Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery

SHapley Additive exPlanations (SHAP)-based, multivariate machine-learning techniques with external validation: Construction of a preoperative interpretable predictive model for intestinal resection of incarcerated inguinal hernia

BACKGROUND

Currently, there are a lack of effective tools for preoperative risk assessment of intestinal resection in patients with inguinal incarcerated hernia. The purpose of this study is to investigate the variable characteristics associated with intestinal resection and develop an interpretable preoperative prediction model, aiming to assist clinicians in preoperative risk for intestinal resection in patients with inguinal incarcerated hernia.

METHODS

The data from 2 medical institutions were retrospectively collected, and they were grouped according to whether intestinal resection was performed intraoperatively and the pathologic results. Lasso and multifactor logistic regression screened variables, and 10 machine-learning algorithms built and validated the model, with evaluation using the confusion matrix and SHapley Additive exPlanations value.

RESULTS

Lasso regression and multifactorial logistic regression analyses showed that peritonitis, intestinal obstruction, neutrophil count, C-reactive protein, and preoperative total protein were the key characteristic variables. The area under curve of models constructed by 10 algorithms in the external validation set were all above 0.8, and the k-nearest neighbor algorithm had the most comprehensive model performance. The constructed model exhibits good predictive performance on the external validation set.

CONCLUSION

Accurate preoperative prediction of intraoperative intestinal ischemia in patients with incarcerated inguinal hernia is crucial. This study identified peritonitis, intestinal obstruction, neutrophil count, C-reactive protein, and preoperative total protein as characteristic variables for predicting intraoperative intestinal ischemia in these patients. The constructed prediction model can assist clinicians in more accurately assessing intestinal viability during surgery, offering valuable insights for evaluating intestinal resection risk.

Protective nutrition strategy in the acute phase of critical illness: why, what and how to protect

Nutritional support is crucial for critically ill patients. Recent clinical studies suggest that both overfeeding during the acute phase of critical illness and overly conservative or delayed nutritional therapy can pose significant risks. Given substantial individual variability among critically ill patients, it is challenging to prescribe universally applicable and objective feeding strategies; Instead, we pointed out which nutritional interventions were harmful. We also summarized the reasons for protective nutrition, and elaborated the advantages of protective nutrition from three perspectives: gastrointestinal protection, nutritional protection and metabolic protection. In particular, it is emphasized that overfeeding will lead to metabolic disorders, such as mitochondrial dysfunction, autophagy inhibition, ketogenic inhibition, hyperglycemia, insulin resistance, etc. These detrimental processes can exacerbate one another, contributing to multiple organ dysfunction syndrome and poorer clinical outcomes. We also propose protective nutrition strategies comparable to lung protective ventilation strategies, which may benefit patients. Vigilant monitoring during nutritional implementation is also paramount, enhancing awareness of adverse events for early diagnosis and intervention to mitigate their harm.

Reflections on the domino effect of a patient with multimorbidity: A case report and literature review

RATIONALE

As China enters an accelerated stage of global population aging, multimorbidity has emerged as a significant public health challenge. Current management strategies often focus primarily on index diseases, neglecting the complex interplay of multiple conditions in elderly patients.

PATIENT CONCERNS

An 86-year-old female with multimorbidity, including diabetes, hypertension, and osteoporosis, sustained a femoral fracture. Following "artificial bone replacement" surgery, she experienced significant loss of consciousness with a drastic decline in hemoglobin from 110 to 39 g/L.

DIAGNOSES

The patient's femoral fracture triggered a cascade of complications, resulting in hypoglycemic coma, gastrointestinal bleeding, and acute cerebral infarction. Utilizing a multimorbidity framework, general practitioners hypothesized and subsequently confirmed nonocclusive mesenteric ischemia (NOMI) as the cause of bleeding.

INTERVENTIONS

Management included timely interventions focused on addressing the underlying NOMI, specifically volume expansion and vasodilator therapy.

OUTCOMES

Following the targeted interventions addressing both the primary conditions and complications, the patient recovered sufficiently to be discharged from the hospital.

LESSONS

This case underscores the importance of holistic approaches in clinical practice when managing elderly patients with multimorbidity. It demonstrates how multiple conditions can interact in a domino effect and highlights the value of considering less common diagnoses like NOMI in complex elderly patients with multiple comorbidities.

Acute arterial mesenteric ischaemia: comparison of partial and complete occlusion of the superior mesenteric artery

OBJECTIVES

To describe the characteristics and outcomes of patients with an incomplete occlusion of the superior mesenteric artery (SMA) (persistence of contrast-enhanced vessel lumen) and compare them to those with a complete occlusion of the SMA (complete interruption of the contrast-enhanced vessel lumen) in arterial acute mesenteric ischaemia (AMI).

MATERIAL AND METHODS

Retrospective study of arterial AMI patients (2006-2022). Demographics, laboratory tests, clinical characteristics, CT, treatments and outcomes were compared between patients with complete or incomplete SMA obstruction after adjusting for aetiology (embolic or atherosclerotic). The primary outcome was 30-day mortality, and the secondary outcome was 6-month gastrointestinal disability-free survival (no short bowel syndrome or parenteral nutritional support or permanent stoma).

RESULTS

151 patients (65 women, mean age 69) were included, 62 (41%) with incomplete and 89 (59%) with occlusive SMA occlusion. After adjusting for aetiology, chronic kidney failure (p = 0.03) and normal bowel enhancement on CT (p < 0.01) were associated with incomplete SMA occlusion. Patients with incomplete SMA occlusion were more frequently treated by endovascular revascularisation (p < 0.01) and stenting (p < 0.01), while patients with complete SMA occlusion were treated by open revascularisation. The 30-day mortality rate was 13% with no difference between incomplete (11%) and complete SMA occlusion (15%; p = 0.89). Nevertheless, complete SMA occlusion patients had a lower 6-month gastrointestinal disability-free survival rate (p = 0.01), more transmural necrosis (p < 0.01) and a higher risk of gastrointestinal disability (p = 0.02).

CONCLUSION

Incomplete SMA occlusion can cause AMI with a similar 30-day mortality rate to completely occlusive forms. However, it is associated with poorer gastrointestinal outcomes, regardless of aetiology.

