized by decreased levels of immunoglobulins, this vascular emergency becomes even more daunting. Hypogammaglobulinemia can impair the immune system's response to both infection and ischemic injury, intensifying the severity of intestinal damage. This report describes the case of a 52-year-old female with hypogammaglobulinemia who presented with severe abdominal pain. Surgical exploration revealed 100 cm of necrotic small bowel extending from 150 cm distal to the ligament of Treitz to within 10 cm of the ileocecal valve. The necrotic section was surgically removed, and primary anastomosis was performed. This instance highlights the significant impact of immunodeficiency on the progression and management of acute mesenteric ischemia, demonstrating the critical need for early intervention and tailored management strategies, especially in immunocompromised patients, to prevent severe outcomes. The case illuminates the importance of recognizing immunodeficiency as a complicating factor in acute gastrointestinal emergencies, stressing the necessity for prompt and effective medical and surgical interventions to improve prognosis and patient outcomes in complex clinical scenarios.

CT evaluation of bowel wall enhancement in pneumatosis intestinalis: preventing non-therapeutic laparotomies.

PURPOSE: To evaluate the diagnostic performance of bowel wall enhancement for diagnosing concomitant bowel ischemia in patients with parietal pneumatosis (PI) diagnosed at abdominal CT. MATERIALS AND METHODS: From January 1, 2012 to December 31, 2021, 226 consecutive patients who presented with PI on abdominal CT from any bowel segment were included. Variables at the time of the CT were retrospectively extracted from medical charts. CT examinations were blindly analyzed by two independent radiologists. The third reader classified all disagreement of bowel enhancement in three categories: (1) normal bowel enhancement; (2) doubtful bowel wall enhancement; (3) absent bowel wall enhancement. Multivariable logistic regression analysis was performed. Concomitant bowel ischemia was defined as requirement of bowel resection specifically due to ischemic lesion in operated patients and death from bowel ischemia in non-operated patients. RESULTS: Overall, 78/226 (35%) patients had PI associated with concomitant bowel ischemia. At multivariate analysis, Only absence or doubtful bowel wall enhancement was associated with concomitant bowel ischemia (OR = 167.73 95%CI [23.39-4349.81], P < 0,001) and acute mesenteric ischemia associated with PP (OR = 67.94; 95%CI [5.18-3262.36], P < 0.009). Among the 82 patients who underwent a laparotomy for suspected bowel ischemia, rate of non-therapeutic laparotomy increased from 15/59 (25%), 2/6 (50%) and 16/17 (94%) when bowel wall enhancement was absent, doubtful and normal respectively. CONCLUSION: Absence of enhancement of the bowel wall is the primary feature associated with concomitant bowel ischemia. It should be carefully assessed when PI is detected to avoid non-therapeutic laparotomy.

Preoperative risk factors for 90-day postoperative mortality outcome in patients with non-occlusive mesenteric ischemia.

PURPOSE: The mortality rate for non-occlusive mesenteric ischemia remains high even after patients survive the acute postoperative period with tremendous treatment efforts, including emergency surgery, which is challenging. The aim of this study was to explore the preoperative risk factors for 90-day postoperative mortality in patients with non-occlusive mesenteric ischemia. METHODS: This single-center, retrospective cohort study included patients diagnosed with non-occlusive mesenteric ischemia who underwent emergency surgery between August 2014 and January 2023. All patients were divided into survival-to-discharge and mortality outcome groups at the 90-day postoperative follow-up. Preoperative factors, including comorbidities, preoperative status of vital signs and consciousness, blood gas analysis, blood test results, and computed tomography, were compared between the two groups. RESULTS: Twenty patients were eligible, and 90-day mortality was observed in 10 patients (50%). The mortality outcome group had significantly lower HCO3- (20.9 vs. 14.6, p = 0.006) and higher lactate (4.4 vs. 9.4, p = 0.023) levels than did the survival outcome group. The median postoperative time to death was 19 [2-69] days, and five patients (50%) died after postoperative day 30, mainly because hemodialysis was discontinued because of hemodynamic instability in patients requiring hemodialysis. CONCLUSION: Low preoperative HCO3- and high lactate levels may be preoperative risk factors for 90-day postoperative mortality in patients with non-occlusive mesenteric ischemia. However, patients on hemodialysis die from discontinuing hemodialysis even after surviving the acute postoperative phase. Therefore, indications for emergency surgery in patients with risk factors for postoperative mortality should be carefully determined.

