NSTEMI: Not Just a ‘Small Heart Attack’

Managing Mesenteric-Side Small Bowel Perforation in the Setting of Non-ST Elevation Myocardial Infarction: A Dual Challenge

Small bowel perforations are critical surgical emergencies, and those occurring on the mesenteric side are particularly uncommon. These perforations can lead to significant morbidity due to potential vascular compromise and the rapid spread of intraluminal contents. When a patient concurrently presents with a non-ST elevation myocardial infarction (NSTEMI), the clinical management becomes even more intricate. Balancing the urgency of surgical intervention for bowel perforation with the potential cardiac risks associated with surgery, especially in the context of a concurrent NSTEMI, poses a significant clinical challenge. An 86-year-old male with an extensive cardiac history presented with a complaint of abdominal pain, primarily localized to the left lower quadrant. Diagnostic investigations, including a contrast-enhanced computerized tomography (CT) scan, identified extraluminal air and pronounced inflammation adjacent to a loop of small bowel, consistent with perforation. Simultaneously, elevated troponin levels and specific electrocardiogram (ECG) changes confirmed an NSTEMI diagnosis. Following a multidisciplinary discussion, the patient underwent exploratory laparotomy, resulting in small bowel resection. Postoperative cardiac monitoring managed a brief episode of supraventricular tachycardia effectively. This case highlights the intricacies involved in managing a patient with a rare mesenteric-side small bowel perforation while also dealing with an NSTEMI. While the causes of spontaneous small bowel perforations can vary, this case presented an added layer of complexity without a clear predisposing factor. The presence of NSTEMI introduced challenges in determining the timing and approach to surgical intervention. The necessity for collaboration between surgical and cardiology teams was evident, ensuring a comprehensive assessment of the patient's cardiac risk and optimizing cardiac medications. Managing a patient with concurrent small bowel perforation and NSTEMI demands meticulous clinical judgment and inter-specialty collaboration. This case offers valuable insights into the considerations and challenges faced in such unique clinical scenarios, emphasizing the importance of individualized patient care.