CRITICAL RELEVANCE STATEMENT

Acute arterial mesenteric ischaemia caused by incomplete occlusion of the superior mesenteric artery demonstrates similar 30-day mortality to complete occlusion but distinctively better gastrointestinal outcomes, emphasising nuanced imaging evaluation for targeted management strategies in these patients.

KEY POINTS

Occlusive acute mesenteric ischaemia can be caused by incomplete superior mesenteric artery (SMA) occlusion. Acute mesenteric ischaemia caused by incomplete SMA occlusion has a similar 30-day mortality rate to complete SMA occlusion. A complete occlusion of the SMA is associated with poorer gastrointestinal outcomes.

CT of acute abdomen in the elderly

Abdominal disorders represent 10 to 15% of all Emergency Department visits in elderly patients. This educational review focuses on acute abdomen pathologies specific to the elderly and on their imaging patterns and proposes a strategy for performing CT scans in this population. Bowel obstruction is the most common cause of emergency surgery in the elderly with a higher proportion of colonic obstructions, in particular obstructive colorectal cancer and sigmoid volvulus. Concerning abdominal inflammatory processes, such as cholecystitis, appendicitis, and diverticulitis, gangrenous cholecystitis and complicated appendicitis are relatively frequently encountered due to delayed diagnoses. Bowel ischemia, which includes acute mesenteric ischemia (AMI) and ischemic colitis (IC), is also much more common after the age of 80. Although ischemic colitis is mainly related to cardiovascular risk factors, it can also result from a persistent distension above a colonic cancer or from fecal impaction. Finally, extra-abdominal pathologies responsible for acute abdominal pain, such as inferior myocardial infarction, should not be overlooked. In clinical practice, when possible thanks to sufficient and appropriate radiological resources, we recommend a scan without injection of contrast and an injection depending on the results of the unenhanced scan, decided by the radiologist present at the CT scan room during the examination. CRITICAL RELEVANCE STATEMENT: CT is critical in the diagnosis and management of patients over 75 years old with an acute abdomen, given the difficulty of clinico-biological diagnosis, the frequency of complicated forms, and the morbidity induced by delayed diagnosis. KEY POINTS: The most common site and cause of bowel obstruction in the elderly is large bowel obstruction due to colon cancer. Discrepancy between a poor clinical examination and complicated forms on imaging, particularly for inflammation and infections, is responsible for late diagnosis and increased morbidity. Ischemia, including of the small bowel, colon, and gallbladder are common cause of acute abdomen in elderly. In patients with upper quadrant pain, consider extra-abdominal causes such as pneumonia or myocardial infarction.

Racial and Gender Disparities in the Management and Outcomes of Patients With Acute Mesenteric Ischemia: A Nationwide Retrospective Cohort Analysis

INTRODUCTION

Acute mesenteric ischemia (AMI) is often associated with poor prognosis without immediate intervention. Despite the severity of AMI, little is known regarding gender and race specific disparities in outcomes of hospitalized patients. The aim of this study was to characterize gender and race specific disparities in patients hospitalized with AMI using the U.S. National Inpatient Sample (NIS) database.

METHODS

A retrospective cohort study was performed on patients admitted with a primary diagnosis of AMI between January 1, 2016, and December 31, 2020, using the NIS database. Demographics, comorbidities, and in-hospital outcomes were compared between racial groups and genders. Categorical and continuous variables were analyzed with chi-squared test and multivariable linear regression, respectively. Odds ratios (ORs) for the race and gender cohorts were obtained with logistic regression models.

RESULTS

Of 99,225 patients, 55,420 (55.8%) were female. Compared to males, females had lower odds of in-hospital mortality (OR 0.93, P = 0.04), acute kidney injury (OR 0.70, P < 0.001), vasopressor use (OR 0.79, P < 0.001), invasive (OR 0.77, P < 0.001) and noninvasive mechanical ventilation (OR 0.70, P < 0.001), hemodialysis (OR 0.92, P < 0.001), venous thromboembolism (OR 0.78, P < 0.001), myocardial infarction (OR 0.80, P = 0.003), sudden cardiac arrest (OR 0.89, P = 0.002), and small bowel resection (OR 0.92, P = 0.003). Relative to White patients, Hispanic patients had significantly lower odds of inpatient mortality (OR 0.87, P = 0.04) and Native American patients had a higher risk of inpatient mortality (OR 1.64, P = 0.01). African American patients were significantly less likely to undergo percutaneous vascular intervention (OR 0.39, P < 0.001) and more likely to undergo small bowel resection (OR 1.25, P < 0.001).

CONCLUSIONS

AMI has worse outcomes in males. Disparities were also observed based on the race of the patients, with a worse complication profile among certain minority groups.

Real-time ancillary diagnostics for intraoperative assessment of intestinal viability in horses-looking for answers across species

Clinical intestinal viability assessment is associated with significant limitations, and there is an undisputable need for ancillary diagnostics during colic surgery. Human and companion animal surgeons struggle with similar intraoperative issues, yet there is little exchange between specialists. Therefore, this narrative review aimed to create an overview of real-time ancillary diagnostics with the potential for intraoperative intestinal viability assessment in horses. Most real-time ancillary diagnostics can be classified as either tissue perfusion or oxygenation assessments. Intestinal perfusion may be quantified using dark field microscopy, laser Doppler flowmetry, or fluorescence angiography (FA). In particular, indocyanine green FA has gained popularity in human medicine and is increasingly employed to predict intestinal injury. Intestinal oxygen saturation can be measured by pulse oximetry or mixed tissue oximetry. The latter can be conducted using visible light or near-infrared spectrophotometry, and these measurements correlate with clinical outcomes in various species. Other real-time diagnostics include thermography and techniques currently under development, such as laser speckle flowgraphy or photoacoustic imaging. The modalities discussed are minimally invasive and may be used for intraoperative assessments of the intestine. However, limitations include the occurrence of artifacts and the subjective nature of some modalities. Techniques such as indocyanine green FA and tissue oximetry are already available in veterinary practice and have the potential for use during colic surgery. However, blinded clinical trials are lacking in all species, and more research is needed to determine the accuracy and cutoff values in equine-specific intestinal lesions.

