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1.  Delayed intestinal stricture following non-resectional treatment for non-occlusive mesenteric ischemia associated with hepatic portal venous gas: a case report 
BMC Surgery  2015;15:37.
Hepatic portal venous gas associated with non-occlusive mesenteric ischemia is indicative of a serious pathology that leads to bowel necrosis and it has a high mortality rate. Although non-occlusive mesenteric ischemia is acknowledged as a condition that requires early surgical treatment, it has been reported that bowel necrosis and surgical resection of the gangrenous lesion may be avoided if the condition is identified quickly and the cause is detected at an early phase. However, no reports or guidelines have been published that describe the management of patients in whom bowel necrosis and surgical treatment were avoided. We report the case of a patient who presented with non-occlusive mesenteric ischemia who was managed with non-resectional treatment at an early phase and had a delayed small-bowel stricture.
Case presentation
A 24-year-old man presented to the hospital with fever, abdominal pain, and vomiting. Abdominal computed tomography confirmed a diffuse gaseous distention with small-bowel pneumatosis and hepatic portal venous gas. An urgent laparotomy was performed, because septic shock associated with diffuse peritonitis and bowel necrosis was strongly suspected. Although we found purulent ascites and a perforated appendix at the time of surgery, gangrenous and transmural ischemic changes were not evident in the small bowel and colon. We performed an appendectomy without a bowel resection, and the patient was discharged on an oral diet. However, he was re-admitted to hospital, because 4 days after discharge he developed postoperative paralytic ileus. Non-operative management was chosen, but his symptoms did not improve. We decided to perform a laparotomy 40 days after the initial operation, and a considerable adhesion was detected. Therefore, only a synechotomy was performed. On day 57, he experienced symptoms that were associated with bowel obstruction once again. On day 59, a partial resection of the jejunum was performed. Severe luminal strictures were apparent within the jejunum, and marked structural changes were evident.
While non-surgical management can be chosen for selected patients with non-occlusive mesenteric ischemia, continuous observation to evaluate the development of delayed strictures that lead to bowel obstructions is required in patients who undergo non-resectional treatment.
PMCID: PMC4392740  PMID: 25885337
Non-occlusive mesenteric ischemia; Hepatic portal venous gas; Delayed stricture; Stenosis
2.  Fenestrated Endovascular Grafts for the Repair of Juxtarenal Aortic Aneurysms 
Executive Summary
Endovascular repair of abdominal aortic aneurysm (AAA) allows the exclusion of the dilated aneurismal segment of the aorta from the systematic circulation. The procedure requires, however, that the endograft extends to the healthy parts of the aorta above and below the aneurysm, yet the neck of a juxtarenal aortic aneurysm (JRA) is too short for a standard endovascular repair. Fenestrated endovascular aortic repair (f—EVAR) provides a solution to overcome this problem by enabling the continuation of blood flow to the renal and visceral arteries through holes or ‘fenestrations’ in the graft. These fenestrations are designed to match the ostial diameter of the renal and visceral arteries.
There are three varieties fenestration, small, large, and scallop, and their location needs to be customized to fit the anatomy of the patient. If the device is not properly designed, if the alignment is inaccurate, or if the catheterization of the visceral arteries is not possible, the procedure may fail. In such cases, conversion to open surgery may become the only option as fenestrated endografts are not retrievable.
It is recommended that a stent be placed within each small fenestration to the target artery to prevent shuttering of the artery or occlusion. Many authors have noted an increased risk of vessel occlusion in unstented fenestrations and scallops.
Once placed in a patient, life-long follow-up at regular intervals is necessary to ensure the graft remains in its intended location, and that the components have adequate overlap. Should the need arise, routine follow-up allows the performance of timely and appropriate intervention through detection of events that could impact the long-term outcomes.
Alternative Technology
The technique of fenestrated endovascular grafting is still in evolution and few studies have been with published mid-term outcome data. As the technique become more common in vascular surgery practices, it will be important to determine if it can provide better outcomes than open surgical repair (OSR).
In an OSR approach, aortic clamping above one or both renal arteries, or above the visceral arteries, is required. The higher the level of aortic clamping, the greater the risk of cardiac stress and renal or visceral ischemia. During suprarenal or supraceliac aortic clamping, strain-induced myocardial ischemia may also occur due to concomitant rise in cardiac afterload and a decrease in cardiac output. Reports indicate that 6% of patients undergoing surgical repair develop myocardial infarction. The ideal level of clamp location remains controversial with conflicting views having been reported.
A search of electronic databases (OVID MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library, and the International Agency for Health Technology Assessment [INAHTA] database was undertaken to identify evidence published from January 1, 2004 to December 19, 2008. The search was limited to English-language articles and human studies. The automatic search alerts were received and reviewed up to March 23, 2009.
The literature search and automatic search update identified 320 citations, of which 13 met inclusion/exclusion criteria. One comparative study presented at an international seminar, five single-arm studies on f—EVAR, and 7 studies on OSR (one prospective and six retrospective) were considered for this analysis.
To grade the strength of the body of evidence, the grading system formulated by the GRADE working group and adopted by MAS, was applied. The GRADE system classifies evidence quality as high (Grade A), moderate (Grade B), or low (Grade C) according to four key elements: study design, study quality, consistency across studies, and directness.
A summary of the characteristics of the f—EVAR and OSR studies found through the literature search is shown in Table ES-1.
Patient Characteristics: f–EVAR Studies versus OSR Studies
JRA, Juxtarenal aortic aneurysm; SRA, Suprarenal aortic aneurysm; TAA, Thoracic aortic aneurysm
Mortality Outcomes
The pooled estimate for 30-day mortality was 1.8% among the f—EVAR studies and 3.1% among the OSR studies that reported data for the repair of JRA separately. The pooled estimate for late mortality was 12.8% among the f—EVAR studies and 23.7% among the OSR studies that reported data for JRA separately.
Visceral Artery Events Reported in f—EVAR Studies
Renal Events during f-EVAR
A total of three main renal arteries and two accessory renal arteries became occluded during the procedure. These were all due to technical issues, except one accessory renal artery in which the artery was intentionally covered. One patient required open surgery following the procedure.
Renal Events During the follow-up
A total of 12 renal arteries (12 patients) were found to be occluded during follow-up. In two patients, the same side accessory renal artery was also occluded. Four (1.5%) patients lost one kidney and five (2.3%) patients underwent dialysis, three (1.4%) of which became permanent.
A total of 16 cases of renal artery stenosis (16 patients) occurred during follow-up. Eight of these were treated and eight were observed. Segmental renal infarcts were found in six patients but renal function was not impaired.
Mesenteric Events during f-EVAR
Three mesenteric events occurred during the f—EVAR procedures resulting in two deaths. One patient developed bowel ischemia due to embolization of the superior mesenteric artery (SMA); this patient died 13 days after the procedure from multiorgan failure. One patient died eights days after the procedure from mesenteric ischemia and bowel perforation. The third SMA event occurred during surgery with subsequent occlusion in early follow-up.
