Nonocclusive Mesenteric Ischemia Associated with Ogilvie Syndrome

Nonocclusive mesenteric ischemia (NOMI) is one type of acute mesenteric ischemia. Colonic pseudoobstruction, known as Ogilvie syndrome, is a disorder defined by colonic distension in the absence of mechanical obstruction. A relationship between these diseases has not yet been reported, based on a review of the literature. We report a patient with NOMI secondary to Ogilvie syndrome. An 82-year-old woman reported three days of intermittent abdominal pain. Plain computed tomography scan showed colonic obstruction at the rectosigmoid colon. Colonoscopy was performed that showed a large amount of stool and no evidence of tumor or other physical causes of obstruction. We diagnosed the patient with Ogilvie syndrome and continued nonoperative management. On the third hospital day, she complained of abdominal distension. A repeat CT scan showed pneumatosis intestinalis in the small bowel and ascending colon, with portal venous gas. Emergency laparotomy was performed with diagnosis of mesenteric ischemia. Intraoperatively, there were multiple skip ischemic lesions in the small intestine and cecum. We resected the ischemic bowel and performed a distal jejunostomy. Her residual small bowel measured just 20 cm in length. Postoperatively, her general status gradually improved. She was discharged with total parenteral nutrition and a small amount of enteral nutrition.

Download Full-text

Nonocclusive mesenteric ischemia associated with postoperative jejunal tube feeding: Indicators for clinical management

Journal of International Medical Research ◽

10.1177/0300060520929128 ◽

2020 ◽

Vol 48 (8) ◽

pp. 030006052092912

Author(s):

Hendrik Christian Albrecht ◽

Mateusz Trawa ◽

Stephan Gretschel

Keyword(s):

Small Bowel ◽

Mesenteric Ischemia ◽

Clinical Symptoms ◽

Treatment Guideline ◽

Tube Feeding ◽

Pneumatosis Intestinalis ◽

Abdominal Distension ◽

Bowel Necrosis ◽

Nonocclusive Mesenteric Ischemia ◽

Jejunal Tube

Postoperative nutrition via a jejunal tube after major abdominal surgery is usually well tolerated. However, some patients develop nonocclusive mesenteric ischemia (NOMI). This morbid complication has a grave prognosis with a mortality rate of 41% to 100%. Early symptoms are nonspecific, and no treatment guideline is available. We reviewed cases of NOMI at our institution and cases described in the literature to identify factors that impact the clinical course. Among five patients, three had no necrosis and one had segmental necrosis and perforation. These patients recovered with limited resection and decompression of the bowel and abdominal compartment. In one patient with extended bowel necrosis at the time of re-laparotomy, NOMI progressed and the patient died of multiple organ failure. The extent of small bowel necrosis at the time of re-laparotomy is a relevant prognostic factor. Therefore, early diagnosis and treatment of NOMI can improve the prognosis. Clinical symptoms of abdominal distension, cramps and high reflux plus paraclinical signs of leukocytosis, hypotension and computed tomography findings of a distended small bowel with pneumatosis intestinalis and portal venous gas can help to establish the diagnosis. We herein introduce an algorithm for the diagnosis and management of NOMI associated with jejunal tube feeding.

Download Full-text

The Pathogenesis of Nonocclusive Mesenteric Ischemia: Implications for Research and Clinical Practice

Journal of Intensive Care Medicine ◽

10.1177/0885066618788827 ◽

2018 ◽

Vol 34 (10) ◽

pp. 771-781 ◽

Cited By ~ 10

Author(s):

Hussam Al-Diery ◽

Anthony Phillips ◽

Nicholas Evennett ◽

Sanjay Pandanaboyana ◽

Michael Gilham ◽

...

Keyword(s):