Management of acute mesenteric ischaemia in adult patients: a systematic review and meta-analysis

BACKGROUND

Guidance on managing acute mesenteric ischaemia (AMI) is largely based on expert opinion and retrospective studies pooling different subtypes of AMI. In clinical practice, management strategy is often selected based on the patient's severity of illness, whereas randomized controlled trials or even adjusted analyses comparing different strategies are rarely available. We aimed to perform a systematic review and meta-analysis on the effect of different management options when adjusted for the baseline severity of illness.

METHODS

A literature search was performed in PubMed, the Cochrane Library, Web of Science and Scopus. Studies recruiting patients after the year 2000, assessing at least 10 adult patients with reliably confirmed AMI, and comparing different management approaches were considered for inclusion. Thirteen study questions on different management strategies in different subtypes of AMI were formulated a priori. We included studies reporting results of adjusted analyses or reporting any variables reflecting the severity of illness in both study groups under comparison.

RESULTS

A total of 3324 publications were identified, 321 were selected for full-text review and 31 included in the review and analysis. Most of the studies comparing different management strategies of AMI did not report the severity of illness in the groups under comparison. Any variable that could be considered to reflect the severity of illness was reported in 26 studies. The available data only allowed one meta-regression analysis comparing initial endovascular revascularization versus open surgery in arterial occlusive AMI, including four studies that reported white blood cell count and lactate. The results indicate that the significant advantage of the endovascular approach suggested in the crude analysis may be abolished when adjusting for the severity of the illness. Narrative summaries and raw data are presented for other research questions.

CONCLUSIONS

The severity of illness plays an important role in the selection of management strategy and largely determines the outcome of any treatment, yet is generally not considered in available studies assessing the management of AMI. There is a major gap in the literature precluding appropriate analyses on treatment effects. Future studies should report subtypes of AMI and the severity of illness for each group.

STUDY REGISTRATION

PROSPERO CRD42024568497, date of registration: July 20th, 2024.

Acute mesenteric ischemia diagnosed via computed tomography in a dog following vehicular blunt force trauma: a Case Report

Acute mesenteric ischemia (AMI) refers to a group of vascular disorders that disrupt intestinal blood flow, resulting in intestinal ischemia and necrosis if left untreated. In both humans and dogs, this condition appears to be rare but deadly. There has only been one documented case of traumatic acute mesenteric ischemia in a dog, and the diagnosis was conducted through laparotomy. We present the case of a dog that was struck by a vehicle and subsequently developed traumatic acute mesenteric ischemia, which was diagnosed through computed tomography (CT). The dog presented with profuse hemorrhagic diarrhea, which persisted throughout the hospitalization. The dog's condition eventually deteriorated as a result of diffuse intestinal ischemia, diagnosed using computed tomography (CT). Due to the anticipated poor prognosis, the dog was euthanized humanely. Traumatic acute mesenteric ischemia in dogs may be an underdiagnosed consequence of vehicular trauma, necessitating further diagnostic investigation in dogs with persistent gastrointestinal signs that are unresponsive to medical therapy.

Endovascular Management of Acute and Chronic Mesenteric Ischemia

BACKGROUND

Mesenteric ischemia demands prompt and effective revascularization. Endovascular therapy (EVT) has become a well-established treatment modality with several benefits. This review examines current EVT options for managing acute and chronic mesenteric ischemia (CMI) in contemporary practice.

METHOD

A comprehensive literature review was conducted to evaluate endovascular techniques for mesenteric ischemia, including angioplasty, stenting, thrombectomy, thrombolysis, pharmacological thrombectomy, local vasodilator infusion, and hybrid approaches. We also evaluated access sites and postoperative management.

RESULTS

EVT offers several advantages in the management of mesenteric ischemia, with various access sites and techniques available for single or combined use. EVT has largely replaced open revascularization for CMI and is increasing in use for acute mesenteric ischemia (AMI). The utility of each approach varies by disease chronicity, with different risk-benefit profiles. While short-term outcomes are favorable, long-term patency rates and the need for reinterventions remain concerns. Further research is needed to compare open to endovascular revascularization.

CONCLUSION

EVT provides diverse revascularization options for mesenteric ischemia, particularly for high-risk patients. While it has favorable short-term outcomes, EVT may be associated with higher rates of restenosis and reintervention in the long term and the overall mortality rates for this disease process remain high, particularly for AMI. The choice between endovascular and open surgical approaches should be individualized on patient factors, lesion characteristics, and surgeon or interventionist expertise. Further prospective and randomized trials are needed to better elucidate outcomes from this approach and guide operative management.

Bowel Ischemia From Suspected Non-occlusive Mesenteric Ischemia: A Case Report

Acute ischemia of the bowel is a rare but life-threatening diagnosis in the emergency department (ED). While early detection is key to appropriate management, the utility of investigative modalities is limited by poor sensitivity and specificity. This report outlines the case of a 37-year-old female patient who presented to a tertiary hospital ED with severe, generalized, abdominal pain for several hours after eating at a restaurant. She had a known history of treatment for breast cancer, on chemotherapy, and was also diagnosed with dihydropyrimidine dehydrogenase (DPD) deficiency. Laboratory investigations, including C-reactive protein and full blood counts (FBCs), were not significantly suggestive of bowel ischemia, and CT abdomen and pelvis with intravenous (IV) contrast and angiogram revealed no obvious vascular occlusion. Severe, persistent pain out of proportion to physical examination raised suspicion of a non-occlusive mesenteric ischemia (NOMI), and a diagnostic laparotomy was performed, uncovering an infarcted duodenal segment that underwent resection and anastomosis. Post-op, the patient recovered well and was discharged without complications. Given the absence of typical risk factors, such as advanced age, atrial fibrillation, coagulopathy, cardiac disease, or a low-flow state in our patient, we explore the association of chemotherapeutic agents with NOMI, as well as the implications of DPD deficiency. A high index of suspicion for mesenteric ischemia should be maintained for any patient with severe, intractable abdominal pain, out of proportion to the clinical examination, even in the absence of conventional risk factors. Patients with malignancies may require additional consideration of ischemia risk from the use of chemotherapeutic agents, with possibly an increased risk with platinum-based compounds. Known DPD deficiency may also worsen chemotherapeutic drug-related toxicities, although its implication in ischemia is not well established.

