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.
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.
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.
Acute mesenteric ischemia; chronic mesenteric ischemia; nonocclusive mesenteric ischemia; intestinal angina
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.
Vasculitis is an inflammation of vessel walls, followed by alteration of the blood flow and damage to the dependent organ. Vasculitis can cause local or diffuse pathologic changes in the gastrointestinal (GI) tract. The variety of GI lesions includes ulcer, submucosal edema, hemorrhage, paralytic ileus, mesenteric ischemia, bowel obstruction, and life-threatening perforation.The endoscopic and radiographic features of GI involvement in vasculitisare reviewed with the emphasis on small-vessel vasculitis by presenting our typical cases, including Churg-Strauss syndrome, Henoch-Schönlein purpura, systemic lupus erythematosus, and Behçet’s disease. Important endoscopic features are ischemic enterocolitis and ulcer. Characteristic computed tomographic findings include bowel wall thickening with the target sign and engorgement of mesenteric vessels with comb sign. Knowledge of endoscopic and radiographic GI manifestations can help make an early diagnosis and establish treatment strategy.
Behçet’s disease; Churg-Strauss syndrome; Computed tomography; Endoscopy; Gastrointestinal tract; Henoch-Schönlein purpura; Histopathology; Lupus mesenteric vasculitis; Systemic lupus erythematosus; Vasculitis
Background. Small bowel ischemia due to superior mesenteric vein thrombosis (MVT) is rare during pregnancy. However, additional precipitating factors should usually be identified. Case. A 31-year-old woman, pregnant at 34 weeks, was sent to the emergency department because of acute peritonitis. An emergency exploration revealed a segmental gangrene of the small intestine without any mechanical obstruction. Together with the termination of pregnancy, resection of the damaged small bowel was performed, and an end-to-end enterostomy was followed. Based on the operative and pathological findings, small bowel ischemia might be attributed to superior mesenteric vein thrombosis. Conclusion. Hypercoagulation state normally found in pregnant women is believed to lead to this catastrophic condition without other precipitating factors.
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.
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.
Introduction. In mesenteric infarction due to arterial occlusion, laser Doppler flowmetry and spectrometry are known reliable noninvasive methods for measuring microvascular blood flow and oxygen utilisation. Case Presentation. As an innovation we used these methods in a patient with acute extensive mesenteric infarction due to venous occlusion, occurring after radical right hemicolectomy. Aiming to avoid short bowel syndrome, we spared additional 110 cm of small bowel, instead of leaving only 80 centimetres of clinically viable small bowel in situ. The pathological examination showed only 5 mm of vital mucosa to be left distal to the dissection margin. No further interventions were necessary. Conclusion. Laser doppler flowmetry and spectrometry are potentially powerful methods to assist the surgeon's decision-making in critical venous mesenteric perfusion, thus having an important impact on clinical outcome.
Abdominal angina is a descriptive term for abdominal pain that can occur postprandially in patients with occlusive mesenteric vascular disease due to insufficient increase in blood flow.
In this case a 60-year-old Caucasian woman with a 2 year history of abdominal angina presented to hospital for elective mesenteric revascularization surgery. Postoperative recovery was complicated by graft occlusion resulting in hepatic ischemia as well as splenic and small bowel infarction.
This case highlights the importance of keeping this differential diagnosis in mind when dealing with patients who have a long history of abdominal pain and discusses some of the complications that may occur after surgical treatment.
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.
Ischemic colitis; Mesenteric vein; Splenic vein
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.
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.
Enteric free flaps have proven to be useful in the reconstruction of the esophagus. This study was designed to determine whether cold preservation can prolong the ischemia time of enteric flaps from the distal small bowel. Adult mongrel dogs were anesthetized, and the abdomen was opened at the midline. Two 10-cm portions of the distal small bowel were identified and dissected out on a single pedicle. The bowel was then divided, and one segment was cooled with iced saline sponges while the second segment was not. The blood supply to both segments was then clamped. After 2 hours, the bowel was reanastomosed, and the cold segment was marked. Twenty-four hours later, the dogs were reanesthetized and given fluorescein and the bowel was then examined under the Woods lamp. Sections from both the warm ischemia and cold ischemia bowel were examined histologically. Results indicated that cooling the bowel can retard histologic changes that ischemia produces in the bowel.