Mesenteric Ischemia ◽

Delayed Diagnosis ◽

Acute Mesenteric Ischemia ◽

Ct Scanning ◽

Abdominal Distension ◽

Major Surgery ◽

Future Research ◽

Abdominal Pressure ◽

Unexpected Finding ◽

Nonocclusive Mesenteric Ischemia

Nonocclusive mesenteric ischemia (NOMI) is a condition that can encompass ischemia, inflammation, and infarction of the intestinal wall. In contrast to most patients with acute mesenteric ischemia, NOMI is distinguished by patent arteries and veins. The clinical presentation of NOMI is often insidious and nonspecific, resulting in a delayed diagnosis. Patients most at risk are those with severe acute and critical disease, including major surgery and trauma. Nonocclusive mesenteric ischemia is part of a spectrum, from mild, asymptomatic, and an unexpected finding on CT scanning, through to those exhibiting abdominal distension and peritonitis. Severe NOMI is associated with a significant mortality rate. This review of NOMI pathophysiology was conducted to document current concepts and evidence, to examine the implications for diagnosis and treatment, and to identify gaps in knowledge that might direct future research. The key pathologic mechanisms involved in the genesis of NOMI represent an exaggerated normal physiological response to maintain perfusion of vital organs at the expense of mesenteric perfusion. A supply–demand mismatch develops in the intestine due to the development of persistent mesenteric vasoconstriction resulting in reduced blood flow and oxygen delivery to the intestine, particularly to the vulnerable superficial mucosa. This mismatch can be exacerbated by raised intra-abdominal pressure, enteral nutrition, and the use of certain vasoactive drugs, ultimately resulting in the development of intestinal ischemia. Strategies for prevention, early detection, and treatment are urgently needed.

Download Full-text

Acute Mesenteric Ischemia: The Importance of Early Surgical Consultation

The American Surgeon ◽

10.1177/000313480907500305 ◽

2009 ◽

Vol 75 (3) ◽

pp. 212-219 ◽

Cited By ~ 13

Author(s):

Islam G. Eltarawy ◽

Yasser M. Etman ◽

Mazen Zenati ◽

Richard L. Simmons ◽

Matthew R. Rosengart

Keyword(s):

Odds Ratio ◽

Retrospective Cohort ◽

Mesenteric Ischemia ◽

Disease Onset ◽

Lactate Concentration ◽

Acute Mesenteric Ischemia ◽

Abdominal Distension ◽

Ct Imaging ◽

Appropriate Care ◽

Elevated Lactate

Acute mesenteric ischemia continues to be associated with high mortality. We hypothesized that delays in surgical consultation and operation are independently associated with increased mortality and sought to identify modifiable characteristics associated with delayed management. We conducted a retrospective cohort study of 72 patients diagnosed with acute mesenteric ischemia. Twenty-six (36%) patients died, of which 14 (54%) had care withdrawn. Delay in operation (>6 hours after surgical consultation) was associated with increased mortality (adjusted OR 3.7; 90% CI, 1.1-12). For patients for whom care was not withdrawn, delay in surgical consultation (>24 hours after disease onset) was associated with increased mortality (adjusted OR, 9.4; 90% CI, 1.3-65), as was delay in operation (adjusted OR, 4.9; 90% CI, 1.1-22). For those managed medically, early surgical consultation was associated with improved mortality (Odds Ratio [OR], 0; 90% Confidence Interval [CI], 0-0.34). Patients with delayed surgical consultation were more likely to have abdominal distension, elevated lactate concentration, acute renal failure, vasopressor administration, and a lack of abdominal pain. The acquisition of CT imaging trended toward an association with delayed surgical consultation ( P = 0.06). We conclude that early surgical consultation is associated with improved outcome even for patients managed without operative intervention, and that CT imaging may delay appropriate care.

Download Full-text

A Case of Septicemia due to Nonocclusive Mesenteric Ischemia Occurring in Induction Chemotherapy

Case Reports in Otolaryngology ◽

10.1155/2018/7426819 ◽

2018 ◽

Vol 2018 ◽

pp. 1-4

Author(s):

Hideki Tanaka ◽

Kiyoaki Tsukahara ◽

Isaku Okamoto ◽

Rio Kojima ◽

Kazuhiro Hirasawa ◽

...

Keyword(s):