Mesenteric Ischemia: Predicting Problems

BackgroundMesenteric ischemia is an uncommon diagnosis that is often overlooked until patients present with non-salvageable bowel. Our objective was to identify risk factors for mesenteric ischemia, clinical warning signs, and imaging findings that could suggest earlier diagnosis and intervention.MethodsWe queried our health system's electronic health record (EHR) to identify patients with ischemic bowel and/or a diagnosis of mesenteric ischemia between November 2013 and December 2020. Using stringent exclusion criteria, we included patients whose event was likely caused by atherosclerotic disease. From the EHR, we abstracted these patients' comorbidities and symptoms from the previous 6 months. We evaluated relevant computed tomography scans (CTs) obtained up to 2 years prior to admission and graded stenosis of the celiac artery and the superior mesenteric artery (SMA).ResultsForty-five patients met inclusion criteria. The most prevalent comorbidities were hypertension, hyperlipidemia, and heart disease. Over half of the patients in the cohort had mentioned suspicious abdominal symptoms during the 6 months preceding admission. Of the patients who had a CT within the 2 years prior to admission, there was discordance between the formal interpretations and independent reviews with significant stenosis being noted more commonly on independent review. Furthermore, in-hospital mortality was significantly higher when pre-presentation imaging noted SMA stenosis >70%.DiscussionThese data suggest that patients who were at risk of developing mesenteric ischemia had underlying vascular disease, a history of concerning symptoms, and prior CT imaging consistent with mesenteric atherosclerotic disease which could potentially be acted upon before the manifestation of an acute event.

Radiological diagnosis of acute mesenteric ischemia in adult patients: a systematic review and meta-analysis

Computed tomography (CT) is widely used in diagnosing acute mesenteric ischemia (AMI), but robust identification of distinctive subtypes and stages of progression is lacking. Systematic literature search in PubMed, Cochrane Library, Web of Science and Scopus was conducted in May 2024. Studies including at least 10 adult patients and reporting radiological diagnosis of AMI versus no AMI or transmural ischemia versus no transmural ischemia were included. Meta-analyses on sensitivity and specificity of different radiological features in diagnosing AMI were conducted. From 2628 titles, 490 studies underwent full text review, and 81 were included in 14 meta-analyses. Diagnostic accuracy of CT angiography (CTA) was high - sensitivity of 92.0% and specificity of 98.8% (I2 45% and 79%, respectively), but lower for other CT protocols (sensitivity 75.8 and specificity 90.5; I2 83%). In most included studies, distinction of subtypes and severity of AMI (non-transmural or transmural) was not possible. Amongst the non-vascular features, absent/reduced bowel wall enhancement provided the best prognostic value (sensitivity 57.9 and specificity 90.1). CTA is the method of choice for diagnosing AMI with high diagnostic accuracy. None of the non-vascular features alone is sufficiently reliable to diagnose AMI or its progression to transmural necrosis, whereas a combination of different radiological features conveys a potential.

Diagnosis and management of acute mesenteric ischemia: What you need to know

ABSTRACT

Acute mesenteric ischemia (AMI) is associated with high mortality rates. There are multiple challenges to establishing an accurate early diagnosis and providing state-of-the-art care for AMI patients. A high index of suspicion is key for early diagnosis. Once suspicion is raised, a triphasic computed tomography angiography is the essential diagnostic tool. Avoiding delays, using hybrid operating rooms and contemporary revascularization techniques for arterial occlusive AMI, can significantly improve the prognosis. Regional health care systems should be developed to direct AMI patients into centers with sufficient capabilities for providing all aspects of care at all hours. The acute care surgeon has a central role in performing laparotomies and bowel resections when needed and coordinating the management flow in close collaboration with vascular surgeons and interventional radiologists for prompt and effective revascularization. A significant share of patients with an arterial occlusive AMI can be managed by endovascular revascularization without the need for a laparotomy. There are no reliable tools for predicting transmural bowel necrosis, and individual assessment and clinical experience are very important in decision-making when choosing between laparotomy and close observation. During laparotomy, an atherosclerotic occlusion at the root of the superior mesenteric artery can be stented by using a retrograde open mesenteric or percutaneous approach, and surgical bypass is seldom needed. Using hospital-specific management pathways is very useful for the standardization of care in arterial occlusive AMI. In venous AMI, systemic anticoagulation is sufficient in most cases. In patients whose symptoms do not resolve, there are various options for endovascular and surgical revascularization. In nonocclusive mesenteric ischemia, prevention by maintaining sufficient abdominal perfusion pressure is key. High-level evidence is scarce, but with current knowledge, the prognosis of AMI patients has plenty of room for improvement.

Macrophage Membrane Coated Manganese Dioxide Nanoparticles Loaded with Rapamycin Alleviate Intestinal Ischemia-Reperfusion Injury by Reducing Oxidative Stress and Enhancing Autophagy

Background

Intestinal ischemia-reperfusion (I/R) injury is a common and severe clinical issue. With high morbidity and mortality, it burdens patients and the healthcare system. Despite the efforts in medical research, current treatment options are unsatisfactory, urging novel therapeutic strategies. Oxidative stress and dysregulated autophagy play pivotal roles in the pathogenesis of I/R injury, damaging intestinal tissues and disrupting normal functions. The aim of this study is to fabricate macrophage membrane-coated manganese dioxide nanospheres loaded with rapamycin [Ma@(MnO₂+RAPA)] for alleviating intestinal I/R injury.

Methods

We engineered honeycomb MnO2 nanospheres coated with a macrophage membrane to act as a drug delivery system, encapsulating RAPA. In vitro OGD/R model in IEC-6 cells and in vivo mouse I/R injury models were used. Targeting ability was evaluated through in-vivo imaging system. Effects on cell viability, reactive oxygen species (ROS) levels, oxygen generation, inflammatory factors, apoptosis, autophagy, and biocompatibility were detected by methods such as MTT assay, fluorescence microscopy, ELISA kit, TUNEL assay, Western blotting and histological analysis.

Results

In this study, Ma@(MnO₂+RAPA) efficiently deliver RAPA to damaged tissues and exhibited good ROS-responsive release. Our data showed that Ma@(MnO₂+RAPA) reduced ROS, increased O₂, inhibited inflammation, and promoted autophagy while reducing apoptosis in IEC-6 cells. In a mouse I/R model, Ma@(MnO₂+RAPA) significantly reduced Chiu's score, improved tight conjunction proteins, decreased apoptosis, reduced levels of inflammatory cytokines and oxidative stress. RAPA released from the Ma@(MnO₂+RAPA), enhanced the expression of autophagy-regulated proteins p62, Beclin-1, and LC3II. The biocompatibility and safety of Ma@(MnO₂+RAPA) were confirmed through histological analysis and biochemical detection in mice.

