Mesenteric Infarction With Cerebral Thrombotic Relapses and Pulmonary Embolism Two and Four Months After COVID-19.

The aim of the present study was to report different sites of thrombotic events during and after coronavirus disease 2019 (COVID-19) in a 49-year-old patient who had acute mesenteric infarction in acute phase, stroke 2 months after and pulmonary thromboembolism 4 months after infection by COVID-19. The obese, previously healthy patient experienced myalgia and headache with subfebrile peaks and was tested positive for COVID-19 with a fast polymerase chain reaction (PCR) assay. Ten days after the onset of symptoms, the patient was submitted to exploratory laparotomy, which revealed 20 cm of small intestine loop with signs of suffering and thickening of the wall approximately 120 cm from the ileocecal valve. Two months after the event, angiotomography was performed, revealing effacement of the sulci in the right parietal region and hypersignal of the right middle cerebral artery with stop in M1. Two months later (4 months after the mesenteric infarction), chest angiotomography revealed signs of acute pulmonary thromboembolism, with no typical image of pulmonary infarction. Despite all these complications in the postoperative period, the patient survived.

Management of acute mesenteric ischaemia: Results of a worldwide survey.

BACKGROUND: Acute mesenteric ischaemia (AMI) is a condition with high mortality. This survey assesses current attitudes and practices to manage AMI worldwide. METHODS: A questionnaire survey about the practices of diagnosing and managing AMI, endorsed by several specialist societies, was sent to different medical specialists and hospitals worldwide. Data from individual health care professionals and from medical teams were collected. RESULTS: We collected 493 individual forms from 71 countries and 94 team forms from 34 countries. Almost half of respondents were surgeons, and most of the responding teams (70%) were led by surgeons. Most of the respondents indicated that diagnosis of AMI is often delayed but rarely missed. Emergency revascularisation is often considered for patients with AMI but rarely in cases of transmural ischaemia (intestinal infarction). Responses from team hospitals with a dedicated special unit (14 team forms) indicated more aggressive revascularisation. Abdominopelvic CT-scan with intravenous contrast was suggested as the most useful diagnostic test, indicated by approximately 90% of respondents. Medical history and risk factors were thought to be more important in diagnosis of AMI without transmural ischaemia, whereas for intestinal infarction, plasma lactate concentrations and surgical exploration were considered more useful. In elderly patients, a palliative approach is often chosen over extensive bowel resection. There was a large variability in anticoagulant treatment, as well as in timing of surgery to restore bowel continuity. CONCLUSIONS: Delayed diagnosis of AMI is common despite wide availability of an adequate imaging modality, i.e. CT-scan. Large variability in treatment approaches exists, indicating the need for updated guidelines. Increased awareness and knowledge of AMI may improve current practice until more robust evidence becomes available. Adherence to the existing guidelines may help in improving differences in treatment and outcomes.

Mortality Prediction Model before Surgery for Acute Mesenteric Infarction: A Population-Based Study.

Surgery for acute mesenteric infarction (AMI) is associated with high mortality. This study aimed to generate a mortality prediction model to predict the 30-day mortality of surgery for AMI. We included patients ≥18 years who received bowel resection in treating AMI and randomly divided into the derivation and validation groups. After multivariable analysis, the 'Surgery for acute mesenteric infarction mortality score' (SAMIMS) system was generated and was including age >62-year-old (3 points), hemodialysis (2 points), congestive heart failure (1 point), peptic ulcer disease (1 point), diabetes (1 point), cerebrovascular disease (1 point), and severe liver disease (4 points). The 30-day-mortality rates in the derivation group were 4.4%, 13.4%, 24.5%, and 32.5% among very low (0 point), low (1−3 point(s)), intermediate (4−6 points), and high (7−13 points)-risk patients. Compared to the very-low-risk group, the low-risk (OR = 3.332), intermediate-risk (OR = 7.004), and high-risk groups (OR = 10.410, p < 0.001) exhibited higher odds of 30-day mortality. We identified similar results in the validation group. The areas under the ROC curve were 0.677 and 0.696 in the derivation and validation groups. Our prediction model, SAMIMS, allowed for the stratification of the patients' 30-day-mortality risk of surgery for acute mesenteric infarction.