Mesenteric Ischemia ◽

Abdominal Distension ◽

Oropharyngeal Carcinoma ◽

Continuous Hemodiafiltration ◽

Nonocclusive Mesenteric Ischemia ◽

Intestinal Necrosis ◽

Neck Tumors ◽

Contrast Enhanced ◽

Serious Disease ◽

Enhanced Computed Tomography

In nonocclusive mesenteric ischemia (NOMI), mesenteric ischemia and intestinal necrosis occur despite the absence of organic blockage in mesenteric blood vessels. As abdominal pain is often absent and few characteristic findings are seen in blood biochemistry, imaging diagnosis or other examinations, discovery is often delayed. With a mortality rate of 56–79%, NOMI is a very serious disease. However, few reports have described this pathology in association with chemotherapy regimens such as those used for malignant head and neck tumors. We encountered a case of NOMI during induction therapy combining cisplatin, docetaxel, and 5-fluorouracil. The patient was a 74-year-old man receiving chemotherapy for T2N2bM0 stage IVA oropharyngeal carcinoma. Febrile neutropenia appeared on treatment day 8. An antibacterial agent and a granulocyte colony-stimulating factor were administered, but septic shock developed and he was transferred to the intensive care unit. Abdominal distension was present and contrast-enhanced computed tomography of the abdomen suggested NOMI. Emergency surgery on day 9 resected the necrotized small intestine and created a single-hole ileostomy. The patient subsequently recovered with 2 weeks of continuous hemodiafiltration and other intensive therapies. Otolaryngological surgeons seldom encounter intestinal diseases, which are thus easily overlooked. The present case report may help in achieving early diagnosis.

Download Full-text

Can the Preoperative Serum Lactate Level Predict the Extent of Bowel Ischemia in Patients Presenting to the Emergency Department with Acute Mesenteric Ischemia?

BioMed Research International ◽

10.1155/2017/8038796 ◽

2017 ◽

Vol 2017 ◽

pp. 1-5 ◽

Cited By ~ 10

Author(s):

Peter C. Ambe ◽

Kai Kang ◽

Marios Papadakis ◽

Hubert Zirngibl

Keyword(s):

Lactate Level ◽

Mesenteric Ischemia ◽

Clinical Decision Making ◽

Elevated Serum ◽

Acute Mesenteric Ischemia ◽

Serum Lactate ◽

Bowel Ischemia ◽

Serum Lactate Level ◽

Ischemic Bowel ◽

Preoperative Serum

Purpose. Early recognition of acute mesenteric ischemia (AMI) can be challenging. Extensive bowel necrosis secondary to AMI is associated with high rates of mortality. The aim of this study was to investigate the association between preoperative serum lactate level and the extent of bowel ischemia in patients with AMI. Methods. Data of patients with abdominal pain and elevated serum lactate undergoing emergency laparotomy for suspected AMI within 24 hours of presentation was retrospectively abstracted. The length of the ischemic bowel segment was compared with the preoperative serum lactate level. Results. 36 female and 39 male patients, with median age 73.1 ± 12.3 years, were included for analysis. The median preoperative lactate was 2.96 ± 2.59 mmol/l in patients with ≤50 cm, 6.86 ± 4.08 mmol/l in patients with 51–100 cm, 4.73 ± 2.76 mmol/l in patients with >100 cm ischemic bowel, and 14.07 ± 4.91 mmol/l in the group with multivisceral ischemia. Conclusion. Although elevated serum lactate might permit an early suspicion and thus influence the clinical decision-making with regard to prioritization of surgery in patients with suspected AMI, a linear relationship between serum lactate and the extent of bowel ischemia could not be established in this study.

Download Full-text

Acute Mesenteric Ischemia in COVID-19 Patients

Journal of Clinical Medicine ◽

10.3390/jcm11010200 ◽

2021 ◽

Vol 11 (1) ◽

pp. 200

Author(s):

Dragos Serban ◽

Laura Carina Tribus ◽

Geta Vancea ◽

Anca Pantea Stoian ◽

Ana Maria Dascalu ◽

...

Keyword(s):

Small Bowel ◽

Mesenteric Ischemia ◽

Intestinal Ischemia ◽

Clinical Laboratory ◽

Fluid Management ◽

Acute Mesenteric Ischemia ◽

Bowel Ischemia ◽

Reactive Protein ◽

Contrast Enhanced Ct ◽

The Moment

Acute mesenteric ischemia is a rare but extremely severe complication of SARS-CoV-2 infection. The present review aims to document the clinical, laboratory, and imaging findings, management, and outcomes of acute intestinal ischemia in COVID-19 patients. A comprehensive search was performed on PubMed and Web of Science with the terms “COVID-19” and “bowel ischemia” OR “intestinal ischemia” OR “mesenteric ischemia” OR “mesenteric thrombosis”. After duplication removal, a total of 36 articles were included, reporting data on a total of 89 patients, 63 being hospitalized at the moment of onset. Elevated D-dimers, leukocytosis, and C reactive protein (CRP) were present in most reported cases, and a contrast-enhanced CT exam confirms the vascular thromboembolism and offers important information about the bowel viability. There are distinct features of bowel ischemia in non-hospitalized vs. hospitalized COVID-19 patients, suggesting different pathological pathways. In ICU patients, the most frequently affected was the large bowel alone (56%) or in association with the small bowel (24%), with microvascular thrombosis. Surgery was necessary in 95.4% of cases. In the non-hospitalized group, the small bowel was involved in 80%, with splanchnic veins or arteries thromboembolism, and a favorable response to conservative anticoagulant therapy was reported in 38.4%. Mortality was 54.4% in the hospitalized group and 21.7% in the non-hospitalized group (p < 0.0001). Age over 60 years (p = 0.043) and the need for surgery (p = 0.019) were associated with the worst outcome. Understanding the mechanisms involved and risk factors may help adjust the thromboprophylaxis and fluid management in COVID-19 patients.