Conclusion

Our results demonstrated that Ma@(MnO₂+RAPA) alleviated intestinal I/R injury by reducing oxidative stress, promoting autophagy, and inhibiting inflammation. This study offers a potential therapeutic strategy for the treatment of intestinal ischemia-reperfusion injury.

Diagnostic Accuracy of Dual-Energy Computed Tomography for Bowel Necrosis in Acute Abdomen With Bowel Ischemia

Introduction Immediate diagnosis of bowel necrosis in acute abdominal conditions is essential for proper treatment. Dual-energy computed tomography (DECT) has recently emerged as a tool to assess intestinal viability in bowel ischemia. However, DECT's diagnostic accuracy for bowel necrosis in clinical practice remains undefined. Methods This single-center retrospective cohort study at a Japanese tertiary care hospital assessed DECT's diagnostic accuracy for bowel necrosis. We included patients who underwent emergency operations for abdominal conditions with bowel ischemia from April 2013 to March 2022. Patients without DECT were excluded. The reference standard was bowel necrosis determined by surgical findings. Four evaluators (two residents and two specialists) independently reviewed DECT images blinded to confirmed diagnoses. We calculated pooled and individual sensitivity, specificity, likelihood ratios, and accuracy. Results Twenty-eight patients were included. Pooled sensitivity and specificity were 0.65 (95% confidence interval (CI), 0.52-0.77) and 0.83 (95% CI, 0.70-0.92), respectively. Residents demonstrated higher sensitivity than specialists. Pooled positive and negative likelihood ratios were 3.76 (95% CI, 2.02-7.00) and 0.42 (95% CI, 0.29-0.61). Overall accuracy was 0.73 (95%CI, 0.64-0.81). Inter-evaluator agreement was moderate (Fleiss' kappa, 0.42). Conclusion DECT demonstrated moderate diagnostic accuracy for bowel necrosis in this Japanese tertiary care setting. While clinically valuable, DECT's diagnostic capability was not definitive. To optimize DECT's potential, future research should employ disease-specific image reconstruction techniques and provide evaluators with specialized DECT interpretation training.

Ischemic intestinal stenosis complicated with portal and superior mesenteric vein thrombosis: Case reports and literature review

RATIONALE

The main complication of the portal vein (PV) and superior mesenteric vein (SMV) thrombosis is intestinal infarction due to acute intestinal ischemia. However, in a small number of cases, chronic ischemia-induced bowel stenosis also occurs, and there are no published articles with a comprehensive literature review on this late complication. Therefore, we aimed to clarify the progression and clinical features of intestinal stenosis which is caused by thrombosis of the PV and SMV, and to share therapeutic experience.

PATIENT CONCERNS

We report 4 cases of ischemic intestinal stenosis occurring 4-8 weeks after successful treatment of PV and SMV thrombosis, and retrospectively analyzed the literature from 1990 to July 2024 for relevant cases to report.

DIAGNOSES

All 4 patients were admitted to the hospital due to abdominal pain and were diagnosed with ischemic intestinal stenosis complicated with PV and SMV thrombosis through imaging studies.

INTERVENTIONS

The 4 patients received thrombolytic and anticoagulant therapy due to PV and SMV thrombosis. Subsequently, they underwent partial small bowel resection and double enterostomy because of the development of intestinal stenosis.

OUTCOMES

Postoperative follow-up was conducted for the patients. Three patients underwent enterostomy reduction with a favorable prognosis, while 1 patient was lost to follow-up.

LESSONS

Patients with PV and SMV thrombosis should receive prompt anticoagulant or interventional therapy. In addition, closer follow-up should be carried out to ensure an earlier diagnosis of ischemic intestinal stenosis, leading to more timely treatment and a better prognosis.

Hybrid surgery for imminent rupture of superior mesenteric artery aneurysms

A case of a superior mesenteric artery aneurysm presented with an impending rupture. The aneurysm was located in the right side branch of the superior mesenteric artery. The patient underwent an emergency hybrid procedure, which included aneurysm embolization and exclusion of the aneurysm with an endoluminal stent graft. The blood supply to the right side branch was restored by bypass grafting with an autologous vein graft. The postoperative course was uneventful with no evidence of mesenteric ischemia. Postoperative computed tomography angiography confirmed complete aneurysm exclusion and sac size reduction, as well as patency of the stent graft and bypass.

Transjugular intrahepatic portosystemic shunt combined with dual-access thrombolysis for acute severe non-cirrhotic portal-mesenteric vein thrombosis

OBJECTIVE

Non-cirrhotic porto-mesenteric vein thrombosis (NC-PMVT) is a rare but severe clinical condition. The study aims to assess the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) coupled with dual-access thrombolysis in patients with acute severe NC-PMVT.

METHODS

From January 2018 to February 2023, a total of 25 patients with acute severe NC-PMVT who were treated with TIPS in conjunction with mechanical thrombectomy and dual-access thrombolysis. The period of thrombolysis was determined by the improvement of clinical symptoms and vascular recanalization. The technical success, recanalization rate, clinical success, and procedure-related complications were analyzed.

RESULTS

The technical success rate was 100 %. The median duration for thrombolytic catheter removal was 5 (IQR 3.5 - 7) days. Full and partial recanalization were accomplished in 10 (40 %) and 15 (60 %) patients respectively before discharge. No significant procedure-related complications were reported. The clinical success rate was 88 %, with a mortality rate of 12 %. Over a median follow-up of 8 months, 3/22 (13.64 %) patients had a recurrence of thrombosis; 1/22 (4.54 %) patients underwent partial intestinal resection one and a half months post-discharge; the remaining patients did not experience any portal hypertensive complications.

CONCLUSION

The combination of TIPS and dual-access thrombolysis appears to be safe and effective for patients with acute severe NC-PMVT.

Combining clinical and radiological features improves prediction of bowel ischemia in patients with CT findings of pneumatosis intestinalis

BACKGROUND

Pneumatosis intestinalis on CT presents a diagnostic dilemma, because it could reflect bowel ischemia or benign finding.