Association between Postoperative Adjuvant Vasodilator Therapy and In-Hospital Mortality for Non-Occlusive Mesenteric Ischemia: A Nationwide Observational Study.

BACKGROUND: Although several clinical guidelines recommend vasodilator therapy for non-occlusive mesenteric ischemia (NOMI) and immediate surgery when bowel necrosis is suspected, these recommendations are based on limited evidence. METHODS: In this retrospective nationwide observational study, we used information from the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018 to identify patients with NOMI who underwent abdominal surgeries on the day of admission. We compared patients who received postoperative vasodilator therapy (vasodilator group) with those who did not (control group). Vasodilator therapy was defined as venous and/or arterial administration of papaverine and/or prostaglandin E1 within 2 days of admission. The primary outcome was in-hospital mortality. Secondary outcomes included the prevalence of additional abdominal surgery performed ≥3 days after admission and short bowel syndrome. RESULTS: We identified 928 eligible patients (149 in the vasodilator group and 779 in the control group). One-to-four propensity score matching yielded 149 and 596 patients for the vasodilator and control groups, respectively. There was no significant difference in in-hospital mortality between the groups (control vs. vasodilator, 27.5% vs. 30.9%; risk difference, 3.4%; 95% confidence interval, -4.9 to 11.6; p=0.42) and no significant difference in the prevalences of abdominal surgery, bowel resection ≥3 days after admission, and short bowel syndrome. CONCLUSIONS: Postoperative vasodilator use was not significantly associated with a reduction in in-hospital mortality or additional abdominal surgery performed ≥3 days after admission in surgically treated NOMI patients.

The growing trend of vascular intestinal disorder in young individuals: a 20-year analysis.

Background: Vascular intestinal disorder (VID) is a condition with a low incidence, but a high mortality risk. The increasing prevalence of substance abuse and metabolic syndrome among young individuals could impact the burden of VID. This study aimed to evaluate the impact of VID on young individuals. Methods: Our study harnessed data from the Global Burden of Disease study, spanning 2000 to 2019. With this extensive dataset, we conducted a comprehensive analysis of the prevalence, mortality rates, and impact on disability-adjusted life years (DALYs) related to VID among young individuals aged 15 to 49 years. Results: Globally, there were an estimated 32,628 cases, 3869 deaths, and 201,099 million DALYs attributed to VID in young individuals. Geographically, the regions of America had the highest burden of VID in young individuals. From 2000-2019, there was an increasing prevalence in all areas, with the most pronounced change observed in Southeast Asia (annual percentage change [APC] +2.17%, P<0.001). Over the study period, there was a more rapid increase in prevalence in males (APC +0.82%, P<0.001) than in females (APC +0.59%, P<0.001). Rates of death and DALYs declined in most regions, except for the Eastern Mediterranean region, where there was a slight increase (APC +0.85%, P<0.001 and 0.88%, P<0.001, respectively). Conclusion: Over the past decade, the burden of VID in young individuals has been increasing, particularly in Southeast Asia and the Eastern Mediterranean region, necessitating immediate and inclusive measures to tackle the rising burden.

Acute Mesenteric Ischemia Mimicking Severe COVID-19 Pneumonia: A Case Report on Diagnostic Challenges and Management.