Download Full-text

Cascade of Surgical Complications: A Case of Necrotizing Fasciitis

Archives of Infectious Diseases & Therapy ◽

10.33140/aidt.03.03.03 ◽

2019 ◽

Vol 3 (3) ◽

Keyword(s):

Small Bowel ◽

Necrotizing Fasciitis ◽

Abdominal Distension ◽

Small Bowel Resection ◽

Emergency Laparotomy ◽

Joint Reconstruction ◽

Tertiary Centre ◽

Level 3 ◽

General Surgeons

A 60 year old female presented with abdominal distension and non-specific abdominal pain and describes herself to have a ‘lazy bowel’, with a complicated surgery history. Patient subsequently underwent an emergency laparotomy for multiple small bowel perforations, requiring small bowel resection. The patient developed necrotizing fasciitis (NF) due to an increased use of inotropes during surgery which causes excessive vasoconstriction, and she had a major portion of the abdominal flab removed. This followed by a 33 day ITU admission (level 3) due to septic shock and poor pulmonary compliance. During the ITU stay, the patient was taken back into theatre 14 times for vac dressing changes to reduce the pressure from 150 mmHg down to 25 mmHg. Back in the surgery ward, the patient developed a fistula due to the vac dressing eroding the small bowel, leading to a proximal jejunostomy in situ which effectively worked as a high output stoma. The patient later suffered from re-feeding syndrome as the feed was primarily through the jejunostomy. Eventually absorbable mesh was added behind the vac dressing to protect the soft tissue underneath and the final stage was referral to plastic surgeons that would a joint reconstruction of the abdominal wall with the general surgeons at St Marks (tertiary centre for intestinal feeding and the combined reconstruction).

Download Full-text

Nonocclusive Mesenteric Ischemia Rescued by Immediate Surgical Exploration in a Boy with Severe Neurodevelopmental Disability

Case Reports in Pediatrics ◽

10.1155/2019/5354074 ◽

2019 ◽

Vol 2019 ◽

pp. 1-4

Author(s):

Manami Mizumoto ◽

Fumihiro Ochi ◽

Toshihiro Jogamoto ◽

Kentaro Okamoto ◽

Mitsumasa Fukuda ◽

...

Keyword(s):

Mesenteric Ischemia ◽

Cardiopulmonary Arrest ◽

Hypovolemic Shock ◽

Acute Mesenteric Ischemia ◽

Underlying Disease ◽

Sudden Onset ◽

Mesenteric Arteries ◽

Nonocclusive Mesenteric Ischemia ◽

Surgical Exploration ◽

Neurodevelopmental Disability

Background. Nonocclusive mesenteric ischemia (NOMI) defines acute mesenteric ischemia without occlusion of the mesenteric arteries. The most common cause of NOMI is vasoconstriction or vasospasm of a mesenteric artery. NOMI generally affects patients >50 years of age, and few cases have been reported in children. Case Presentation. A 15-year-old boy with severe neurodevelopmental disability developed sudden-onset fever, abdominal distention, and dyspnea. Laboratory and radiological findings indicated acute intestinal obstruction and prerenal failure. He developed transient cardiopulmonary arrest and hypovolemic shock. Emergent laparotomy was performed, which revealed segmentally necrotic intestine from the jejunum to the ascending colon with pulsation of peripheral intestinal arteries, leading to a diagnosis of NOMI. The necrotic intestine was resected, and stomas were created. He was discharged on postoperative day 334 with short bowel syndrome as a complication. Conclusions. NOMI should be considered a differential diagnosis for intestinal symptoms with severe general conditions in both adults and children with underlying disease. Immediate surgical exploration is essential with NOMI to save a patient’s life.