Early identification of acute mesenteric ischemia (AMI) is challenging. The wide variability in clinical presentation challenges providers to make an early accurate diagnosis. Despite major diagnostic and treatment advances over the past decades, mortality remains high. Arterial embolus and superior mesenteric artery thrombosis are common causes of AMI. Non-occlusive causes are less common, but vasculitis may be important, especially in younger people. Because of the unclear clinical presentation and non-specific laboratory findings, low clinical suspicion may lead to loss of valuable time. During this diagnostic delay, progression of ischemia to transmural bowel infarction with peritonitis and septicemia may further worsen patient outcomes. Several diagnostic modalities are used to assess possible AMI. Multi-detector row computed tomographic angiography is the current gold standard. Although computed tomographic angiography leads to an accurate diagnosis in many cases, early detection is a persistent problem. Because early diagnosis is vital to commence treatment, new diagnostic strategies are needed. A non-invasive simple biochemical test would be ideal to increase clinical suspicion of AMI and would improve patient selection for radiographic evaluation. Thus, AMI could be diagnosed earlier with follow-up computed tomographic angiography or high spatial magnetic resonance imaging. Experimental in vitro and in vivo studies show promise for alpha glutathione S transferase and intestinal fatty acid binding protein as markers for AMI. Future research must confirm the clinical utility of these biochemical markers in the diagnosis of mesenteric ischemia.
Acute mesenteric ischemia; Diagnosis; Biological markers; Intestinal fatty acid binding protein; Alpha-glutathione S transferase
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.
Autodigestion; small intestine permeability; pancreatic enzymes; inflammatory mediators
A case of granulomatous ileocolitis which also showed features of ulcerative colitis, and in which lesions were believed to be due to inflammation of previously undescribed structures, microdiverticula, was reported previously. Subsequently, sections of the segments of bowel received from 17 cases of regional enteritis and 16 cases of ulcerative colitis were re-examined for the presence of similar microdiverticula and submucosal epithelial elements. The same structures were present in five cases of regional enteritis and in 14 of ulcerative colitis. A granulomatous type of inflammatory response was found in the bowel and lymph nodes in 14 of the 17 cases of regional enteritis, and in none of the cases labelled ulcerative colitis. In spite of this, difficulty was experienced in placing some cases in one or other diagnostic category. This re-emphasizes the possibility that the two conditions may not be etiologically discrete, and that both may be, in fact, related to the presence of microdiverticula. In addition, it may be that colitis cystica profunda is a result of microdiverticulosis in which the submucosal glandular structures attain unusually large proportions.
Introduction. Intestinal ischaemia is a devastating disease process that could lead to bowel gangrene and death if either not diagnosed early or left untreated; death is usually caused by irreversible shock, intestinal necrosis, or septicaemia. It is usually seen in elderly patients with atherosclerotic disease. The course of bowel ischaemia may affect variable lengths of the intestine and it is not unusual for the condition to be followed by uneventful recovery. Case presentation. We are reporting an unusually rare case where an elderly patient passed an extraordinarily long segment of bowel, including rectum, the whole of the large bowel, and part of the small bowel, through anus following an episode of nonobstructive mesenteric ischaemia (NOMI) complicating myocardial infarction. To our knowledge, there are only eight cases reported in the literature where the condition was diagnosed upon the passage of short segments of the large bowel particularly of the rectosigmoid segment through the anus. Conclusion. Physician should keep a high level of suspicion in order to prevent it or at least recognise it early on and offer adequate management and hence reducing morbidity and mortality.