Mesenteric Events during Follow-up
During follow-up, five (1.8%) SMA occlusions/partial occlusions and one SMA stenosis were noted. Three of the five patients with SMA occlusion/partial occlusion remained asymptomatic and no further intervention was necessary. One patient underwent SMA bypass surgery and in two patients, the problem solved by SMA stenting. A summary of the outcomes reported in the f—EVAR and OSR studies is shown in Table ES-2.
Summary of Outcomes: Fenestrated Endovascular Graft Versus Open Surgical Repair for Treatment of Juxtarenal Aortic Aneurysm
Short- and medium-term results (up to 2 years) of f—EVAR for the repair of JRA showed that outcomes in f—EVAR series compare favourably with the figures for the OSR series; however, uncertainty remains regarding the long-term results. The following observations are based on low quality evidence.
F—EVAR has lower 30-day mortality than OSR (1.8% vs. 3.1%) and a lower late-mortality over the period of time that patients have been followed (12.8% vs. 23.7%).
There is a potential for the loss of target vessels during or after f—EVAR procedures. Loss of a target vessel may lead to loss of its respective end organ. The risk associated with this technique is mainly due to branch vessel ischemia or occlusion (primarily among the renal arteries and SMA). Ischemia or occlusion of these arteries can occur during surgery due to technical failure and/or embolization or it may occur during follow-up due to graft complications such as graft migration, component separation, or arterial thrombosis. The risk of kidney loss in this series of f—EVAR studies was 1.5% and the risk of mesenteric ischemia was 3.3%. In the OSR studies, the risk of developing renal insufficiency was 14.4% and the risk of mesenteric ischemia was 2.9%.
F—EVAR has a lower rate of postoperative cardiac and pulmonary complications.
Endoleak occurs in 22.5% of patients undergoing f—EVAR (all types) and about 8% of these require treatment. Most of the interventions performed to treat such endoleaks conducted using a minimally invasive approach.
Due to the complexity of the technique, patients must be appropriately selected for f—EVAR, the procedure performed by highly experienced operators, and in centers with advanced, high-resolution imaging systems to minimize the risk of complications.
Graft fenestrations have to be custom designed for each patient to fit and match the anatomy of their visceral arteries. Planning and sizing thus requires scrutiny of the target vessels with a high degree precision. This is important not only to prevent end organ ischemia and infarction, but to avoid prolonging procedures and subsequent adverse outcomes.
Assuming the average cost range of FEVAR procedure is $24,395-$30,070 as per hospital data and assuming the maximum number of annual cases in Ontario is 116, the average estimated cost impact range to the province for FEVAR procedures is $2.83M-$3.49M annually.
PMCID: PMC3377528  PMID: 23074534
3.  Mesenteric ischemia: the importance of differential diagnosis for the surgeon 
BMC Surgery  2013;13(Suppl 2):S51.
Intestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods (US, CT) will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies.
Basing on our institutions experience, 163 cases of mesenteric ischemia/infarction from various cases, investigated with CT and undergone surgical treatment were retrospectively evaluated, in particular trought the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction (liver, kidney, spleen).
To make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive (arterial, venous) and non occlusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text.
The radiological findings of mesenteric ischemia have different course in case of different etiology. In venous etiology the progression of damage results faster than arterial even if the symptomatology is less acute; bowel wall thickening is an early finding and easy to detect, simplifying the diagnosis. In arterial etiology the damage progression is slower than in venous ischemia, bowel wall thinning is typical but difficult to recognize so diagnosis may be hard. In the NOMI before/without reperfusion the ischemic damage is similar to AAMI with additional involvement of large bowel parenchymatous organs. In reperfusion after NOMI and after AAMI the CT and surgical findings are similar to those of AVMI, and the injured bowel results quite easy to identify. The prompt recognition of each condition is essential to ensure a successful treatment.
PMCID: PMC3850956  PMID: 24267670
Intestinal ischemia; Computed Tomography; Emergency radiology
Shock (Augusta, Ga.)  2012;38(3):262-267.
In bowel ischemia, impaired mucosal integrity may allow intestinal pancreatic enzyme products to become systemic and precipitate irreversible shock and death. This can be attenuated by pancreatic enzyme inhibition in the small bowel lumen. It is unresolved, however, whether ischemically-mediated mucosal disruption is the key event allowing pancreatic enzyme products systemic access, and whether intestinal digestive enzyme activity in concert with increased mucosal permeability leads to shock in the absence of ischemia. To test this possibility, the small intestinal lumen of non-ischemic rats was perfused for two hours with either digestive enzymes, a mucin disruption strategy (i.e., mucolytics) designed to increase mucosal permeability, or both, and animals were observed for shock. Digestive enzymes perfused included trypsin, chymotrypsin, elastase, amylase and lipase. Control (n=6) and experimental animals perfused with pancreatic enzymes only (n=6) or single enzymes (n=3 for each of the five enzyme groups) maintained stable hemodynamics. After mucin disruption using a combination of enteral N-acetylcysteine, atropine, and increased flow rates, rats (n=6) developed mild hypotension (p<0.001 compared to groups perfused with pancreatic enzymes only after 90 minutes) and increased intestinal permeability to intralumenally perfused FITC-dextrans-20kD (p<0.05) compared to control and enzyme-only groups, but there were no deaths. All animals perfused with both digestive enzymes and subjected to mucin disruption (n=6) developed hypotension and increased intestinal permeability (p<0.001 after 90 minutes). Pancreatic enzymes were measured in the intestinal wall of both groups subjected to mucin disruption, but not in the enzyme-only or control groups. Depletion of plasma protease inhibitors was found only in animals perfused with pancreatic enzymes plus mucin disruption, implicating increased permeability and intralumenal pancreatic enzyme egress in this group. These experiments demonstrate that increased bowel permeability via mucin disruption in the presence of pancreatic enzymes can induce shock and increase systemic protease activation in the absence of ischemia, implicating bowel mucin disruption as a key event in early ischemia. Digestive enzymes and their products, if allowed to penetrate the gut wall may trigger multiorgan failure and death.
PMCID: PMC3422435  PMID: 22576000
Autodigestion; small intestine permeability; pancreatic enzymes; inflammatory mediators
5.  Small bowell perforation and mesentery injury after an unusual blunt abdominal trauma–Case report 
•Blunt abdominal trauma after injury with a straw of bale in a rural hospital.•Prompt evaluation with FAST and computed tomography did not show small bowell perforation.•Despite this the patient went to surgery wich revealed jejunal perforation.•Missed or another perforation needing re-surgery.•Highly clinical suspicion depending on the mechanism of abdominal trauma.
In blunt abdominal trauma, lesions of the small bowell and mesentery are often underdiagnosed; although unusual, they represent the third most injured organ, with increasing morbidity and mortality.