Download Full-text

Mesenteric Ischemia

10.2310/im.4713 ◽

2016 ◽

Author(s):

Ugo A. Ezenkwele

Keyword(s):

Abdominal Pain ◽

Mesenteric Ischemia ◽

Acute Mesenteric Ischemia ◽

Computed Tomographic Angiography ◽

Low Flow ◽

Chronic Mesenteric Ischemia ◽

Flow State ◽

Nonocclusive Mesenteric Ischemia ◽

Vasodilator Therapy ◽

Bowel Infarction

Acute mesenteric ischemia is interruption of intestinal blood flow by embolism, thrombosis, or a low-flow state. Bowel infarction is the end result of a process initiated by mediator release and inflammation. On clinical assessment, the early hallmark is severe abdominal pain but minimal physical findings. The abdomen remains soft, with little or no tenderness. Mild tachycardia may be present. Early diagnosis is difficult, but selective mesenteric angiography and computed tomographic angiography have the most sensitivity; other imaging studies and serum markers can show abnormalities but lack sensitivity and specificity early in the course of the disease, when diagnosis is most critical. Treatment is by embolectomy, anticoagulation, revascularization of viable segments, or resection; sometimes vasodilator therapy is successful. If diagnosis and treatment take place before infarction occurs, mortality is low; after intestinal infarction, mortality approaches 30 to 70%. For this reason, in the emergency department, clinical diagnosis should supersede diagnostic tests, which may delay treatment. This review contains 6 highly rendered figures, 4 tables, and 33 references. Key words: acute mesenteric ischemia; bowel necrosis; chronic mesenteric ischemia; mesenteric occlusive disease; mesenteric venous thrombosis; nonocclusive mesenteric ischemia; postprandial abdominal pain; superior mesenteric artery thromboembolism

Download Full-text

Abstract 490: Acute Superior Mesenteric Artery Occlusion Presenting as Strangulated Inguinal Hernia

Arteriosclerosis Thrombosis and Vascular Biology ◽

10.1161/atvb.33.suppl_1.a490 ◽

2013 ◽

Vol 33 (suppl_1) ◽

Author(s):

Shanjin Cao ◽

Lihong Huo ◽

Rongrong Ge ◽

Li Sun ◽

Zev Carrey ◽

...

Keyword(s):

Septic Shock ◽

Inguinal Hernia ◽

Small Bowel ◽

Bowel Movement ◽

Acute Mesenteric Ischemia ◽

Small Bowel Resection ◽

Artery Occlusion ◽

Multiple Organ ◽

Emergency Laparotomy ◽

Oral Contrast

An 85yo woman presented with diffused colicky abdominal pain and vomiting for 12hr. Patient still had bowel movement and passed flatus. Patient was otherwise healthy without past medical or surgical history, and taking no medications. PE: no distress, afebrile, vitals are stable. Cardiopulmonary exam only revealed tachycardia; Abdomen: soft, non-tender, no distension, bowel sounds hyperactive; there was an 8[[Unable to Display Character: ]]6 cm irreducible, firm but non-tender right inguinal hernia. Labs: leukocytosis, bicarbonate 20. CT abdomen with oral contrast suggested small bowel obstruction secondary to right inguinal hernia. The hernia was then reduced manually. Post the reduction patient had one foul smell watery bowel movement. However, patient deteriorated quickly. Repeat labs: bicarbonate 8, anion gap 23, lactic acid 11, ABG: 7.01/29/246/7/99%. EKG: A-fib with tachycardia. Patient’s blood pressure dropped necessitating IV fluid and vasopressor support. Strangulated hernia with septic shock was suspected and emergency laparotomy was performed. Ascending, transverse and descending colon past the splenic curve were found necroses with foul-smelling turbid fluid intraperitoneally; the small bowel was minimally dilated with a kink 25cm beyond the ileocelcal valve with evidence of previous incarceration. Subtotal colectomy and partial small bowel resection with ileostomy was performed. Pathology confirmed terminal ileum and colonic gangrene; recent mesentery venous thrombi. Despite appropriate therapy, patient continued to be in septic shock and developed multiple organ failure, a stroke, and then brain death. Acute mesenteric ischemia (AMI) is a rare abdominal emergency with high mortality, which could be caused by direct strangulation of the SMA by the inguinal hernia (Tiwary SK et al 2008) or thromoboembolism, e.g., emboli from A-fib, septic emboli, local thrombosis. Since there is no evidence that the incarcerated portion of small bowel had necrosis, this case is mostly likely caused by the paroxysmal A-fib-derived emboli. Due to the lack of typical clinical expression, a high index of suspicion is essential for prompt diagnosis. CT angiography is the current cornerstones for diagnosis of AMI, so treatment can be initiated expeditiously.

Download Full-text