Intestinal infarction in the absence of occlusive mesenteric vascular disease

Nonocclusive mesenteric ischemia remains a diagnostic dilemma

BACKGROUND

Despite reports of low mortality and high bowel-salvage rates in nonocclusive mesenteric ischemia (NOMI), our experience has been much less favorable. This study analyzes our experience with NOMI.

PATIENTS AND METHODS

A retrospective chart review (1979 to 1992) identified 113 patients with acute mesenteric ischemia, of whom 13 (12%) met our criteria for NOMI.

RESULTS

Patients were grouped into early and late presenters. The 5 early presenters were women, younger (mean age [+/- SD] 50 +/- 5.8 years), with no risk factors, and had vague symptoms leading to a delay in diagnosis. The 7 late presenters were older (mean age [+/- SD] 63 +/- 5.3 years) with identifiable risk factors; all had bowel infarction at the time of initial diagnosis.

CONCLUSIONS

Vague symptoms and a wide range of patients at risk make early diagnosis of NOMI uncommon. In the absence of early diagnosis, bowel resection with its high morbidity and mortality remains the only applicable treatment option in the vast majority of patients.

Current theories of pathogenesis and treatment of nonocclusive mesenteric ischemia

Nonocclusive mesenteric ischemia (NOMI) is a poorly understood condition marked by progressive intestinal ischemia leading to infarction, sepsis, and death in a high proportion of patients. The mortality rate for this intestinal disorder remains high, even when the diagnosis is made early in the disease course. This paper presents a comprehensive review of NOMI with a detailed discussion of its history, pathophysiology, diagnosis, and treatment.

Acute mesenteric infarction in elderly patients

The clinical features, the treatment given, the factors governing treatment selection, and the result of such treatment were analyzed in all patients aged 65 years and over in whom a tissue diagnosis of acute mesenteric infarction was made at a major teaching hospital. Thirty-two such patients, of mean age 78.5 years, were identified during the 8-year study period. Expected clinical features of bowel infarction were commonly absent; for example, there was no abdominal pain and no abdominal tenderness in 29% and 26% of patients, respectively. A sizeable minority of patients (29%) were acutely confused at presentation. All patients not undergoing surgery died shortly after admission to hospital. For those 20 patients (63%) who underwent abdominal surgery, half were discharged alive from hospital. Whether or not the patient survived was associated with the ward to which they were originally admitted. Those admitted to a surgical ward tended to be younger and had a more typical clinical presentation than their counterparts admitted to a medical ward. In particular they were more likely to have abdominal pain and distention and less likely to be confused. Surgical intervention was undertaken more often and earlier in those admitted to surgical wards and this may have accounted for the better outcome. It should be emphasized that acute mesenteric ischemia is a potentially correctable surgical condition even in very elderly people. A realization that the presentation is often atypical should increase the likelihood of early recognition and lead to improved patient survival.

Hepatic infarction associated with terminal hemorrhagic necrotizing enteropathy (THNE): case report

A case of hepatic infarction associated with terminal hemorrhagic necrotizing enteropathy (THNE) in an 84-year-old woman with cardiac failure is presented. The autopsy showed hepatic infarction, THNE, fibrous endocarditis, generalized arteriosclerosis, myocardial hypertrophy, liver congestion, and other findings as described. Both rare infarctions (hepatic and intestinal) seemed to have originated not only as a result of impaired systemic circulation due to cardiac failure, but also from liver congestion due to peripheral circulatory deficiency through the portal vein. The circulatory correlation between these infarcts of the liver and intestine is discussed.