Presentation of case
The authors present the case of a 68 years old male, admitted to the emergency department after being hit by a bale of straw, weighing around 300 kg, in the abdomen. After successful ressuscitation, a CT scan was performed, suggesting hemoperitoneum because of vascular lesion of the right colon bleeding. An exploratory laparotomy was performed, confirming the presence of blood in the abdominal cavity and identifying jejunal perforation, an apparently innocent hematoma of the small bowel mesentery (beside the bowel wall) distally to the first lesion and a laceration of the sigmoid serosa; a segmental jejunal resection and suture of the colon serosa were performed. In the early post-operative period, an enteric discharge was noticed, mandating surgical reexploration; a previously unnoticed bowel perforation, in the mesenteric border where the hematoma was identified, justified an additional enterectomy, after what the patients recovery progressed uneventfully.
In this case, a sudden increase in abdominal pressure could explain that missed rupture of the mesenteric border of the jejunum, also causing the mesenteric hematoma, or, in spite of that, a state of low perfusion could have lead to total wall ischemia of an already irrigation compromised segment.
Only noted after surgical exploration, despite prior evaluation with a computed tomography. Small bowell and mesenteric injuries are potentially missed due to decreased exploratory laparotomies for blunt abdominal trauma.
Although uncommon, small bowel and mesenteric injuries are associated with high morbidity and mortality. High clinical suspicion is essential for an early diagnosis
PMCID: PMC4336400  PMID: 25576959
Blunt abdominal trauma; Small bowell perforation; Mesenteric injury
6.  Small Bowel Transplant 
The Medical Advisory Secretariat undertook a review of the evidence on the effectiveness and cost-effectiveness of small bowel transplant in the treatment of intestinal failure.
Small Bowel Transplantation
Intestinal failure is the loss of absorptive capacity of the small intestine that results in an inability to meet the nutrient and fluid requirements of the body via the enteral route. Patients with intestinal failure usually receive nutrients intravenously, a procedure known as parenteral nutrition. However, long-term parenteral nutrition is associated with complications including liver failure and loss of venous access due to recurrent infections.
Small bowel transplant is the transplantation of a cadaveric intestinal allograft for the purpose of restoring intestinal function in patients with irreversible intestinal failure. The transplant may involve the small intestine alone (isolated small bowel ISB), the small intestine and the liver (SB-L) when there is irreversible liver failure, or multiple organs including the small bowel (multivisceral MV or cluster). Although living related donor transplant is being investigated at a limited number of centres, cadaveric donors have been used in most small bowel transplants.
The actual transplant procedure takes approximately 12-18 hours. After intestinal transplant, the patient is generally placed on prophylactic antibiotic medication and immunosuppressive regimen that, in the majority of cases, would include tacrolimus, corticosteroids and an induction agent. Close monitoring for infection and rejection are essential for early treatment.
Medical Advisory Secretariat Review
The Medical Advisory Secretariat undertook a review of 35 reports from 9 case series and 1 international registry. Sample size of the individual studies ranged from 9 to 155.
As of May 2001, 651 patients had received small bowel transplant procedures worldwide. According to information from the Canadian Organ Replacement Register, a total of 27 small bowel transplants were performed in Canada from 1988 to 2002.
Patient Outcomes
The experience in small bowel transplant is still limited. International data showed that during the last decade, patient survival and graft survival rates from SBT have improved, mainly because of improved immunosuppression therapy and earlier detection and treatment of infection and rejection. The Intestinal Transplant Registry reported 1-year actuarial patient survival rates of 69% for isolated small bowel transplant, 66% for small bowel-liver transplant, and 63% for multivisceral transplant, and a graft survival rate of 55% for ISB and 63% for SB-L and MV. The range of 1-year patient survival rates reported ranged from 33%-87%. Reported 1-year graft survival rates ranged from 46-71%.
Regression analysis performed by the International Transplant Registry in 1997 indicated that centres that have performed at least 10 small bowel transplants had better patient and graft survival rates than centres that performed less than 10 transplants. However, analysis of the data up to May 2001 suggests that the critical mass of 10 transplants no longer holds true for transplants after 1995, and that good results can be achieved at any multiorgan transplant program with moderate patient volumes.
The largest Centre reported an overall 1-year patient and graft survival rate of 72% and 64% respectively, and 5-year patient and graft survival of 48% and 40% respectively. The overall 1-year patient survival rate reported for Ontario pediatric small bowel transplants was 61% with the highest survival rate of 83% for ISB.
The majority (70% or higher) of surviving small bowel transplant recipients was able to wean from parenteral nutrition and meet all caloric needs enterally. Some may need enteral or parenteral supplementation during periods of illness. Growth and weight gain in children after ISB were reported by two studies while two other studies reported a decrease in growth velocity with no catch-up growth.
The quality of life after SBT was reported to be comparable to that of patients on home enteral nutrition. A study found that while the parents of pediatric SBT recipients reported significant limitations in the physical and psychological well being of the children compared with normal school children, the pediatric SBT recipients themselves reported a quality of life similar to other school children.
Survival was found to be better in transplants performed since 1991. Patient survival was associated with the type of organ transplanted with better survival in isolated small bowel recipients.
Adverse Events
Despite improvement in patient and graft survival rates, small bowel transplant is still associated with significant mortality and morbidity.
Infection with subsequent sepsis is the leading cause of death (51.3%). Bacterial, fungal and viral infections have all been reported. The most common viral infections are cytomegalorvirus (18-40%) and Epstein-Barr virus. The latter often led to ß-cell post-transplant lymphoproliferative disease.
Graft rejection is the second leading cause of death after SBT (10.4%) and is responsible for 57% of graft removal. Acute rejection rates ranged from 51% to 83% in the major programs. Most of the acute rejection episodes were mild and responded to steroids and OKT3. Antilymphocyte therapy was needed in up to 27% of patients. Isolated small bowel allograft and positive lymphocytotoxic cross-match were found to be risk factors for acute rejection.
Post-transplant lymphoproliferative disease occurred in 21% of SBT recipients and accounted for 7% of post-transplant mortality. The frequency was higher in pediatric recipients (31%) and in adults receiving composite visceral allografts (25%). The allograft itself is often involved in post-transplant lymphoproliferative disease. The reported incidence of host versus graft disease varied widely among centers (0% - 14%).
Surgical complications were reported to occur in 85% of SB-L transplants and 25% of ISB transplants. Reoperations were required in 45% - 66% of patients in a large series and the most common reason for reoperation was intra-abdominal abscess.
The median cost of intestinal transplant in the US was reported to be approximately $275,000US (approximately CDN$429,000) per case. A US study concluded that based on the US cost of home parenteral nutrition, small bowel transplant could be cost-effective by the second year after the transplant.
There is evidence that small bowel transplant can prolong the life of some patients with irreversible intestinal failure who can no longer continue to be managed by parenteral nutrition therapy. Both patient survival and graft survival rates have improved with time. However, small bowel transplant is still associated with significant mortality and morbidity. The outcomes are inferior to those of total parenteral nutrition. Evidence suggests that this procedure should only be used when total parenteral nutrition is no longer feasible.