This article demonstrates the need for abdominal imaging in COVID-19 patients with systemic symptoms in the differential diagnosis of acute mesenteric ischemia and critical COVID-19 pneumonia. We detail the case of a 91-year-old man, initially diagnosed with severe COVID-19 pneumonia, who was later found to have acute mesenteric ischemia through abdominal CT imaging, despite lacking typical abdominal symptoms. Abdominal CT revealed intramural and portal emphysema, leading to a diagnosis of acute mesenteric ischemia. Given the patient's advanced age and poor condition, supportive care was chosen, with the patient passing away 12 hours post-admission. This case highlights the critical need for comprehensive evaluation, including abdominal imaging, in COVID-19 patients with systemic symptoms to identify other serious conditions like acute mesenteric ischemia, especially in the absence of specific abdominal pain. Early detection is vital for appropriate management and improved patient outcomes.

Postprandial abdominal pain and weight loss as the initial presentation of abdominal neuroendocrine tumor recurrence.

Key Clinical Message: Neuroendocrine tumors, rare and slow-growing, primarily affect the gastrointestinal tract, causing symptoms due to hormone secretion or mass effect. This case image described postprandial abdominal pain as an atypical initial presentation of abdominal neuroendocrine tumor recurrence in a middle-aged male. Abstract: Neuroendocrine tumors are a group of rare, slow-growing neoplasms, most commonly affecting the gastrointestinal tract. Clinical presentations include symptoms related to the mass or hypersecretion of hormones, such as flushing, diarrhea, or bronchoconstriction. Postprandial abdominal pain is most commonly related to chronic mesenteric ischemia from atherosclerotic changes but is rarely linked to external mass compression, including gastrointestinal tumors. Hereby, the authors highlight an uncommon presentation of NET, which is very challenging to diagnose and demands a high index of suspicion.

Fulminant Non-occlusive Mesenteric Ischemia After Head Trauma: Report of Two Cases.

There have been no case reports of non-occlusive mesenteric ischemia (NOMI) following head trauma. Our two patients with non-surgical traumatic intracerebral hemorrhage succumbed to NOMI one week after the injury. Both were women over age 80 years and were clinically improving before NOMI occurred. One patient had been eating since admission, while the other had not, which prompted the initiation of enteral nutrition on day 5. The patients shared many characteristics: 1) over age 80 years; 2) minor brain contusion; 3) constipation for a week; 4) minimal abdominal symptoms; 5) rapidly developing leukocytosis, hyperglycemia, hypernatremia, and elevated blood urea nitrogen; 6) massive diarrhea with a small amount of blood on the same day that laboratory data became abnormal; and 7) fever and shock developed shortly after diarrhea appeared. Because of the fulminant worsening of the condition, shock status, and old age, surgical intervention was considered high risk and not performed in either patient. In retrospect, if NOMI had been diagnosed earlier when the acute pancreatitis-like symptoms began, surgical intervention may have saved their lives. Clinicians should be aware that NOMI can occur after relatively minor head trauma, which can cause death if the diagnosis is delayed.

A rare cause of abdominal pain in pregnancy - mesenteric artery thrombosis and miscarriage in a 34-year-old patient.

BACKGROUND: Mesenteric arterial thrombosis is an extremely rare thrombotic event, especially during pregnancy, that can cause rapid fatal consequences unless the patient receives early definitive treatment. CASE PRESENTATION: We report the case of a 34-year-old female presenting in her seventh week of gestation with severe abdominal pain who was promptly diagnosed with mesenteric artery occlusion amidst incipient miscarriage. The patient underwent a successful mesentery artery embolectomy, recovered and was later diagnosed with elevated factor VIII activity. CONCLUSION: The diagnosis of mesenteric ischemia should be considered in pregnant women presenting with severe abdominal pain and any prior predisposing factors. Our case highlights the pivotal role of the emergency physician in maintaining a high index of suspicion coupled with timely and determined action. The prognosis of this high mortality condition depends on prompt diagnosis, early definite management and successful multidisciplinary cooperation.

Copenhagen Mesenteric stent study (COMESS)-a randomized trial of stent versus covered stent treatment for chronic mesenteric ischemia.