Colonization with Altered Schaedler Flora Impacts Leukocyte Adhesion in Mesenteric Ischemia-Reperfusion Injury.

The microbiota impacts mesenteric ischemia-reperfusion injury, aggravating the interaction of leukocytes with endothelial cells in mesenteric venules. The role of defined gut microbiomes in this life-threatening pathology is unknown. To investigate how a defined model microbiome affects the adhesion of leukocytes in mesenteric ischemia-reperfusion, we took advantage of gnotobiotic isolator technology and transferred altered Schaedler flora (ASF) from C3H/HeNTac to germ-free C57BL/6J mice. We were able to detect all eight bacterial taxa of ASF in fecal samples of colonized C57BL/6J mice by PCR. Applying qRT-PCR for quantification of species-specific 16S rDNA sequences of ASF bacteria, we found a major shift in the abundance of ASF 500, which was greater in C57BL/6J mice relative to the C3H/HeNTac founder breeding pair. Using high-speed epifluorescence intravital microscopy to visualize the venules of the small bowel mesentery, we found that gnotobiotic ASF-colonized mice showed reduced leukocyte adherence, both pre- and post-ischemia. Relative to germ-free mice, the counts of adhering leukocytes were increased pre-ischemia but did not significantly increase in ASF-colonized mice in the post-ischemic state. Collectively, our results suggest a protective role of the minimal microbial consortium ASF in mesenteric ischemia-reperfusion injury.

Acute Mesenteric Infarction: The Chameleon of Acute Abdomen Evaluating the Quality of the Diagnostic Parameters in Acute Mesenteric Ischemia.

INTRODUCTION/OBJECTIVE: Acute mesenteric ischemia (AMI) is difficult to diagnose. Since the established parameters have low sensitivity and specificity, the aim of this study is to analyze the diagnostic quality of the established parameters of AMI. METHODS: All patients that underwent emergency surgery due to suspected diagnosis of mesenteric ischemia at the University Medical Center Hamburg-Eppendorf between 2008 and 2014 were evaluated. Overall, 275 patients were enrolled and pre-, intra- and postoperative data were evaluated. RESULTS: In 200 patients, a mesenteric ischemia was confirmed intraoperatively, and 75 patients had no ischemia. Comparing these groups, the rate of patients with pH < 7.2 (25 vs. 12%; p = 0.021) and elevated mean CRP level (175 ± 117 mg/L vs. 139 ± 104 mg/L; p = 0.019) was significantly higher in ischemic patients. There was no significant difference in the level of preoperative lactate. Concerning abdominal CT scan, a sensitivity and specificity of 61 and 68%, respectively, was found. CONCLUSION: New diagnostic parameters are needed. So far, explorative laparotomy is the only reliable diagnostic method to detect mesenteric infarction.

Acute mesenteric ischemia-like syndrome associated with suspected Spirocerca lupi aberrant migration in dogs.

OBJECTIVE: To describe acute mesenteric infarction due to suspected Spirocerca lupi aberrant migration in 5 dogs. CASE SERIES SUMMARY: All dogs were large breed, none of which exhibited typical clinical signs associated with spirocercosis. All dogs were eventually diagnosed with septic peritonitis. On exploratory laparotomy, thickening of the jejunal arteries, surrounding mesojejunum, and segmental necrosis were identified. Similar thickening and hematoma formation were found in other regions of the mesentery. In 4 of the cases, the necrotic segment was located in the distal jejunum. Histology revealed thrombotic mesenteric vessels with intralesional S. lupi nematode larvae. Resection and anastomosis of the necrosed section was performed and all but 1 dog survived and were discharged within 1-6 days. NEW OR UNIQUE INFORMATION PROVIDED: Spirocerca lupi is a potential cause of mesenteric infarction in endemic areas when no other obvious etiology is identified.

What predicts the outcome in patients with intestinal ischemia? A single center experience.