PURPOSE

To determine radiological and clinical features that can predict bowel ischemia in patients with pneumatosis intestinalis on CT.

MATERIALS AND METHODS

Patients with "pneumatosis" in abdominal CT reports performed between 1/1/2002 and 12/31/2018 were retrospectively included. Pneumatosis intestinalis was confirmed by review of images. Radiological features of pneumatosis, laboratory data, clinical signs and symptoms were collected. Pathologic pneumatosis intestinalis (PPI) was defined as presence of ischemic (viable or dead) bowel on surgery or death during admission or within 30 days of discharge due to ischemia. Univariate statistical analysis was used to identify features associated with PPI, followed by multivariate logistic regression models.

RESULTS

A total of 313 consecutive patients with pneumatosis intestinalis (162 (52%) men, median age 67 years, IQR 55-78 years) were included. Pathologic pneumatosis intestinalis was present in 114/313 (36%) patients. Presence of arterial or venous thrombosis, porto-mesenteric gas, fat stranding, and location in the small bowel were significantly associated with PPI. A combined clinical and radiological model, which included age, WBC, creatinine, abdominal distention, rebound or guarding, shock, presence of porto-mesenteric gas and fat stranding showed an AUC of 0.85 for prediction of PPI, higher than models using clinical (AUC = 0.80, p = 0.005) or radiological factors (AUC = 0.80, p < 0.0001) alone.

CONCLUSION

Improved prediction of pathological pneumatosis intestinalis can be achieved by a model incorporating both clinical and radiological features (AUC = 0.85)rather than by either clinical (AUC = 0.80) or radiological (AUC = 0.80) features alone.

Deep learning-assisted diagnosis of acute mesenteric ischemia based on CT angiography images

Purpose

Acute Mesenteric Ischemia (AMI) is a critical condition marked by restricted blood flow to the intestine, which can lead to tissue necrosis and fatal outcomes. We aimed to develop a deep learning (DL) model based on CT angiography (CTA) imaging and clinical data to diagnose AMI.

Methods

A retrospective study was conducted on 228 patients suspected of AMI, divided into training and test sets. Clinical data (medical history and laboratory indicators) was included in a multivariate logistic regression analysis to identify the independent factors associated with AMI and establish a clinical factors model. The arterial and venous CTA images were utilized to construct DL model. A Fusion Model was constructed by integrating clinical factors into the DL model. The performance of the models was assessed using receiver operating characteristic (ROC) curves and decision curve analysis (DCA).

Results

Albumin and International Normalized Ratio (INR) were associated with AMI by univariate and multivariate logistic regression (P < 0.05). In the test set, the area under ROC curve (AUC) of the clinical factor model was 0.60 (sensitivity 0.47, specificity 0.86). The AUC of the DL model based on CTA images reached 0.90, which was significantly higher than the AUC values of the clinical factor model, as confirmed by the DeLong test (P < 0.05). The Fusion Model also showed exceptional performance in terms of AUC, accuracy, sensitivity, specificity, and precision, with values of 0.96, 0.94, 0.94, 0.95, and 0.98, respectively. DCA indicated that the Fusion Model provided a greater net benefit than those of models based solely on imaging and clinical information across the majority of the reasonable threshold probabilities.

Conclusion

The incorporation of CTA images and clinical information into the model markedly enhances the diagnostic accuracy and efficiency of AMI. This approach provides a reliable tool for the early diagnosis of AMI and the subsequent implementation of appropriate clinical intervention.

A predictive clinical-radiomics nomogram for early diagnosis of mesenteric arterial embolism based on non-contrast CT and biomarkers

PURPOSE

Mesenteric artery embolism (MAE) is a relatively uncommon abdominal surgical emergency, but it can lead to catastrophic clinical outcomes if the diagnosis is delayed. This study aims to build a prediction model of clinical-radiomics nomogram for early diagnosis of MAE based on non-contrast computed tomography (CT) and biomarkers.

METHOD

In this retrospective study, a total of 364 patients confirmed as MAE (n = 131) or non-MAE (n = 233) who were randomly divided into a training cohort (70%) and a validation cohort (30%). In the training cohort, the minimum redundancy maximum relevance (mRMR) and the least absolute shrinkage and selection operator (LASSO) algorithms were used to select optimal radiomics features from non-contrast CT images for calculating Radscore which was utilized to establish the radiomics model. Logistic regression analysis was performed to screen clinical factors, and then generate the clinical model. A predictive nomogram model was built using Radscore and the selected clinical risk factors, which was evaluated through the receiver operating characteristic (ROC) curve, calibration curve and decision curve analysis (DCA).

RESULTS

Thirteen radiomics features were chosen to calculate Radscore. Age, white blood cell (WBC) count, creatine kinase (CK) and D-dimer were determined as the independent clinical factors. The clinical-radiomics nomogram model showed the best performance in training cohort. The nomogram model was with higher area under curve (AUC) value of 0.93, compared to radiomics model with AUC value of 0.90 or clinical model with AUC value of 0.78 in the validation cohort. The calibration curve showed that nomogram model achieved a good fit in both cohorts (P  = 0.59 and 0.92, respectively). The DCA indicated that nomogram model was significantly favorable for clinical usefulness of MAE diagnosis.

CONCLUSIONS

The nomogram provides an effective tool for the early diagnosis of MAE, which may play a crucial role in shortening the time for therapeutic decision-making, thereby reducing the risk of intestinal necrosis and death.

Chlamydophila psittaci pneumonia followed by lower gastrointestinal ischemic necrosis: a case report

Background

Psittacosis, also known as parrot fever, is an uncommon infectious disease caused by Chlamydophila psittaci (C. psittaci). While C. psittaci infections are usually not life-threatening, the pathogenesis and associated complications are not yet fully understood.

Case description

A 54-year-old male was hospitalized due to a cough, accompanied by expectoration and dyspnea. After admission, the patient's breathing rapidly deteriorated, and despite the use of a ventilator, it was challenging to maintain respiratory function. While initiating extracorporeal membrane oxygenation (ECMO) and empirical anti-infection treatments, the alveolar lavage fluid was collected and examined by metagenomics next generation sequencing (mNGS). The mNGS result indicated C. psittaci. Subsequently, the anti-infection regimen was immediately adjusted. The respiratory function improved on the 13th day after admission, and ECMO was withdrawn. However, the patient developed abdominal distension and intestinal edema. After intravenous infusion therapy, intestinal ischemia and necrosis occurred and surgical resection was performed. The patient's condition improved after the operation and he was transferred to a local hospital for rehabilitation.