PMCID: PMC3387750  PMID: 23074441
7.  Non-occlusive mesenteric ischemia leading to 'pneumatosis intestinalis': a series of unfortunate hemodynamic events 
Cases Journal  2008;1:60.
Non-occlusive mesenteric ischemia (NOMI) is not uncommon in intensive care units. NOMI indicate ischemia of bowel wall without any significant obstruction in the mesenteric arteries. Common causes of NOMI include sepsis, severe cardiac failure, and any critical illness. Mesenteric circulation can suffer due to low cardiac output leading to very unfortunate outcomes. Pneumatosis Intestinalis is a radiologic sign which represent gas in the bowel wall, and could indicate mesenteric ischemia.
Case Presentation
We present a fatal case of a patient who developed NOMI secondary to multiple factors. Patient died after a long protracted course in the hospital secondary to severe septic shock.
This case emphasizes the importance of early detection and management of NOMI in a patient with low cardiac output and abdominal pain. In majority of the studies, NOMI is associated with high morbidity and mortality.
PMCID: PMC2499993  PMID: 18657272
8.  Acute thrombosis of the superior mesenteric artery in a 39-year-old woman with protein-S deficiency: a case report 
Acute thromboembolic occlusion of the superior mesenteric artery is a condition with an unfavorable prognosis. Treatment of this condition is focused on early diagnosis, surgical or intravascular restoration of blood flow to the ischemic intestine, surgical resection of the necrotic bowel and supportive intensive care. In this report, we describe a case of a 39-year-old woman who developed a small bowel infarct because of an acute thrombotic occlusion of the superior mesenteric artery, also involving the splenic artery.
Case presentation
A 39-year-old Caucasian woman presented with acute abdominal pain and signs of intestinal occlusion. The patient was given an abdominal computed tomography scan and ultrasonography in association with Doppler ultrasonography, highlighting a thrombosis of the celiac trunk, of the superior mesenteric artery, and of the splenic artery. She immediately underwent an explorative laparotomy, and revascularization was performed by thromboendarterectomy with a Fogarty catheter. In the following postoperative days, she was given a scheduled second and third look, evidencing necrotic jejunal and ileal handles. During all the surgical procedures, we performed intraoperative Doppler ultrasound of the superior mesenteric artery and celiac trunk to control the arterial flow without evidence of a new thrombosis.
Acute mesenteric ischemia is a rare abdominal emergency that is characterized by a high mortality rate. Generally, acute mesenteric ischemia is due to an impaired blood supply to the intestine caused by thromboembolic phenomena. These phenomena may be associated with a variety of congenital prothrombotic disorders. A prompt diagnosis is a prerequisite for successful treatment. The treatment of choice remains laparotomy and thromboendarterectomy, although some prefer an endovascular approach. A second-look laparotomy could be required to evaluate viable intestinal handles. Some authors support a laparoscopic second-look. The possibility of evaluating the arteriotomy, during a repeated laparotomy with a Doppler ultrasound, is crucial to show a new thrombosis. Although the prognosis of acute mesenteric ischemia due to an acute arterial mesenteric thrombosis remains poor, a prompt diagnosis, aggressive surgical treatment and supportive intensive care unit could improve the outcome for patients with this condition.
PMCID: PMC3036636  PMID: 21244677
9.  Intestinal Ischemia: US-CT findings correlations 
Critical Ultrasound Journal  2013;5(Suppl 1):S7.
Intestinal ischemia is an abdominal emergency that accounts for approximately 2% of gastrointestinal illnesses. It represents a complex of diseases caused by impaired blood perfusion to the small and/or large bowel including acute arterial mesenteric ischemia (AAMI), acute venous mesenteric ischemia (AVMI), non occlusive mesenteric ischemia (NOMI), ischemia/reperfusion injury (I/R), ischemic colitis (IC). In this study different study methods (US, CT) will be correlated in the detection of mesenteric ischemia imaging findings due to various etiologies.
Basing on experience of our institutions, over 200 cases of mesenteric ischemia/infarction investigated with both US and CT were evaluated considering, in particular, the following findings: presence/absence of arterial/venous obstruction, bowel wall thickness and enhancement, presence/absence of spastic reflex ileus, hypotonic reflex ileus or paralitic ileus, mural and/or portal/mesenteric pneumatosis, abdominal free fluid, parenchymal ischemia/infarction (liver, kidney, spleen).
To make an early diagnosis useful to ensure a correct therapeutic approach, it is very important to differentiate between occlusive (arterial,venous) and nonocclusive causes (NOMI). The typical findings of each forms of mesenteric ischemia are explained in the text.
At present, the reference diagnostic modality for intestinal ischaemia is contrast-enhanced CT. However, there are some disadvantages associated with these techniques, such as radiation exposure, potential nephrotoxicity and the risk of an allergic reaction to the contrast agents. Thus, not all patients with suspected bowel ischaemia can be subjected to these examinations. Despite its limitations, US could constitutes a good imaging method as first examination in acute settings of suspected mesenteric ischemia.
PMCID: PMC3711730  PMID: 23902826
10.  Superior mesenteric arterial branch occlusion causing partial jejunal ischemia: a case report 
Ischemic bowel disease comprises both mesenteric ischemia and colonic ischemia. Mesenteric ischemia can be divided into acute and chronic ischemia. These are two separate entities, each with their specific clinical presentation and diagnostic and therapeutic modalities. However, diagnosis may be difficult due to the vague symptomatology and subtle signs.
Case presentation
We report the case of a 68-year-old Caucasian woman who presented with abdominal discomfort, anorexia, melena and fever. A physical examination revealed left lower quadrant tenderness and an irregular pulse. Computed tomography of her abdomen as well as computed tomography enterography, enteroscopy, angiography and small bowel enteroclysis demonstrated an ischemic jejunal segment caused by occlusion of a branch of the superior mesenteric artery. The ischemic segment was resected and an end-to-end anastomosis was performed. The diagnosis of segmental small bowel ischemia was confirmed by histopathological study.
Mesenteric ischemia is a pathology well-known by surgeons, gastroenterologists and radiologists. Acute and chronic mesenteric ischemia are two separate entities with their own specific clinical presentation, radiological signs and therapeutic modalities. We present the case of a patient with symptoms and signs of chronic mesenteric ischemia despite an acute etiology. To the best of our knowledge, this is the first report presenting a case of acute mesenteric ischemia with segmental superior mesenteric artery occlusion.
PMCID: PMC3298780  PMID: 22309387
11.  Acute non-occlusive mesenteric ischemia of the small bowel in a patient started on hemodialysis: a case report 
Cases Journal  2008;1:217.
Non-occlusive mesenteric ischemia is not uncommon in chronic hemodialysis patients and is the major cause of an acute abdomen in this population. Intensive ultrafiltration and intradialytic hypotension are usually the precipitation factors. A definite diagnosis is usually late and associated with high mortality. We present a rare case of a patient who developed abdominal symptoms during his first week on HD without having obvious hypotensive episodes.
