Time is Tissue: The Importance of Clinical Suspicion in a Case of Mesenteric Ischemia
AAPA ePoster library. Gibbons C. 05/17/17; 180490; 73
Colleen Gibbons
Colleen Gibbons
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Abstract
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Mesenteric ischemia is caused by critical reduction in intestinal blood flow that frequently results in bowel necrosis, and thus, is a medical/surgical emergency. The condition accounts for about 1% of acute abdomen hospitalizations in the U.S.; however, it is the cause of acute abdomen in an estimated 10% of patients age 70 and above. For several decades, the mortality rate has remained high, ranging from 60-80%, due to continued difficulty in recognizing mesenteric ischemia before bowel infarction occurs. In this case, a 73-year-old female presented with diffuse, intolerable abdominal pain with associated nausea/vomiting, diarrhea, and diaphoresis occurring for the past 24 hours. Past medical history was significant for hypertension, hyperlipidemia, breast cancer, lung cancer, and a 40-pack year tobacco use history. Physical exam revealed a soft abdomen, diffusely tender to palpation, with the presence of faint bowel sounds. Despite the relative lack of findings upon examining the abdomen, the patient was clearly in distress. She was unable to lie still, moaning, pale, and grasping her abdomen in discomfort. The combination of laboratory results showing leukocytosis and lactic acidosis, and the patient's presentation of pain out of proportion to physical exam findings, led to the consideration of mesenteric ischemia as a top differential. A CTA of the abdomen with contrast was performed revealing critical stenosis of the superior mesenteric artery (95-99% stenosis) with no evidence of bowel infarction at the time. The patient was taken to the OR for emergent mesenteric revascularization and after a 14-day hospital stay was discharged home in stable condition. Due to the wide variation in clinical presentation and non-specific laboratory findings, making an early and accurate diagnosis of mesenteric ischemia is difficult. Delays in diagnosis allow for the progression of intestinal ischemia to bowel infarction, and thus, worse patient outcomes. This case exemplifies how maintaining a high index of clinical suspicion in acute abdomen patients, especially those over age 60, can prevent loss of valuable time, spare bowel infarction and, ultimately, save a life....
Mesenteric ischemia is caused by critical reduction in intestinal blood flow that frequently results in bowel necrosis, and thus, is a medical/surgical emergency. The condition accounts for about 1% of acute abdomen hospitalizations in the U.S.; however, it is the cause of acute abdomen in an estimated 10% of patients age 70 and above. For several decades, the mortality rate has remained high, ranging from 60-80%, due to continued difficulty in recognizing mesenteric ischemia before bowel infarction occurs. In this case, a 73-year-old female presented with diffuse, intolerable abdominal pain with associated nausea/vomiting, diarrhea, and diaphoresis occurring for the past 24 hours. Past medical history was significant for hypertension, hyperlipidemia, breast cancer, lung cancer, and a 40-pack year tobacco use history. Physical exam revealed a soft abdomen, diffusely tender to palpation, with the presence of faint bowel sounds. Despite the relative lack of findings upon examining the abdomen, the patient was clearly in distress. She was unable to lie still, moaning, pale, and grasping her abdomen in discomfort. The combination of laboratory results showing leukocytosis and lactic acidosis, and the patient's presentation of pain out of proportion to physical exam findings, led to the consideration of mesenteric ischemia as a top differential. A CTA of the abdomen with contrast was performed revealing critical stenosis of the superior mesenteric artery (95-99% stenosis) with no evidence of bowel infarction at the time. The patient was taken to the OR for emergent mesenteric revascularization and after a 14-day hospital stay was discharged home in stable condition. Due to the wide variation in clinical presentation and non-specific laboratory findings, making an early and accurate diagnosis of mesenteric ischemia is difficult. Delays in diagnosis allow for the progression of intestinal ischemia to bowel infarction, and thus, worse patient outcomes. This case exemplifies how maintaining a high index of clinical suspicion in acute abdomen patients, especially those over age 60, can prevent loss of valuable time, spare bowel infarction and, ultimately, save a life....
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