Conclusion

This case report demonstrates the development of intestinal ischemic necrosis following severe C. psittaci pneumonia. This unique association has not been reported previously and highlights the importance of potential gastrointestinal complications in severe C. psittaci pneumonia, which are often underestimated. Timely diagnoses and treatments of such infections and complications are necessary to achieve favorable clinical outcomes.

Ischemic colitis presenting as a colonic mass: a case report and diagnostic challenges

Ischemic colitis (IC) is a multifaceted condition that often manifests with nonspecific symptoms such as abdominal pain and bloody diarrhea, particularly in older adults with vascular risk factors. Diagnosis is supported by elevated levels of white blood cells, lactate, and C-reactive protein (CRP). Computed tomography (CT) imaging typically reveals wall thickening and fat stranding in watershed areas. Colonoscopy may demonstrate mucosal erythema, ulceration, or necrosis. IC can be differentiated from inflammatory bowel disease (IBD), diverticulitis, and colorectal cancer based on symptom patterns and imaging findings. The absence of specific biomarkers can complicate diagnosis, potentially causing delays. Illustrating these challenges is the case of a 53-year-old male patient who arrived at the hospital exhibiting abdominal pain and diarrhea. Enhanced CT scans and colonoscopy identified a mass in the ileocecal region of the colon, and subsequent tissue biopsy revealed ischemic lesions in the submucosa. Initially diagnosed with IC, the patient's symptoms gradually improved with conservative treatment, which included antibiotics, fluid resuscitation, and bowel rest. Follow-up endoscopy showed significant lesion improvement, and no recurrence was detected during subsequent follow-ups. This case illustrates the healing process of IC as manifested by colon mass under endoscopy. Also, it highlights the critical importance of timely diagnosis and personalized treatment strategies in atypical presentations to improve patient outcomes.

Negative-Pressure Wound Therapy: A Novel Approach for Terminal Ileum Anastomosis Success

BACKGROUND Terminal ileum (TI) anastomoses present challenges due to anatomical features and pressure from the ileocecal valve (ICV). The use of negative-pressure wound therapy (NPWT) is commonly used to treat chronic skin ulcers. Its use for temporary abdominal closure following anastomosis is controversial but has shown promise in patients with inflammatory or vascular disease. This report presents 3 successful cases in which NPWT was used after TI anastomosis surgery. CASE REPORT Case 1: A 65-year-old woman with chronic kidney disease and paroxysmal atrial fibrillation was diagnosed with mesenteric ischemia. Surgical resection removed a segment of the jejunum and ileum, with an end-to-side anastomosis 10 cm from the ICV. NPWT was initiated, and abdominal wall closure was achieved. Case 2: A 73-year-old man with a history of an incarcerated left inguinal hernia, previously treated with herniorrhaphy and intestinal resection, presented with generalized peritonitis and anastomotic dehiscence 70 cm from the ICV. Resection was performed, followed by ileectomy for ischemia 15 cm from the ICV and a 2-layer isoperistaltic side-to-side anastomosis. NPWT was initiated to reduce edema and achieve primary abdominal closure. Case 3: A 69-year-old man diagnosed with mesenteric ischemia underwent resection of 40 cm of ischemic intestine. Follow-up laparotomy revealed the need for manual end-to-end anastomosis 12 cm from the ICV. NPWT was applied due to the inability to achieve primary closure. CONCLUSIONS Despite concerns regarding vascularization and pressure near the ICV, these cases demonstrate that NPWT can be safely utilized following TI anastomosis. This challenges conventional guidelines and supports its use, even in high-risk anastomoses.

Acute mesenteric ischaemia in the elderly - results of combined endovascular and surgical treatment. Primary study

Acute mesenteric ischaemia (AMI) is a sudden onset of impaired bowel perfusion. Has a high mortality rate and is difficult to diagnose. Therapy involves endovascular, surgical, or a combination of both. Because of baseline differences, the comparison between endovascular and open surgical treatment is subject to selection bias. The aim of this study was to evaluate the results of treatment of AMI by open or endovascular approach in combination with laparotomy, and evaluation of treatment strategy in similar situations. Clinical data from 21 patients treated for AMI between 2018 and 2022 were retrospectively reviewed and compared. The primary endpoint of the study was in-hospital mortality. The secondary endpoint was the statistical evaluation of risk factors for mortality. All patients underwent acute endovascular revascularisation. Aspiration thromboembolectomy was performed in nine patients, stenting in seven, PTA in one and surgery in three. Endovascular therapy was unsuccessful for technical reasons in 3 patients. None of the monitored parameters reached statistical significance. The best results were achieved in the early diagnosis group. The overall mortality of acute mesenteric ischaemia in our cohort was 34.8%. Acute mesenteric ischaemia is a serious condition affecting mainly elderly patients with a high mortality rate, but the diagnosis of mesenteric ischaemia is not an automatic death sentence. To achieve the best therapeutic outcome, mesenteric ischaemia needs to be diagnosed and treated at an early stage. The best therapeutic outcomes are achieved in centres with 24-hour access to endovascular revascularisation and surgical therapy.

[Endovascular treatment and selection criteria for acute mesenteric ischemia]

OBJECTIVE

To demonstrate the results of endovascular intervention in patients with acute arterial mesenteric ischemia, while observing the indications developed in the clinic.

MATERIAL AND METHODS

In total, endovascular approach in the treatment of acute mesenteric ischemia were used in 49 patients in the clinic. In compliance with the developed indications and criteria, endovascular intestinal revascularization was performed in 27 patients. Various endovascular intervention techniques were used (aspiration, balloon dilation, artery stenting and their combinations). Extracorporeal filtration techniques were used as a treatment for reperfusion syndrome after intestinal revascularization in 10 patients.

RESULTS

Angiographic success in the form of complete restoration of the main blood flow in the basin of the superior mesenteric artery and its large branches was obtained in 85% of cases. Intestinal viability was preserved in 15 (56%) patients. After successful endovascular surgery, intestinal necrosis was diagnosed on laparoscopy in the remaining 12 (44%) patients, which required extensive (n=2) or non-extensive (n=10) resection. Postoperative mortality was 48% (13 patients).