Case presentation
A 76-year-old man was admitted with pulmonary edema and renal failure developed abdominal symptoms during his first week on hemodialysis without having obvious hypotensive episodes. Abdominal diagnostic procedures were all unrevealing. Mesenteric ischemia was diagnosed during laparoscopy done on the basis of physical findings and clinical suspicion. Ischemic small bowel of the distal ileum was resected and histopathology examination of the small bowel demonstrated transmural ischemic necrosis with hemorrhages and non-occluded mesenteric artery. Patient maid a steady recovery, and was discharged on the 11th post-operative day.
Mesenteric ischemia should be systematically suspected in dialysis patients experiencing even mild and nonspecific abdominal symptoms with or without hemodialysis-induced hypotensive episodes. Identification of patients at risk and prevention of intradialytic hypotension may help to reduce the incidence of this potentially fatal complication in hemodialysis patients.
PMCID: PMC2572606  PMID: 18838003
12.  The Influence of Neocate in Paediatric Short Bowel Syndrome on PN Weaning 
Clinical management of short bowel syndrome remains a multistage process. Although PN is crucial, early introduction of enteral feeding is mandatory. We describe retrospectively 4 patients with an ultrashort bowel who could be weaned off PN on very short terms after introduction of an amino-acid-based formula (Neocate). Patient 1 had congenital short bowel with 50 cm small bowel and 30 cm colon. He had persistent diarrhoea on a semielementary formula. When Neocate was introduced he could be weaned from PN within 6 months. Patient 2 needed multiple surgical interventions because of NEC at D 27. He maintained 40 cm small bowel and an intact colon and remained PN dependent on semielemental formula. After introducing Neocate, PN could be weaned within 3 months. In the next 2 patients, Neocate was introduced as initial enteral feeding after bowel resection following antenatal midgut volvulus. Patient 3 had 20 cm small bowel and an intact colon. PN was weaned after 2 months. Patient 4 had 9 cm small bowel and an intact colon. PN was weaned after 13 months. In all patients Ileocaecal valve (ICV) was preserved. No consensus is reached on the type of formula to use for short bowel syndrome. Compared to recent data in the literature, the weaning period in these 4 patients was significantly shortened on an aminoacid based formula. The reason for this may lie in the antiallergic properties of this formula. We recommend the use of an amino-acid-based formula to induce earlier weaning of PN.
PMCID: PMC2915748  PMID: 20721339
13.  Early Feeding Is Feasible after Emergency Gastrointestinal Surgery 
Yonsei Medical Journal  2014;55(2):395-400.
This study was undertaken to assess the feasibility of early feeding in patients that have undergone emergency gastrointestinal (GI) surgery.
Materials and Methods
The authors retrospectively reviewed 84 patients that underwent emergency bowel resection and/or anastomosis from March 2008 to December 2011. Patients with severe shock, intestinal ischemia, sustained bowel perforation, or short bowel syndrome were excluded. Patients were divided into the early (group E; n=44) or late (group L; n=40) group according to the time of feeding commencement. Early feeding was defined as enteral feeding that started within 48 hours after surgery. Early and late feeding groups were compared with respect to clinical data and surgical outcomes.
The most common cause of operation was bowel perforation, and the small bowel was the most commonly involved site. No significant intergroup differences were found for causes, sites, or types of operation. However, length of stay (LOS) in the intensive care unit (1 day vs. 2 days, p=0.038) and LOS in the hospital after surgery were significantly greater (9 days vs. 12 days, p=0.012) in group L than group E; pulmonary complications were also significantly more common (13.6% vs. 47.5%, p=0.001) in group L than group E.
After emergency GI surgery, early feeding may be feasible in patients without severe shock or bowel anastomosis instability.
PMCID: PMC3936612  PMID: 24532509
Emergency treatment; enteral nutrition; gastrointestinal tract
14.  Serum lactate and phosphate as biomarkers of intestinal ischemia in a Ugandan tertiary hospital: a cross-sectional study 
Intestinal ischemia is a common complication of intestinal obstruction and arises from impaired perfusion. The resultant local and systemic inflammatory response and bacterial translocation come with a significant degree of morbidity and mortality. This study therefore aimed to investigate the predictive value of elevated levels of serum lactate and phosphate as biomarkers of intestinal ischemia among patients with mechanical intestinal obstruction.
This was a cross-sectional analytical study done at Mulago Hospital in Uganda. Ethical approval was obtained. All eligible patients had a blood sample drawn for assay analysis. Determination of bowel ischemia status was by physical examination at laparotomy. Analyses were performed using Stata software, version 10.1, and 2 × 2 tables were used to calculate sensitivity and specificity.
Serum lactate was predictive of bowel ischemia, while phosphate was not. Of the 81 patients enrolled 70 qualified for analysis; 40/70 (57%) had ischemic bowel, while 30/70 (43%) had normal bowel. Among those with ischemic bowel, 28/40 (70%) had reversible ischemia, and 12/40 (30%) had irreversible ischemia. Serum lactate assay had a sensitivity of 66% and specificity of 53% for bowel ischemia in general and a higher sensitivity of 71% and specificity of 80% for irreversible bowel ischemia.
Lactate was predictive of bowel ischemia in general (p = 0.011), PPV = 14%, but more significantly predictive of irreversible ischemia (p = 0.009), PPV = 42%. NPV for lactate in both forms of ischemia was 93%. Hernias (33/70, 47%) were the most common cause of intestinal obstruction.
Serum lactate assay had moderate sensitivity for bowel ischemia due to acute mechanical intestinal obstruction. The assay can be used to aid diagnosis of bowel ischemia in low technology settings.
PMCID: PMC4177190  PMID: 24304560
Bowel ischemia; Biomarkers; Serum lactate; Phosphate
15.  Mesenteric Ischemia 
Mesenteric ischemia is classified as either acute or chronic. The former is a life-threatening emergency in which a sudden reduction in intestinal blood flow may ultimately result in bowel infarction. The most common causes are arterial embolism, arterial thrombosis, nonocclusive mesenteric ischemia, and mesenteric venous thrombosis. A high index of suspicion, early diagnosis and rapid intervention are necessary so that normal mesenteric perfusion is restored before fatal bowel infarction can occur. Chronic mesenteric ischemia is usually caused by stenotic or occlusive disease involving the proximal segments of the mesenteric arterial supply to the bowel, usually as a result of atherosclerosis. Intestinal angina is the classic presentation, defined as recurrent postprandial abdominal pain that subsides in 1 to 2 hours, with associated weight loss and aversion to food. When combined with the clinical presentation, physical examination, and laboratory data, imaging plays a key role in the diagnosis of either acute or chronic mesenteric ischemia. Recognition of pertinent imaging findings and various treatment options may aid in preventing the serious and possibly fatal sequelae that may occur in cases of mesenteric ischemia.