BACKGROUND: Current management of mesenteric ischemia is primarily endovascular stent treatment. Typical CMI symptoms are postprandial abdominal pain, food fear, weight loss, and diarrhea. Revascularization is often necessary, as mesenteric ischemia may progress to bowel necrosis and death if left untreated. This study aims to compare the outcome using bare metal stent (BMS) or covered stent (CS) in the endovascular treatment of chronic and acute on chronic mesenteric ischemia. METHODS: This is an investigator-driven, prospective, randomized, single-blinded, and single-center, national cohort study at the Copenhagen University Hospital, Denmark. A total of 98 patients with chronic mesenteric ischemia (CMI) and acute-on-chronic mesenteric ischemia (AoCMI) will be randomized to treatment with either BeSmooth BMS (Bentley Innomed GmbH) or BeGraft CS (Bentley Innomed GmbH). Randomization occurs intraoperatively after lesion crossing. DISCUSSION: There is currently no published data from prospective controlled trials regarding the preferred type of stent used for the treatment of chronic and acute-on-chronic mesenteric ischemia. This trial will evaluate the short- and long-term outcome of BMS versus CS when treating CMI and AoCMI, as well as the benefit of a more intense postoperative surveillance program. TRIAL REGISTRATION: ClinicalTrials.gov NCT05244629. Registered on February 8, 2022.

Reperfusion Injury-Postendovascular Recanalization in Chronic Mesenteric Ischemia: A Rare Clinical Case Scenario.

Regardless of the number of vessels involved endovascular recanalization of mesenteric vessels is the treatment of choice for chronic mesenteric ischemia. Reperfusion injury post-endovascular recanalization in chronic mesenteric ischemia is a rare clinical scenario as it is mostly encountered in cases of acute mesenteric ischemia. Here in, we describe a case with characteristic clinical and imaging findings of reperfusion syndrome, post-endovascular recanalization of chronically occluded superior mesenteric artery and severely stenosed celiac trunk in a patient with chronic mesenteric ischemia.

A case of contained rupture of the superior mesenteric artery with no distal flow causing mesenteric ischemia following double heart valve replacement surgery.

A visceral artery aneurysm (VAA) is a very rare and lethal vascular anomaly with dramatic consequences. The overall incidence of VAA is 5% of all abdominal artery aneurysms. The involvement of the superior mesenteric artery is even rare (incidence of 3.5-8% of all VAA). The development of superior mesenteric artery pseudoaneurysm following cardiac surgery is scarcely reported in the literature. We report a case of contained rupture of the superior mesenteric artery with no distal flow causing acute mesenteric ischemia (AMI) following double heart valve replacement surgery.

Diagnostic Role of Multi-Detector Computed Tomography in Acute Mesenteric Ischemia.

Mesenteric ischemia diagnosis is challenging, with an overall mortality of up to 50% of cases despite advances in treatment. The main problem that affects the outcome is delayed diagnosis because of non-specific clinical presentation. Multi-Detector CT Angiography (MDCTA) is the first-line investigation for the suspected diagnosis of vascular abdominal pathologies and the diagnostic test of choice in suspected mesenteric bowel ischemia. MDCTA can accurately detect the presence of arterial and venous thrombosis, determine the extent and the gastrointestinal tract involved, and provide detailed information determining the subtype and the stage progression of the diseases, helping clinicians and surgeons with appropriate management. CT (Computed Tomography) can differentiate forms that are still susceptible to pharmacological or interventional treatment (NOM = non-operative management) from advanced disease with transmural necrosis in which a surgical approach is required. Knowledge of CT imaging patterns and corresponding vascular pathways is mandatory in emergency settings to reach a prompt and accurate diagnosis. The aims of this paper are 1. to provide technical information about the optimal CTA (CT Angiography) protocol; 2. to explain the CTA arterial and venous supply to the gastrointestinal tract and the relevant ischemic pattern; and 3. to describe vascular, bowel, and extraintestinal CT findings for the diagnosis of acute mesenteric ischemia.