BACKGROUND: Acute mesenteric ischemia (AMI) is associated with a mortality of 60-80%. Early diagnosis and rapid treatment have a decisive influence on therapy. The aim of this study was to evaluate the prognostic value of AMI markers on mortality, in order to better anticipate the clinical course and to initiate therapeutic steps at an early stage. STUDY DESIGN: An analysis from our prospective database of 302 consecutive patients with AMI who were treated surgically in the Department of General Surgery between February 2003 and October 2014 was performed. Uni- and multivariate analysis of risk factors for mortality have been performed in the total cohort and in two subgroups according to their stay in intensive care unit (ICU) at the time of AMI diagnosis. RESULTS: Of the 302 patients with AMI, 115 were in ICU at the time of diagnosis. Totally, 203 patients underwent computed tomography scan (CT-scan) of the abdomen for diagnosis and 68% of them showed specific signs of AMI. A total of 63 (21%) embolectomies were performed during the surgical procedure. The post-operative mortality rate was 68% (204 patients). Among survivors, 85 (87%) patients developed a short bowel syndrome in the post-operative course. Multivariate analysis showed a significant association between mortality and preoperative lactate>3mmol/L, C-reactive protein>100mg/L and ICU stay at the time of AMI diagnosis. CONCLUSION: Mortality of patients with AMI remains high. Elevated lactate, elevated C-reactive protein and ICU stay are factors associated with increased mortality. Their presence in a patient with suspicion of AMI should trigger a multidisciplinary management in emergency.

Cerebral Venous Air Embolism Secondary to Mesenteric Infarction.

Cerebral air embolism is a rare, yet potentially fatal condition. We present a case of retrograde cerebral venous air emboli arising from the hepatic portal venous system, secondary to a mesenteric infarction. A 69-year-old man with a history of gastrointestinal amyloidosis presented with fever and lethargy. Computed tomography of the brain detected multiple foci of air in the right frontal, fronto-parietal, and left lateral frontal sulci consistent with cerebral venous air emboli. Computed tomography of the abdomen and pelvis revealed moderate thickening and dilatation of the small bowel with diffuse scattered intestinal pneumatosis suggestive of mesenteric infarction with resultant extensive intrahepatic portal venous air. The patient was deemed a poor candidate for surgical intervention and died as a result of septic shock. We believe the cerebral venous air emboli was a result of retrograde flow of air arising from the hepatic venous air ascending via the inferior and superior vena cava to the cerebral venous system. To our knowledge, there have been no reported cases of retrograde cerebral venous air embolism arising from hepatic portal venous system secondary to mesenteric infarction. The clinical significance and prognosis in this setting requires further investigation.

The importance of open emergency surgery in the treatment of acute mesenteric ischemia.

OBJECTIVE: Acute mesenteric ischemia (AMI) is a complex disease with a high mortality rate. A patient's chance of survival depends on early diagnosis and rapid revascularization to prevent progression of intestinal gangrene. We reviewed our experience with open surgery treatment in 54 cases of AMI. METHODS: A monocentric retrospective study was conducted between 01/01/2001 and 04/30/2014; 54 AMI patients with a mean age of 56.6 years underwent surgery (26 women and 28 men). Retrospectively, the risk factors, management until diagnosis, vascular therapy and follow-up were evaluated. RESULTS: The symptom upon admission was an acute abdominal pain event. The delay time from admission to surgery was, on average, 13.9 h (n = 34). The therapeutic procedures were open surgical operations. The complication rate was (53.7 %) (n = 29). The 30-day mortality was 29.6 % (n = 16). The late mortality rate was 24.1 % (n = 13), and the cumulative survival risk was 44.6 %. Survival was, on average, 60.54 months; however, in the over 70-year-old patient subgroup, the survival rate was 9.5 months (p = 0.035). The mortality rate was 27 % (n = 22) in the <12 h delay group, 20 % (n = 5) in the 12-24 h delay group, and 50 % (n = 7) in the > 24 h delay group. CONCLUSIONS: The form of therapy depends on the intraoperative findings and the type of occlusion. Although the mortality rate has decreased in the last decade, in patients over 70 years of age, a significantly worse prognosis was seen.

Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies.