PMCID: PMC3036494  PMID: 21326562
Acute mesenteric ischemia; chronic mesenteric ischemia; nonocclusive mesenteric ischemia; intestinal angina
16.  The Surgical Approach to Short Bowel Syndrome – Autologous Reconstruction versus Transplantation 
Viszeralmedizin  2014;30(3):179-189.
Short bowel syndrome (SBS) is a state of malabsorption resulting from massive small bowel resection leading to parenteral nutrition (PN) dependency. Considerable advances have been achieved in the medical and surgical management of SBS over the last few decades.
This review discusses in detail the surgical approach to SBS.
Widespread use of PN enables long-term survival in patients with intestinal failure but at the cost of PN-associated life-threatening complications including catheter-associated blood stream infection, venous thrombosis, and liver disease. The goal of management of intestinal failure due to SBS is to enable enteral autonomy and wean PN by means of a multi-disciplinary approach. Availability of modified enteral feeding formulas have simplified nutrition supplementation in SBS patients. Similarly, advances in the medical field have made medications like growth hormone and glucagon-like peptide (GLP2) available to improve water and nutrient absorption as well as to enable achieving enteral autonomy. Autologous gastrointestinal reconstruction (AGIR) includes various techniques which manipulate the bowel surgically to facilitate the bowel adaptation process and restoration of enteral nutrition. Ultimately, intestinal transplantation can serve as the last option for the cure of intestinal failure when selectively applied.
SBS continues to be a challenging medical problem. Best patient outcomes can be achieved through an individualized plan, using various AGIR techniques to complement each other, and intestinal transplantation as a last resort for cure. Maximum benefit and improved outcomes can be achieved by caring for SBS patients at highly specialized intestinal rehabilitation centers.
PMCID: PMC4513826  PMID: 26288592
Short bowel syndrome; SBS; Parenteral nutrition; PN; Autologous gastrointestinal reconstruction; AGIR; Longitudinal intestinal lengthening and tailoring; LILT; Serial transverse enteroplasty; STEP; Ultra-short bowel syndrome; USBS
17.  Application of Distractive Forces to the Small Intestine: Defining Safe Limits 
The Journal of surgical research  2010;163(2):169-175.
Distraction enterogenesis is a novel method for increasing small bowel length by the application of linearly directed forces. However, the magnitude of distractive forces that human and animal small bowel can safely withstand is unknown.
Acute ex-vivo force-displacement curves for human (n=5) and pig (n=6) small intestine (with and without mesentery) were made by applying increasing amounts of distractive forces to bowel immersed in normal saline (39°C). Progressive load was applied until gross disruption of the tissue was detected, or the applied force reached 1000 gram-force (gf). Histology was used to detect evidence of load-induced damage. In-vivo blood flow to pig bowel with distractive loads (30–200gf) was measured by laser Doppler.
The relationship between the level of force and degree of displacement was linear. The presence of a mesentery increased stiffness of pig bowel, but did not affect human bowel. Gross tissue disruption in pig and human tissue was seen at forces between 235 and 295 gf respectively. However, in grossly undamaged areas, histology was unchanged even after application of higher loads. With in-vivo testing, mesenteric blood flow was present up to 200 gf; however, blood flow to the bowel wall was reduced to undetectable levels at loads exceeding 100 gf.
While whole bowel tissue may tolerate greater applied loads, blood flow to the bowel wall was compromised at loads over 100 gf, suggesting that any higher forces place the bowel at risk for ischemia. These measurements will help guide the clinical application of distraction enterogenesis.
PMCID: PMC2943053  PMID: 20605600
Distraction enterogenesis; short bowel syndrome; mechanical properties of small bowel; force displacement
18.  Potential Role of Mesenchymal Stem Cells in Alleviating Intestinal Ischemia/Reperfusion Impairment 
PLoS ONE  2013;8(9):e74468.
Transplantation of bone marrow mesenchymal stem cells (MSCs) provides a promising therapeutic efficiency for a variety of disorders caused by ischemia or reperfusion impairment. We have previously demonstrated the efficacy of MSCs in mitigating intestinal ischemia/reperfusion (I/R) injuries in rats, but the mechanism by which MSCs engraft ameliorates I/R injuries has largely been unknown. The present study aimed at investigating probable mechanisms by which MSCs exert their function.
Male donor derived rat MSCs were implanted into intestine of female recipient rat by direct submucosal injection after superior mesenteric artery clamping and unclamping. The homed MSCs were detected by Y chromosome in situ hybridization probe, and the tumor necrosis factor-α (TNF-α) content in intestinal mucosa was determined by ELISA. Expression of proliferative cell nuclear antigen (PCNA) in bowel mucosa was assayed by real-time PCR and intestinal mucosa expression of phosphorylation extracellular signal-regulated kinase (pERK1/2) and nuclear factor-κB (NF-κB) were evaluated by western blot.
Four and seven days after MSCs transplantation, the TNF-α content of bowel mucosa in MSCs group was significantly lower than that in saline group. The PCNA in bowel mucosa showed higher expression in MSCs treated group than the saline group, both at 4 and 7 days after cell transplantation. The expression of intestinal mucosal pERK1/2 in MSCs treated group was markedly higher than that in saline group, and the expression of NF-κB in MSCs treated group was noticeably decreased than that in saline group at 4 and 7 days post MSCs transplantation.
The present investigation provides novel evidence that MSCs have the potential to reduce intestinal I/R injuries probably due to their ability to accelerate cell proliferation and decrease the inflammatory response within intestinal mucosa after ischemia and reperfusion.
PMCID: PMC3772852  PMID: 24058571
19.  Evaluation of splanchnic oximetry, Doppler flow velocimetry in the superior mesenteric artery and feeding tolerance in very low birth weight IUGR and non-IUGR infants receiving bolus versus continuous enteral nutrition 
BMC Pediatrics  2012;12:106.
IUGR infants are thought to have impaired gut function after birth, which may result in intestinal disturbances, ranging from temporary intolerance to the enteral feeding to full-blown NEC.
In literature there is no consensus regarding the impact of enteral feeding on intestinal blood flow and hence regarding the best regimen and the best rate of delivering the enteral nutrition.
This is a randomized, non-pharmacological, single-center, cross-over study including 20 VLBW infants.
Inclusion criteria
* Weight at birth ranging: 700–1501 grams
* Gestational age up to 25 weeks and 6 days
* Written informed consent from parents or guardians
Exclusion criteria
* Major congenital abnormality
* Patients enrolled in other trials
* Significant multi-organ failure prior to trial entry
* Pre-existing cutaneous disease not allowing the placement of the NIRS’ probe
In the first 24 hours of life, between the 48th and 72nd hours of life, and during Minimal Enteral Feeding, all infants’ intestinal perfusion will be evaluated with NIRS and a Doppler of the superior mesenteric artery will be executed.
At the achievement of an enteral intake of 100 mL/Kg/day the patients (IUGR and NON IUGR separately) will be randomized in 2 groups: Group A (n=10) will receive a feed by bolus (in 10 minutes); then, after at least 3 hours, they will receive the same amount of formula administered in 3 hours. Group B (n=10) will receive a feed administered in 3 hours followed by a bolus administration of the same amount of formula (in 10 minutes) after at least 3 hours.
