Gastrointestinal Hemorrhage in Patient with Granulomatosis with Polyangitis

Granulomatosis with polyangitis (GPA) is characterized by a necrotizing granulomatous vasculitis of small arteries and veins. It most commonly affects the upper and lower respiratory tract and kidneys. However, other organs including the gastrointestinal tract can be affected. Gastrointestinal manifestations of GPA are rare and can include ischemia, bowel infarction, and perforation. Hemorrhage is an extremely rare presentation of GPA. We present a case of a woman with GPA and pulmonary renal syndrome on treatment who presents with severe gastrointestinal hemorrhage.

Hypermagnesaemia causing mesenteric ischaemia and small bowel infarction

We present a case of mesenteric ischaemia caused by hypermagnesaemia after ingestion of a large oral dose of magnesium citrate, which resulted in smooth muscle relaxation, hypotension and bowel infarction. The patient had a history of chronic bowel dysmotility and renal impairment. On operative exploration, the bowel was noted to have a distinct pattern of ischaemia along its antimesenteric border. Small bowel resection was performed, and the patient was left in discontinuity, with definitive repair and anastomosis performed 24 hours later. The patient’s magnesium level was 8.39 mg/dL, which was treated with intermittent haemodialysis and eventually normalised over several sessions. Our patient recovered and was discharged after a month-long hospitalisation. She returned shortly after with respiratory failure and died. On review of the literature, we identified similar cases and present a pathophysiological mechanism of hypermagnesaemia causing mesenteric ischaemia, consistent between our cases and those already reported.

Management of Spontaneous Isolated Mesenteric Artery Dissection: A Systematic Review

Background and Aims: There are increasing reports on case series on spontaneous isolated mesenteric artery dissection, that is, dissections of the superior mesenteric artery and celiac artery, mainly due to improved diagnostic capacity of high-resolution computed tomography angiography performed around the clock. A few case–control studies are now available, while randomized controlled trials are awaited. Material and Methods: The present systematic review based on 97 original studies offers a comprehensive overview on risk factors, management, conservative therapy, morphological modeling of dissection, and prognosis. Results and Conclusions: Male gender, hypertension, and smoking are risk factors for isolated mesenteric artery dissection, while the frequency of diabetes mellitus is reported to be low. Large aortomesenteric angle has also been considered to be a factor for superior mesenteric artery dissection. The overwhelming majority of patients can be conservatively treated without the need of endovascular or open operations. Conservative therapy consists of blood pressure lowering therapy, analgesics, and initial bowel rest, whereas there is no support for antithrombotic agents. Complete remodeling of the dissection after conservative therapy was found in 43% at mid-term follow-up. One absolute indication for surgery and endovascular stenting of the superior mesenteric artery is development of peritonitis due to bowel infarction, which occurs in 2.1% of superior mesenteric artery dissections and none in celiac artery dissections. The most documented end-organ infarction in celiac artery dissections is splenic infarctions, which occurs in 11.2%, and is a condition that should be treated conservatively. The frequency of ruptured pseudoaneurysm in the superior mesenteric artery and celiac artery dissection is very rare, 0.4%, and none of these patients were in shock at presentation. Endovascular therapy with covered stents should be considered in these patients.

An unusual case of sepsis due to Salmonella enterica serovar Weltevreden, an emerging pathogen of non-typhoidal salmonellosis

Salmonella enterica serovar Weltevreden is identified as an emerging pathogen, especially in the South and Southeast Asian regions. A 45-year-old male presented with an acute febrile illness, disoriented and confused. Blood culture became positive for Salmonellae enterica serovar Weltevreden. The patient was started on intravenous Ceftriaxone. Despite aggressive management, he developed acute respiratory distress syndrome with septic shock, which required intubation and mechanical ventilation. On the 11th day of admission, he succumbed due to sepsis from peritonitis with bowel infarction. Severe sepsis due to S. Weltevreden is rare. Diabetes, malignancy, therapeutic immune suppression may predispose to invasive disease. Biochemical similarities to other Salmonella species may lead to S. Weltevreden being overlooked by clinicians. Isolates from around the world remain sensitive to most freely available antibiotics. Emergence of resistance to common antimicrobial agents could pose an obvious public health threat.

Transverse colon volvulus in a patient with autism

Transverse colon volvulus is an extremely rare cause of bowel obstruction with approximately 100 cases reported in literature. Transverse colon volvulus presents with signs and symptoms of large bowel obstruction, but it can become a surgical emergency due to bowel infarction or peritonitis. We present a rare case of transverse colon volvulus in a 36-year-old male patient with severe autism. We hope this case report will raise awareness of this disease.

Clinical Profile, Response to therapy and outcomes of post-ischemic intestinal stenosis Secondary to Acute Mesenteric Venous Thrombosis: a retrospective case series study

Background Acute mesenteric venous thrombosis (AMVT) can not only cause acute bowel infarction but result in post-ischemic intestinal stenosis (PIIS), which is rarely reported. Methods Consecutive patients diagnosed with PIIS secondary to AMVT (during the post-thrombotic course, confirmed segmental bowel stenosis) from January 2010 to June 2018 were enrolled. We evaluated the clinical profile, response to therapy, and outcomes of this complication managed at the intestinal stroke center in China. Clinical data are retrospectively analyzed and Wilcoxon signed-rank test was used to evaluate the efficiency of conservative treatment. Results 42 patients with PIIS secondary to AMVT were evaluated. 20 (5-150) days after discharge for AMVT, symptoms of PIIS appeared, and the interval between symptom onset and consultation was 29.5 (2-180) days. In addition, abdominal pain (90.5%), abdominal distension (76.2%), weight loss (71.4%), and nausea or vomiting (54.8%) were the common presentations. Hypoproteinemia was observed in 61.9% of patients, while leukocytosis, anemia and electrolyte disorders were present in 11.9%, 45.2% and 35.7% of patients, respectively. CT excluded thrombosis recurrence and revealed extensive collateral circulation or portal cavernous transformation in 83.3% of patients. Enterography was required only in 81.0% of patients, with positive findings in all patients, including complete obstruction (23.5%), intestinal stricture (64.7%), and extensive mucosal erosion (11.8%). Prompt conservative treatment achieved significantly increases of albumin and pre-albumin levels and correction of electrolyte disorders (all p < 0.05). However, only 4 (9.5%) patients improved after conservative therapy and laparotomy was required in other patients. A median length of 20 (2-100) cm of involved bowel was resected, mainly involving the jejunum (76.3%). Only 1 patient died due to uncontrolled transverse colon bleeding, and other patients’ postoperative courses were uneventful. Conclusion During the post-thrombotic course, clinicians should be aware of the possibility of PIIS in patients with symptoms of ileus and hypoproteinemia. Patients may respond to conservative therapy; however, the majority of patients warrant surgical resection.