AIM: The primary aim of this study was to determine whether the in-hospital mortality for acute mesenteric infarction has reduced in the last decade. The secondary aim was to determine if there was a statistical difference in mortality between patients having acute primary mesenteric infarction due to different causes. METHOD: A literature search was performed of PubMed, Ovid (Embase) and Google Scholar databases. Studies on acute mesenteric infarction of primary vascular pathology were included for pooled analyses while studies that had reported comparative mortality between arterial, venous and non-occlusive mesenteric infarction (NOMI) were included in meta-analyses. Their quality was assessed using the National Institute for Health and Care Excellence assessment scale. Odds ratios (ORs) of mortality were calculated using a Mantel-Haenszel random effect model. RESULTS: The total number of patients was 4527 and the male/female ratio was 1912/2247. The pooled in-hospital mortality was 63%. There was no significant reduction of in-hospital mortality rate in the last decade (P = 0.78). There was a significant difference in in-hospital mortality between acute arterial mesenteric infarction (73.9%) compared with acute venous mesenteric infarction (41.7%) [OR 3.47, confidence interval (CI) 2.43-4.96, P < 0.001] and NOMI (68.5%) compared with acute venous mesenteric infarction (44.2%) (OR 3.2, CI 1.83-5.6, P < 0.001). There was no difference in mortality between acute arterial mesenteric infarction and NOMI (OR 1.08, CI 0.57-2.03, P = 0.82). CONCLUSION: In-hospital mortality rate has not changed in the last decade. Patients with arterial mesenteric infarction or with NOMI are over three times more likely to die during the first hospital admission compared with those with venous mesenteric infarction.

Multi-detector CT features of acute intestinal ischemia and their prognostic correlations.

Acute intestinal ischemia is an abdominal emergency occurring in nearly 1% of patients presenting with acute abdomen. The causes can be occlusive or non occlusive. Early diagnosis is important to improve survival rates. In most cases of late or missed diagnosis, the mortality rate from intestinal infarction is very high, with a reported value ranging from 60% to 90%. Multi-detector computed tomography (MDCT) is a fundamental imaging technique that must be promptly performed in all patients with suspected bowel ischemia. Thanks to the new dedicated reconstruction program, its diagnostic potential is much improved compared to the past and currently it is superior to that of any other noninvasive technique. The increased spatial and temporal resolution, high-quality multi-planar reconstructions, maximum intensity projections, vessel probe, surface-shaded volume rending and tissue transition projections make MDCT the gold standard for the diagnosis of intestinal ischemia, with reported sensitivity, specificity, positive and negative predictive values of 64%-93%, 92%-100%, 90%-100% and 94%-98%, respectively. MDCT contributes to appropriate treatment planning and provides important prognostic information thanks to its ability to define the nature and extent of the disease. The purpose of this review is to examine the diagnostic and prognostic role of MDCT in bowel ischemia with special regard to the state of art new reconstruction software.

Mesenteric infarction due to iatrogenic polycythemia.

BACKGROUND: Polycythemia vera is defined as a chronic myeloproliferative disorder characterized by increased red blood cell count. There have been no reports on mesenteric thrombosis resulting from iatrogenic polycythemia. METHODS: We present a patient with a history of non-small cell lung cancer undergoing maintenance oral chemotherapy on tarceva and adjunctive use of procrit. The patient presented to our emergency department with an acute abdomen and was found to have ischemic bowel from unmonitored procrit, which lead to hyperviscosity of blood and mesenteric infarction. RESULTS: The patient remained intubated with ventilator support. He refused a tracheostomy. He continued on feeding through the J port of the nasojejunal tube. His white cell count, and hematocrit and creatinine levels remained normal. Procrit use and chemotherapy were not restarted. He was transferred to a subacute nursing facility for further treatment. CONCLUSIONS: Procrit and other erythropoiesis stimulating drugs can cause significant morbidity and mortality with an increased risk of cardiovascular events, gastrointestinal bleeding, thromboembolism and stroke. This case report suggests that without closely monitoring hematocrit levels, epoetin may also be associated with an increased risk of mesenteric infarction.