On the randomization day intestinal and cerebral regional oximetry will be measured via NIRS. Intestinal and celebral oximetry will be measured before the feed and 30 minutes after the feed by bolus during the 3 hours nutrition the measurements will be performed before the feed, 30 minutes from the start of the nutrition and 30 minutes after the end of the gavage. An evaluation of blood flow velocity of the superior mesenteric artery will be performed meanwhile. The infants of the Group A will be fed with continuous nutrition until the achievement of full enteral feeding. The infants of the Group B will be fed by bolus until the achievement of full enteral feeding.
Evaluations of intestinal oximetry and superior mesenteric artery blood flow after the feed may help in differentiating how the feeding regimen alters the splanchnic blood flow and oxygenation and if the changes induced by feeding are different in IUGR versus NON IUGR infants.
Trial registration number
PMCID: PMC3447641  PMID: 22828032
Feeding tolerance; Near infrared spectroscopy; Minimal enteral feeding; Enteral nutrition; Parenteral nutrition; Intra-uterine growth restriction; Near infrared spectroscopy; Mesenteric artery Doppler; Bolus nutrition; Intermittent nutrition
20.  Ischemic colitis due to obstruction of mesenteric and splenic veins: A case report 
Ischemic injury to the bowel is a well known disease entity that has a wide spectrum of pathological and clinical findings. A sudden drop in the colonic blood supply is essential to its development. We encountered a 41-year-old male patient, who presented with abdominal pain and bloody diarrhea. A colonoscopy showed markedly edematous mucosa with tortuous dilatation of the veins and a deep ulceration at the rectosigmoid junction. On an abdominal computed tomography (CT) scan and CT angiography, the mesenteric and splenic veins were absent with numerous venous collaterals for drainage. The patient gradually responded to oral aminosalicylate therapy, and was in remission after nine months. In most cases, non-occlusive ischemic injury is caused by idiopathic form and occlusive ischemia is caused by abnormalities of arteries and acute venous thrombosis. However, chronic venous insufficiency due to obstruction of macrovascular mesenteric vein rarely causes ischemia of the bowel. This report describes the first case of ischemic colitis caused by obstruction of the mesenteric and splenic veins.
PMCID: PMC2703860  PMID: 18407609
Ischemic colitis; Mesenteric vein; Splenic vein
21.  Internal hernia and small bowel obstruction following open ileoanal pouch formation: A case report 
•Internal herniae although rare can give rise to potentially serious morbidity and mortality.•This young lady with a previous laparoscopic total colectomy and ileoanal pouch developed small bowel obstruction. “Prompt” surgery avoided bowel resection and losing pouch reconstruction.•Laparoscopic colectomy results in a more mobilization of the mesentery, and less adhesion formation promoting unusual internal hernia.•The case highlights the difficulty in making the diagnosis and the need for timely surgery to prevent small bowel ischemia and infarction.
Internal herniae, although rare, can give rise to potentially serious morbidity and mortality. The protrusion and entrapment of the small bowel through an embryological or iatrogenic mesenteric aperture within the confines of the peritoneal cavity can be difficult to diagnose, and delay treatment (operative). Timely intervention must be achieved to minimize small bowel ischemia and infarction.
Case presentation
In this case, a young lady who had a previous laparoscopic total colectomy and ileostomy developed an unusual internal hernia. Small bowel was passing behind the lesser curvature of the stomach causing the stomach to be rotated to form of a tight “band” trapping bowel. The herniated small bowel was reduced, hence, avoiding resection; the defect closed by interupted 4-0 PDS. “Prompt” surgery avoided small bowel length resection and sacrifice of the ileoanal pouch reconstruction.
It is theorized that a laparoscopic approach results in a more advanced mobilization of the mesentery right up to the small bowel origin, and with less adhesion formation may in fact promote unusual internal hernia and volvulus.
The case presented highlights the difficulty in making the diagnosis, and the pictures clearly indicate an unusual hernia passing directly behind the stomach and involving a large section of the small bowel. The lead up history of several admissions with sub acute small bowel obstruction suggested the underlying problem was adhesional but quite clearly there was a well defined internal hernia. Without timely surgery she would have been at high risk of losing her pouch.
PMCID: PMC4446662  PMID: 25935734
Ileo-anal pouch; Laparoscopy; Internal hernia; Small bowel obstruction
22.  Small bowel stricture as a late sequela of superior mesenteric vein thrombosis 
•64-year-old man admitted with abdominal pain and rectal bleeding found to have thrombosis of portal and superior mesenteric veins on abdominal CT.•Managed conservatively but returned seven months later with obstruction requiring segmental small bowel resection.•Case demonstrates that mesenteric vein thrombosis can be reversed by effective anticoagulation.•Patients escaping early bowel resection due to bowel infarction may still require resection later due to stricture.
The increasing frequency of use of CT in patients with acute abdomen is likely to improve the diagnosis of rarely occurring conditions/causes such as superior mesenteric vein thrombosis (MVT). Despite its severe consequences, MVT often presents with nonspecific clinical features.
Presentation of case
AD, a 64-year-old man was an emergency admission with vague abdominal discomfort of two weeks duration, acute upper abdominal pain, loose stools, fresh rectal bleeding and vomiting. A contrast enhanced abdominal CT showed thrombosis of the proximal portal vein and the entire length of the superior mesenteric vein (SMV) with small bowel ischaemia extending from the terminal ileum to the mid jejunal loops. Tests for paroxysmal nocturnal haemoglobinuria and Janus kinase 2 mutation yielded negative results. AD was readmitted seven months later with small bowel obstruction requiring segmental small bowel resection with end-to-end anastomosis. Abdominal CT had shown complete resolution of MVT but a small bowel stricture.
Thrombosis limited to mesenteric veins results in earlier and more frequent development of infarction compared to portal combined with mesenteric venous thrombosis. Most patients may be successfully treated with anti-coagulation therapy alone. However, surgery may be required to deal with intestinal infarction or late sequela of MVT.
This case demonstrates that MVT can be reversed by effective anticoagulation. However, the price paid for a mild to moderate effect on the bowel may be significant stricture later on. Patients escaping early bowel resection due to massive MVT leading to bowel infarction may still require resection later due to stricture.
PMCID: PMC4334991  PMID: 25544479
Superior mesenteric vein thrombosis; Anticoagulation therapy; Bowel infarction; Bowel stricture
23.  A rare cause of chronic mesenteric ischemia from fibromuscular dysplasia: a case report 
Chronic mesenteric ischemia is a condition that is classically associated with significant atherosclerosis of the abdominal arteries, causing postprandial abdominal pain out of proportion to physical examination. The abdominal pain is exacerbated after meals due to the shunting of blood away from the intestines to the stomach, causing relative ischemia. More than 95% of chronic mesenteric ischemia cases are due to atherosclerosis. We report the first known case of chronic mesenteric ischemia from fibromuscular dysplasia. To the best of our knowledge, this is also the first known case in the literature where postprandial abdominal pain was the presenting symptom of fibromuscular dysplasia.