Ischemia bowel remains a critical problem resulting in up to 80% mortality. The loss of gut barrier function plays an important role. Our previous studies have shown that administration of adrenomedullin (AM), a novel vasoactive peptide, and its binding protein (AMBP-1), reduces the systemic inflammatory response and organ injury after systemic ischemia induced by hemorrhagic shock. However, it remains unknown whether administration of AM/AMBP-1 preserves gut barrier function after gut ischemia reperfusion (I/R). We therefore hypothesized that AM/AMBP-1 prevents structural and functional damages to the intestinal mucosa after gut I/R. To test this, gut ischemia was induced by placing a microvascular clip across the superior mesenteric artery (SMA) for 90 min in male adult rats. After release of the SMA clamp, AM (12 μg/kg BW) and AMBP-1 (40 μg/kg BW) in combination or vehicle (1-ml normal saline) were administered intravenously over a period of 30 min. The mucosal barrier function in the small intestine was assessed in an isolated everted ileum sac using fluorescein-isothiocyanate dextran (FD4) at 4 h after AM/AMBP-1 treatment. FD4 clearance was used as a measure of gut permeability. In additional groups of animals, blood and small intestine samples were collected at 4 h after the treatment. Morphological changes in the small intestine were assessed by H-E staining. Serum concentrations of alanine aminotransferase, aspartate aminotransferase, total bilirubin, direct bilirubin, lactate and lactate dehydrogenase were also assessed. The gene expression and protein levels of TNF-α in the small intestine were determined by RT-PCR and ELISA, respectively. Our results showed that administration of AM/AMBP-1 significantly attenuated the development of intestinal mucosal hyperpermeability during the reperfusion. Treatment with AM/AMBP-1 dramatically improved I/R-induced intestinal mucosal damages, attenuated remote organ injury, and downregulated gene expression and protein levels of TNF-α in the small intestine. In conclusion, AM/AMBP-1 attenuates structural and functional damages to the intestinal mucosa, and it appears to be a novel treatment for reperfusion injury after gut ischemia. The beneficial effect of AM/AMBP-1 on gut barrier function after I/R is associated with downregulation of TNF-α.
Ischemia-reperfusion; intestines; permeability; tissue injury; TNF-α
To evaluate the oral glutamine (GLN) on the luminal microbes and bacterial translocation (BT) in short bowel, 45 Wistar rats were utilized in three groups; A (control), and B and C (short bowel, 85% of small bowel resected). The group A was fed with elemental diet (EmD), B with EmD+2% glycine, and C with EmD+2% GLN. The groups B and C were isocaloric and isonitrogenous. Wet weight, DNA, protein, and histomorphometry of the mucosa and parallel microbial culture from cecal contents, caval blood, and tissue blocks of the liver, spleen, and mesenteric lymph nodes were performed on the 5th, 10th, and 15th day. Mucosal growth was higher in group C than B. Colony forming units (CFU) from cecal contents increased more in group B than in C. BTs in A, B, and C were 7/15, 8/15, and 2/15, respectively. Total CFUs in blood and tissues were 5.8 X 10(4)/g, 5.5 X 10(6)/g, and 1.8 X 10(4)/g, respectively. As for BT, the most frequent organism was Klebsiella in A (79.3%), but E. coli in B and C (94.2% and 55.6%). GLN seems to suppress luminal microbes, and reduces BT in short bowel due to enforced barrier function and proliferation of the mucosa.
During the 10 year period from 1988 to 1997, 64 patients with blunt small bowel and mesenteric injuries were treated at two trauma centres. The majority (52 cases) were victims of motor vehicle accidents, and 54% of them wore seat belts at the time of the accident. There were 22 small bowel injuries (17 full-thickness and 5 seromuscular) and 42 mesenteric injuries (7 with and 35 without a devascularised bowel segment). Shock on admission was present in 34% of the patients and generalised abdominal tenderness in 75%. Diagnostic peritoneal lavage was positive for blood in 25 out of 36 cases in which it was performed (69%), and positive for bowel content in 4/6 patients (67%) with full-thickness bowel perforations or transactions. Emergency room ultrasound was positive for blood in 13/25 cases (52%), and CT scan in 7/17 (41%). It is concluded that blunt small bowel and mesenteric injuries including patients with perforated or ischaemic bowel are difficult to diagnose using currently available diagnostic tools, and require a low threshold for exploration based on clinical suspicion in order to reduce the complications following delayed treatment of these injuries.
