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

2018 ◽  
Vol 34 (10) ◽  
pp. 771-781 ◽  
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.

scholarly journals Nonocclusive Mesenteric Ischemia Associated with Ogilvie Syndrome

2014 ◽  
Vol 2014 ◽  
pp. 1-4 ◽  
Author(s):  
Takashi Sakamoto ◽  
Toshiyuki Suganuma ◽  
Shinichiro Okada ◽  
Kensuke Nakatani ◽  
Sawako Tamaki ◽  
...  
Keyword(s):  
Small Bowel ◽  
Mesenteric Ischemia ◽  
Colonic Obstruction ◽  
Acute Mesenteric Ischemia ◽  
Pneumatosis Intestinalis ◽  
Abdominal Distension ◽  
Emergency Laparotomy ◽  
Nonocclusive Mesenteric Ischemia ◽  
Ischemic Bowel ◽  
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.

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

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.

Acute Mesenteric Ischemia: The Importance of Early Surgical Consultation

2009 ◽  
Vol 75 (3) ◽  
pp. 212-219 ◽  
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.

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

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.

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

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.

Mesenteric Ischemia

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

Normal Lactate and Unenhanced CT-Scan Result in Delayed Diagnosis of Acute Mesenteric Ischemia

2020 ◽  
Vol 115 (11) ◽  
pp. 1902-1905
Author(s):  
Alexandre Nuzzo ◽  
Francisca Joly ◽  
Maxime Ronot ◽  
Yves Castier ◽  
Audrey Huguet ◽  
...  
Keyword(s):  
Ct Scan ◽  
Mesenteric Ischemia ◽  
Delayed Diagnosis ◽  
Acute Mesenteric Ischemia ◽  
Unenhanced Ct

scholarly journals SINGLE CENTER EXPERIENCE IN MANAGEMENT OF ACUTE MESENTERIC ISCHEMIA AND THE IMMEDIATE OUTCOME FOLLOWING SURGICAL SALVAGE

2021 ◽  
Vol 31 (04) ◽  
pp. 201-203
Author(s):  
Shabbir Ahmad ◽  
Ahmad Naeem Akhtar ◽  
Nazia Farooq ◽  
Ajmal Farooq ◽  
Farman Ali ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Mesenteric Ischemia ◽  
Surgical Intervention ◽  
Acute Mesenteric Ischemia ◽  
Rare Condition ◽  
Abdominal Distension ◽  
Early Presentation ◽  
Late Presenters ◽  
Single Center Experience ◽  
Time Period

Acute Mesenteric Ischemia is a rare condition with an incidence of 5/100,000. Occlusive subtype has the better outcome if early presentation and urgent surgical intervention is made. The study was conducted at Lahore General Hospital, Lahore from Jan, 2016 to Jan, 2018. During this time period 12 patients were enrolled in the study fulfilling the inclusion and exclusion criteria. Mean age was 58 years and all were male (range 45 - 75 years). All 12 patients were symptomatic at presentation with severe abdominal pain (94.3%), abdominal distension (63.6%) and vomiting (40.4%) alone or in combination. 7 patients (58.3%) presented within 24 hours from the onset of symptoms whereas 5 patients (41.6%) presented late. All patients who presented within 24 hours of onset of symptoms survived whereas all patients who presented after 24 hours from the onset of symptoms could not survive. The mortality rate for early presenters was zero % while for late presenters it was 100 %. On whole the mortality rate for our 12 patients with Acute Mesenteric Ischemia was 41.7 %. Conclusion Acute mesenteric ischemia patient presentation within 24 hours from the onset of symptoms with early diagnosis and surgical intervention had much better outcome.

Acute Mesenteric Ischemia

2016 ◽  
Author(s):  
Mohammad H. Eslami
Keyword(s):  
Ct Scan ◽  
Mesenteric Ischemia ◽  
Three Dimensional ◽  
Acute Mesenteric Ischemia ◽  
Mesenteric Arteries ◽  
Proximal Jejunum ◽  
Nonocclusive Mesenteric Ischemia ◽  
Total Occlusion ◽  
Mesenteric Vessels

Acute mesenteric ischemia (AMI) is an uncommon life-threatening clinical entity with a reported incidence rate of 0.09 to 0.2% per patient-year at tertiary referral centers. Diagnosis is challenging: the initial presentation of abdominal pain is vague, varied, and similar to other, more common, pathologic abdominal conditions. This review covers clinical evaluation, investigative studies, management, intraoperative consultation, determination of bowel viability, mesenteric ischemia and reperfusion, and outcome after surgical treatment of AMI. Figures show computed tomographic (CT) scan of mesenteric vessels, CT scan of a partially occluding thrombus in the superior mesenteric vein, contrast-enhanced three-dimensional magnetic resonance angiography images of aorta and mesenteric vessels, a schematic drawing demonstrating the usual site for superior mesenteric artery (SMA) thrombosis versus that for SMA embolus, selective angiogram of the SMA in anterior projection demonstrating embolus within the vessel at the typical location, lateral contrast angiogram demonstrating near-occlusion of the celiac artery and total occlusion of the SMA, contrast angiograms of the aorta and mesenteric arteries in a patient with nonocclusive mesenteric ischemia, selective angiogram of the SMA demonstrating a partially occluding embolus in the distal vessel, selective angiogram showing a clot beyond the orifice of the SMA, lodged in the SMA of smaller caliber, algorithm illustrating intraoperative determination of bowel salvageability, evaluation of SMA pulses, and assessment of bowel viability after revascularization, and an intraoperative photograph of diffuse bowel ischemia with classic sparing of the proximal jejunum and transverse colon due to embolus of the SMA.   This review contains 11 highly rendered figures and 65 references

Nonocclusive Mesenteric Ischemia: A Lethal Complication in Peritoneal Dialysis Patients

2007 ◽  
Vol 27 (2) ◽  
pp. 136-141 ◽  
Author(s):  
Fotios Archodovassilis ◽  
Emmanuel E. Lagoudiannakis ◽  
Dimitrios Konstantinos Tsekouras ◽  
Konstantinos Vlachos ◽  
Konstantinos Albanopoulos ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Mesenteric Ischemia ◽  
Intestinal Ischemia ◽  
Correct Diagnosis ◽  
Acute Mesenteric Ischemia ◽  
Dialysis Patients ◽  
Nonocclusive Mesenteric Ischemia ◽  
Stage Renal Disease ◽  
End Stage ◽  
High Index Of Suspicion

Nonocclusive mesenteric ischemia (NOMI) is a relatively uncommon disorder, seen primarily in elderly patients with cardiac disease, and is characterized by progressive intestinal ischemia leading to infarction, sepsis, and death. It is suspected of being the underlying cause in at least 20% – 30% of acute mesenteric ischemia patients. End-stage renal disease patients are among the highest risk populations for developing this lethal complication; however, NOMI is not unique to hemodialysis and can occur in peritoneal dialysis patients as well. Unfortunately, the presentation of NOMI is very similar to that of peritonitis. The key to correct diagnosis is a high index of suspicion in predisposed patients. The high mortality rate is a clear reflection of failure to recognize the syndrome at an earlier, treatable stage. We present our case experience and an extensive review of the literature regarding this dreadful complication that may be reversible if considered early as a possible etiology and the appropriate diagnostic maneuvers undertaken.

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