Mesenteric infarction due to iatrogenic polycythemia / 世界急诊医学杂志（英文）

BACKGROUND:Polycythemia vera is defined as a chronic myeloproliferative disorder characterized by increased red blood cell count. There have been no reports on mesenteric thrombosis resulting from iatrogenic polycythemia.METHODS:We present a patient with a history of non-small cell lung cancer undergoing maintenance oral chemotherapy on tarceva and adjunctive use of procrit. The patient presented to our emergency department with an acute abdomen and was found to have ischemic bowel from unmonitored procrit, which lead to hyperviscosity of blood and mesenteric infarction.RESULTS:The patient remained intubated with ventilator support. He refused a tracheostomy. He continued on feeding through the J port of the nasojejunal tube. His white cell count, and hematocrit and creatinine levels remained normal. Procrit use and chemotherapy were not restarted. He was transferred to a subacute nursing facility for further treatment.CONCLUSIONS:Procrit and other erythropoiesis stimulating drugs can cause significant morbidity and mortality with an increased risk of cardiovascular events, gastrointestinal bleeding, thromboembolism and stroke. This case report suggests that without closely monitoring hematocrit levels, epoetin may also be associated with an increased risk of mesenteric infarction.

Mesenteric Infarction of the Systemic Lupus Erythematosus and Antiphospholipid Syndrome Patient

Antiphospholipid syndrome is characterized by arterial or venous thrombosis and the production of antiphospholipid antibodies. Antiphospholipid syndrome may present primarily or secondary to systemic lupus erythematosus. The clinical features include multiple thrombosis, cerebral diseases, abortion in female, thrombocytopenia and so on. The treatment is based on anticoagulants, steroids, immunosuppressive agents and antiplatelet drugs. We report a case of a 29- year-old man who was admitted to Ewha Womans University Mok-dong Hospital with a generalized peritonitis. On emergency exploratory laparotomy, segmental infarction of the terminal ileum and the right colon was revealed and a right colon and ileal resection was performed. During the postoperative period, the patient was finally diagnosed having antiphospholipid syndrome with systemic lupus erythematosus. He also had ischemic heart disease due to coronary artery thrombosis and pulmonary embolism due to deep vein thrombosis of the lower extremities. He eventually expired following a restorative ileocolostomy owing to anastomotic leakage and sepsis.

Two Cases of Acute Mesenteric Infarction Due to Superior Mesenteric Arterial and Venous Branch Occlusion

Acute mesenteric infarction is a catastrophic illness representing a diverse spectrum of pathologic conditions which ultimately lead to necrosis of the intestine and which is uniformly fatal if left untreated. Despite better understanding of the disease process, acute mesenteric infarction continues to be a lethal disorder with high mortality rate. We experienced two cases of acute mesenteric infarction due to superior mesenteric arterial and venous branch occlusion, respectively, in recent years: One case was focal segmental ischemia with normal radiologic finding including angiography, successfully treated with segmental resection of the necrotized ileum, another case was mesenteric venous thrombosis, also treated with resection of necrotized small intestine followed by second look operation.

Clinical Characteristics of Mesenteric Infarction

BACKGROUND: Mesenteric infarction is a significant cause of death in elderly patients, and is being reported with increasing frequency. The diagnosis seldom is made prior to the onset of gangrene, despite an increased awareness of the lethality of mesenteric ischemia. The outcome for patients with mesenteric ischemia depends on the age of the patient, the extent and the severity of the ischemia and the effectiveness of the collateral blood supply. METHODS: We retrospectively reviewed the cases of 23 patient with mesenteric infarction who had been treated at the Department of Surgery, Hallym University, Chunchon Sacred Heart Hospital, between September 1988 and August 1977. RESULTS: The mean age was 52.3 years and the ratio of males to females was 1:1.6. The most frequent underlying diseases were hypertension, congestive heart failure, atrial fibrillation, and myocardial infarction. The radiologic study of a simple plain abdomen revealed a paralytic ileus in 87% of the cases; a partial vascular occlusion was shown under angiogram. The mean time lapse from onset of symptom to operation was 38.3 hours. Eight (34.8%) patients died when renal failure, ARDS or peritonitis developed. CONCLUSIONS: The cause of the persistently high mortality in patients with mesenteric in farction and to define a more effective form of management based on our results and recent clinical or laboratory findings. This study was concluded that early detection of the mesenteric infarction was reduced postoperative complications.