Existing animal models provide only indirect information about the pathogenesis of infections caused by indigenous gastrointestinal microflora and the kinetics of bacterial translocation. The aim of this study was to develop a novel animal model to assess bacterial translocation and intestinal barrier function in vivo.
In anaesthetized male Wistar rats, 0.5 ml of a suspension of green fluorescent protein-transfected E. coli was administered by intraluminal injection in a model of small bowel obstruction. Animals were randomly subjected to non-ischemic or ischemic bowel obstruction. Ischemia was induced by selective clamping of the terminal mesenteric vessels feeding the obstructed bowel loop. Time intervals necessary for translocation of E. coli into the submucosal stroma and the muscularis propria was assessed using intravital microscopy.
Bacterial translocation into the submucosa and muscularis propria took a mean of 36 ± 8 min and 80 ± 10 min, respectively, in small bowel obstruction. Intestinal ischemia significantly accelerated bacterial translocation into the submucosa (11 ± 5 min, p < 0.0001) and muscularis (66 ± 7 min; p = 0.004). Green fluorescent protein-transfected E. coli were visible in frozen sections of small bowel, mesentery, liver and spleen taken two hours after E. coli administration.
Intravital microscopy of fluorescent bacteria is a novel approach to study bacterial translocation in vivo. We have applied this technique to define minimal bacterial transit time as a functional parameter of intestinal barrier function.
bacterial translocation; green fluorescent protein; gut; obstruction; ischemia; E. coli; intravital microscopy; rat
Stage second-look laparoscopy to determine bowel viability appears to be an effective solution to determine the status of questionable blood supply to the intestine.
Background and Objectives:
An open, second-look laparotomy often is required to assess ischemic bowel after extensive mesenteric lymphadenectomy to cytoreduce midgut carcinoids. Aggressive resection of tumor at the base of the mesentery may compromise the integrity of the blood supply to the involved segment of intestine. Long segments of bowel that initially appear ischemic are sometimes created. The surgeon is faced with the decision to perform a resection or to close the abdomen temporarily knowing that this patient will require a second-look laparotomy.
Segments of bowel showing signs of possible ischemia were preserved based on signs of perfusion. A side-side anastomosis was performed in the standard fashion. A Jackson Pratt drain was placed in an area adjacent to the anastomosis and brought out through the abdominal wall, and the incision was closed. Forty-eight hours later, a laparoscopic second-look operation was performed. A pneumoperitoneum was established using the drain tubing as the CO2 inflation port. The drain was removed, and a 5-mm trocar was inserted into the abdomen via its tract. Segments of previously questionable dusky bowel and the anastomosis were inspected with a laparoscope.
Our 3 second-look operations were completed in approximately 5 minutes, and the patients recovered without complication or prolonged hospital course. Our fourth patient progressed extremely well postoperatively and was able to avoid the planned second-look laparos-copy.
This technique provides an easy solution for the intraoperative finding of questionable blood supply in the intestines.
Midgut carcinoid; Laparotomy; Laparoscopy; Bowel ischemia
The arterial and venous circulation of the bowel is complex and is characterized by marked redundancy of multiple interconnecting branches, which provides a rich blood supply to aid in the digestive process and also serves to protect the bowel from potential ischemia or infarction. As a result of this circulatory pattern, anatomic variants and extensive collateral pathways are common. A thorough knowledge of both the arterial and venous mesenteric circulation, including normal, variant, and collateral anatomy, is necessary for the appropriate evaluation and management of the various disease processes that may affect the vascular supply of the gastrointestinal system.
Mesenteric circulation; mesenteric collateral pathways; variant arterial anatomy
Bowel cancer is common and is a major cause of death. Most people with bowel symptoms who meet the criteria for urgent referral to secondary care will not be found to have bowel cancer, and some people who are found to have cancer will have been referred routinely rather than urgently. If general practitioners could better identify people who were likely to have bowel cancer or conditions that may lead to bowel cancer, the pressure on hospital clinics may be reduced, enabling these patients to be seen more quickly. Increased levels of an enzyme called matrix metalloproteinase 9 (MMP-9) have been found to be associated with such conditions, and this can be measured from a blood sample. This study aims to find out whether measuring MMP-9 levels could improve the appropriateness of urgent referrals for patients with bowel symptoms.