Case presentation
A 44-year-old Caucasian woman with a history of hypertension and preeclampsia, who had taken oral contraceptive pills for 15 years, presented with an intractable, colicky abdominal pain of two weeks duration. This abdominal pain worsened with oral intake. It was also associated with diarrhea and vomiting. Physical examination revealed stage III hypertension out of proportion to her risk factors and diffuse abdominal pain without peritoneal signs. An abdominal computed tomography scan, completed in the emergency room, revealed nonspecific colitis. Laboratory work revealed leukocytosis with a left shift, an erythrocyte sedimentation rate of 79 and a C-reactive protein level of 100. She was started on intravenous flagyl and intravenous ciprofloxacin. However, all microbial cultures were negative including three cultures for clostridium difficile. Urine analysis revealed nephritic range proteinuria. The laboratory profile was within normal limits for perinuclear-anti-neutrophil cytoplasmic antibody, cytoplasmic-anti-neutrophil cytoplasmic antibody, anti-saccharomyces cerevisiae antibody, antinuclear antibody test, celiac profile, lactate, carbohydrate antigen-125 and thyroid stimulating hormone. A colonoscopy was completed, which revealed diffuse colonic lymphoid reactive hyperplasia. A small bowel series was negative for any inflammation. An indium scan, pan-computed tomography scan and transvaginal ultrasound were also negative. Magnetic resonance angiography of her abdomen revealed proximal superior mesenteric artery stenosis, which was confirmed by computed tomography angiogram findings of severe proximal and distal superior mesenteric artery stenosis, consistent with the appearance of fibromuscular dysplasia on angiography in the absence of vasculitis or atherosclerotic disease. The patient's superior mesenteric artery stenosis was subsequently angioplastied suboptimally and had to be stented with an Angioplus stent. One month after she was admitted, her abdominal pain and tolerance to oral feeds improved tremendously.
Fibromuscular dysplasia most commonly presents with renal artery stenosis, which rarely causes abdominal pain. This case illustrates how fibromuscular dysplasia can present as a rare cause of chronic mesenteric ischemia, similar to chronic mesenteric ischemia from atherosclerosis.
PMCID: PMC3002374  PMID: 21092091
24.  Surgical management of peritonitis secondary to acute superior mesenteric artery occlusion 
Diagnosis of acute arterial mesenteric ischemia in the early stages is now possible using modern computed tomography with intravenous contrast enhancement and imaging in the arterial and/or portal phase. Most patients have acute superior mesenteric artery (SMA) occlusion, and a large proportion of these patients will develop peritonitis prior to mesenteric revascularization, and explorative laparotomy will therefore be necessary to evaluate the extent and severity of intestinal ischemia, and to perform bowel resections. The establishment of a hybrid operating room in vascular units in hospitals is most important to be able to perform successful intestinal revascularization. This review outlines current frontline surgical strategies to improve survival and minimize bowel morbidity in patients with peritonitis secondary to acute SMA occlusion. Explorative laparotomy needs to be performed first. Curative treatment is based upon intestinal revascularization followed by bowel resection. If no vascular imaging has been carried out, SMA angiography is performed. In case of embolic occlusion of the SMA, open embolectomy is performed followed by angiography. In case of thrombotic occlusion, the occlusive lesion can be recanalized retrograde from an exposed SMA, the guidewire snared from either the femoral or brachial artery, and stented with standard devices from these access sites. Bowel resections and sometimes gall bladder removal due to transmural infarctions are performed at initial laparotomy, leaving definitive bowel reconstructions to a planned second look laparotomy, according to the principles of damage control surgery. Patients with peritonitis secondary to acute SMA occlusion should be managed by both the general and vascular surgeon, and a hybrid revascularization approach is of utmost importance to improve outcomes.
PMCID: PMC4123374  PMID: 25110423
Acute mesenteric ischemia; Peritonitis; Explorative laparotomy; Endovascular treatment; Hybrid revascularization; Superior mesenteric artery occlusion
25.  Initial transcatheter thrombolysis for acute superior mesenteric venous thrombosis 
AIM: To determine the optimal initial treatment modality for acute superior mesenteric vein thrombosis (ASMVT) in patients with circumscribed peritonitis.
METHODS: A retrospective review was made of the Vascular Surgery Department’s medical records to identify adult patients (≥ 18 years old) presenting with circumscribed peritonitis and diagnosed with ASMVT by imaging or endoscopic examination. Patients were selected from the time period between October 2009 and October 2012 to assess the overall performance of a new first-line treatment policy implemented in May 2011 for patients with circumscribed peritonitis, which recommends transcatheter thrombolysis with local anticoagulation and endovascular mechanical thrombectomy. Of the 25 patients selected for study inclusion, 12 had undergone emergency surgical exploration (group 1) and 13 had undergone the initial catheter-directed thrombolysis (group 2). Data extracted from each patient’s records for statistical analyses included method of diagnosis, symptoms, etiology and risk factors, thrombus location, initial management, morbidity, mortality, duration and total cost of hospitalization (in Renminbi, RMB), secondary operation, total length of bowel resection, duration of and findings in follow-up, and death/survival.
RESULTS: The two treatment groups showed similar rates of morbidity, 30-d mortality, and 1-year survival, as well as similar demographic characteristics, etiology or risk factors, computed tomography characteristics, symptoms, findings of blood testing at admission, complications, secondary operations, and follow-up outcomes. In contrast, the patients who received the initial non-operative treatment of transcatheter thrombolysis had significantly shorter durations of admission to symptom elimination (group 1: 18.25 ± 7.69 d vs group 2: 7.23 ± 2.42 d) and hospital stay (43.00 ± 13.77 d vs 20.46 ± 6.59 d), and early enteral or oral nutrition restoration (20.50 ± 5.13 d vs 8.92 ± 1.89 d), as well as significantly less total length of bowel resection (170.83 ± 61.27 cm vs 29.23 ± 50.24 cm) and lower total cost (200020.4 ± 91505.62 RMB vs 72785.6 ± 21828.16 RMB) (P < 0.05 for all). Statistical analyses suggested that initial transcatheter thrombolysis is correlated with quicker resolution of the thrombus, earlier improvement of symptoms, stimulation of collateral vessel development, reversal of intestinal ischemia, receipt of localizing bowel resection to prevent short bowel syndrome, shorter hospitalization, and lower overall cost of treatment.
CONCLUSION: For ASMVT patients with circumscribed peritonitis, early diagnosis is key to survival, and non-operative transcatheter thrombolysis is feasible and effective as an initial treatment.
PMCID: PMC4017063  PMID: 24833878
Acute superior mesenteric venous thrombosis; Transcatheter thrombolysis; Initial management; Circumscribed peritonitis

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