Unusual causes of gastrointestinal bleeding in the intensive care unit through the radiology lens.

The great majority of patients admitted to the intensive care unit (ICU) for critical gastrointestinal bleeding (GIB) will have a predictable etiology. Once the site is localized to the upper versus the lower gastrointestinal tract, the number of typically encountered etiological possibilities is quite limited. On rare occasions, the cause of GIB requiring ICU care is not one of the standard considerations, potentially leading to diagnostic and therapeutic delays. Within a short time period, three patients were admitted to our institution's medical ICU each with a different unexpected cause of GIB. All three cases generated a variety of instructive images, which are used in the present series to illustrate these conditions and the role of radiology in their evaluation and management.

Antegrade Aorto-Mesenteric Bypass Using a Prefabricated Bovine Pericardium Tube Graft for the Treatment of Chronic Mesenteric Ischemia Complicated With Intestinal Necrosis and Biliary Peritonitis.

Chronic mesenteric ischemia (CMI) is a vascular disorder primarily caused by atherosclerosis, resulting in intestinal ischemia. While endovascular treatment has become the primary modality for most patients, open mesenteric revascularization remains crucial for complex cases. We present a case of CMI in a patient with critical ischemia, leading to small bowel necrosis, where the endovascular recanalization failed and a surgical approach was needed. A supraceliac antegrade aortomesenteric bypass was performed, and successful revascularization of intestinal circulation was achieved. A novel prefabricated bovine pericardium tube was used as a graft, and the bypass was placed behind the pancreas to ensure maximal isolation from the contaminated abdominal cavity. Despite the intestinal revascularization, in the early postoperative period, the overall condition of the patient worsened with obvious signs of peritonitis. The second look operation revealed a ruptured gallbladder with severe biliary peritonitis, likely caused by the preceding splanchnic ischemia. A cholecystectomy, lavage, and drainage were performed. No further intestinal necrosis was observed, and the bowel passage was restored with latero-lateral jejuno-lejunostomy. The follow-up of the patient showed no signs of graft infection. Despite the complications, the patient's postoperative period was stable, and he was discharged on day sixteen. Regular follow-ups confirmed an excellent patency of the bypass.

Should we perform decompressive laparotomy during severe acute pancreatitis with intra-abdominal hypertension below 25 mmHg: Only the gut knows.

We suggest that during severe acute pancreatitis (SAP) with intra-abdominal hypertension, practitioners should consider decompressive laparotomy, even with intra-abdominal pressure (IAP) below 25 mmHg. Indeed, in this setting, non-occlusive mesenteric ischemia (NOMI) may occur even with IAP below this cutoff and lead to transmural necrosis if abdominal perfusion pressure is not promptly restored. We report our experience of 18 critically ill patients with SAP having undergone decompressive laparotomy of which one third had NOMI while IAP was mostly below 25 mmHg.

Open thrombectomy, patch angioplasty, and retrograde stenting for isolated superior mesenteric artery dissection.

Isolated superior mesenteric artery dissection without aortic involvement is an exceptionally rare event. Nonoperative management remains the first-line therapy. However, surgical interventions can be indicated in the event of bowel ischemia. In the present report, we describe a case of complicated isolated superior mesenteric artery dissection treated with a hybrid approach.

Acute ischemic colitis complicating an exacerbation of chronic obstructive pulmonary disease: A case report of gut-lung crosstalk.

Acute ischemic colitis is a pathology as frequent as it is serious and requires urgent management. It's often occurring in a context of particular thromboembolic or hypovolemic risk, but certain clinical situations are not commonly known to provide mesenteric ischemia. Herein, we report the case of a 47-year-old man who presented with a severe acute colitis occurring in the course of acute exacerbation of a chronic obstructive pulmonary diseases with maintained stability of hemodynamic state. The diagnosis of acute ischemic colitis complicating an exacerbation of chronic obstructive pulmonary diseases was made. A clinical and biological improvement quickly marked the patient's condition after the management of the respiratory problem.