People aged 18 years or older referred to a colorectal clinic will be asked to complete a questionnaire about symptoms, recent injuries or chronic illnesses (these can increase the level of matrix metalloproteinases) and family history of bowel cancer. A blood sample will be taken from people who consent to take part to assess MMP-9 levels, and the results of examination at the clinic and/or investigations arising from the clinic visit will be collected from hospital records. The accuracy of MMP-9 will be assessed by comparing the MMP-9 level with the resulting diagnosis. The combination of factors (e.g. symptoms and MMP-9 level) that best predict a diagnosis of malignancy (invasive disease or polyps) will be determined.
Although guidelines are in place to facilitate referrals to colorectal clinics, symptoms alone do not adequately distinguish people with malignancy from people with benign conditions. This study will establish whether MMP-9 could assist this process. If this were the case, measurement of MMP-9 levels could be used by general practitioners to assist in the identification of people who were most likely to have bowel cancer or conditions that may lead to bowel cancer, and who should, therefore, be referred most urgently to secondary care.
Double balloon enteroscopy (DBE) is a revolutionary procedure in which the entire small bowel can be visualized endoscopically. DBE has the advantage of both diagnostic and therapeutic capabilities in the setting of small bowel neoplasms and vascular malformations. We present a unique case of a 76-year-old female who underwent small bowel DBE tattoo marking of a distal small bowel tumor complicated by development of severe abdominal pain postprocedure secondary to bowel air embolism into the mesenteric veins. Mesenteric air can be seen after other endoscopic procedures such as biopsy, mucosal clip placement and polypectomy, or following a colonoscopy. Mesenteric air embolism following small bowel tattooing procedure has not been previously reported in the literature. Mesenteric air when present may be attributed to mesenteric ischemia and can subject the patient to unnecessary surgical intervention if misdiagnosed. Thus, this report holds significance for the radiologist as computed tomography (CT) findings of mesenteric air embolism must be evaluated in the context of appropriate clinical history before treatment decisions are made.
CT air embolism; mesenteric air embolism; small bowel tattoo
Acute mesenteric ischemia is a serious acute abdominal condition requiring early diagnosis and intervention to improve the outcome. Although transmural acute bowel infarction represents about 1% of all cases of acute abdomen, it has a higher annual mortality rate than colon cancer. It tends to affect the colon in segmental fashion, mostly the splenic flexure and rectosigmoid portions of the colon. Isolated ischemia of the right side of the colon is rarely reported, especially in association with shock. Diagnosis of acute colonics ischemia is challenging as it may easily be confused with other non ischemic conditions both clinically and radiologically. Surgical resection is still the main curative approach. We present a case of segmental terminal ileum, cecum and part of ascending colon infarction due to isolated IleoColic artery thrombosis.
Chronic mesenteric ischemia is a rare condition, generally characterized by postprandial abdominal pain. Although chronic mesenteric ischemia accounts for only a small percentage of all mesenteric ischemic events, it can have significant clinical consequences. There are multiple etiologies; however, the most common cause is atherosclerosis. The diagnosis of chronic mesenteric ischemia requires a high clinical index of suspicion. An imaging study can confirm the presence of a stenosis or occlusion involving the mesenteric vessels in patients who are suspected of having chronic mesenteric ischemia. The diagnosis is usually late in its course due to the slow progression of disease and the abundance of mesenteric collaterals. Because of the extensive collateral network, usually at least two of the three visceral vessels need to be affected before patients develop symptoms. Treatment is necessary to avoid progression to bowel ischemia and infarction. Once a diagnosis of chronic mesenteric ischemia is made, treatment options include open surgical revascularization and endovascular revascularization.
Ischemia; mesenteric; atherosclerosis