CONCLUSION

Endovascular surgery in acute mesenteric ischemia is an effective method of intestinal revascularization. To optimize the indications for these interventions, it is necessary to gain experience and conduct large-scale studies.

Damage control surgery in non-traumatic abdominal emergencies: prognostic value of SOFA, APACHEII, and Mannheim peritonitis index

This study aimed to analyze the prognostic value of the SOFA, APACHE II, and MPI (Mannheim Peritonitis Index) scores in the indication for Damage Control Surgery (DCS) in non-trauma. Retrospective analysis of patients undergoing DCS between 2014 and 2019. SOFA and APACHE II scores were calculated using parameters preceding DCS, while MPI was based on surgical descriptions. Statistical analysis: Qualitative variables were compared using the Chi-square test or Fisher's exact test, and quantitative variables using Pearson's correlation coefficient. The Student's T test was employed for mean comparisons. The sample comprised 104 patients (59 males), with a median age of 63.5 years, of whom 52 (50%) were ASA IV. Operative findings leading to DCS included peritonitis (54; 51.9%), intestinal ischemia (39; 37.5%), inability to close the abdomen (8; 7.6%), and bleeding (3; 2.9%). The mortality rate was 75% (78/104). Thirty patients (28.8%) died after DCS; the remainder underwent one (35; 33.6%), two (21; 20.2%); three (8; 7.7%), and four or more (10;9.7%) revision procedures. The median lengths of ICU and hospital stays were 12.5 and 20.5 days, respectively. The median score values were as follows: SOFA: 12 (0-38), APACHE II: 25 (2-47), and MPI: 26 (8-43). Besides ASA classification (p = 0.03), mortality risk was influenced by: age (≤ 65 years vs. > 65 years; p = 0.04), SOFA (≤ 10 vs. > 10; p = 0.03), APACHE II (≤ 25 vs. > 25; p = 0.04), and MPI (≤ 25 vs. > 25; p = 0.003). The SOFA, APACHE II, and MPI scores proved to be valuable tools in the prognostic assessment of patients undergoing DCS in non-traumatic abdominal emergencies.

Outcomes after open and endovascular treatment for mesenteric artery embolism patients: a retrospective inverse probability of treatment-weighted analysis

PURPOSE

This study aims to evaluate outcomes in patients with mesenteric artery embolism (MAE) who received primary endovascular therapy (EVT) or laparotomy, and investigate risk factors for 30-day mortality.

METHODS

A retrospective analysis of 94 MAE patients who underwent two different treatment strategies was undertaken. An inverse probability of treatment weighting (IPTW) method was used to balance the confounding effects of baseline clinical data. Logistic regression analysis was performed to compare the outcomes according to type of treatment regimens before and after IPTW. Univariate and multivariable analysis were conducted to determine the risk factors for 30-day mortality.

RESULTS

Twenty-eight MAE patients received primary EVT, and 66 Open Surgery (OS). Logistic regression analysis showed that there was no significant difference between the EVT and OS group in 30-day mortality rate before (odds ratio [OR] 0.477, 95% confidence interval [CI] 0.170 to 1.340, P = 0.160), and after IPTW (OR 0.647, 95% CI 0.210 to 1.993, P = 0.449). After IPTW, it revealed that the rates of second-look surgery (OR 36.727, 95% CI 5.407 to 249.458, P < 0.001) and hospital stay [> 30 days] (OR 0.006, 95% CI 0.000 to 0.363, P = 0.014) were different in the two groups. D-dimer (> 4 mg/L) and procalcitonin (> 0.5 ng/mL) were the independent risk factors for 30-day mortality in MAE patients postoperatively (P < 0.05).

CONCLUSION

In this retrospective study, MAE patients who performed primary EVT had no obvious difference in 30-day mortality rate compared to those who received OS; but it was conducive to reducing prolonged hospital stays. An increase in procalcitonin level and higher D-dimer were associated with short-term poor prognosis in patients with MAE.

The rheolytic thrombectomy AngioJet™ is a safe and technically feasible method for treating acute and sub-acute occluding lesions in the visceral arteries

BACKGROUND

The aim of this study is to evaluate the safety and feasibility of the AngioJet™ device in the endovascular treatment of visceral ischemia with stenotic or occlusive lesions.

METHODS

Retrospective analysis of patients treated for visceral artery occlusion with thrombectomy using the AngioJet™ (Boston Scientific, MA, USA). Inclusion criteria: patients with stenotic or occluding lesion in visceral arteries including renal and mesenteric arteries, who received endovascular treatment with AngioJet™.

RESULTS

Eighteen patients with acute and sub-acute visceral arteries occlusions underwent endovascular thrombectomy. In twelve cases the procedure was successful, and the patients were discharged with patent target arteries. Four cases required re-intervention and two cases ended with a fatal complication. The technical and clinical success rate in our study was 88,9% (sixteen out of eighteen), these patients were discharged from hospital with patent target arteries.

CONCLUSIONS

The thrombectomy using the AngioJet™ device is an effective and feasible method for the treatment of stenotic or occluding lesions of the visceral arteries with rapid post-interventional clinical improvement and minimal adverse events.

Endovascular revascularization vs open surgical revascularization as the first strategy for arterial acute mesenteric ischemia: A systematic review and meta-analysis

OBJECTIVE

This paired meta-analysis aimed to compare the mortality and morbidity of endovascular revascularization (EVR) and open surgical revascularization (OSR) as the first strategy for arterial acute mesenteric ischemia (AMI).

METHODS

This systematic review and meta-analysis were performed in accordance with the PRISMA statement. A systematic search strategy was performed to identify eligible studies using the following databases: PubMed, Embase, and Cochrane Library database from inception to December 31, 2023, with restriction to the English language. The end search date was January 2, 2024. The primary outcome was short-term mortality. Secondary outcomes included bowel resection, second-look laparotomy, and short bowel syndrome. The counterenhanced funnel plot and the Peters' test were used to assess bias. Outcomes were reported as odds ratio (OR) with a 95% confidence interval (CI) using the Mantel-Haenszel method. The GRADE classification was used to estimate the certainty of evidence.

RESULTS

A total of 11 studies (1141 patients) comparing EVR vs OSR for arterial AMI were identified and analyzed. The mean patient age was 61.9 to 73.6 years and 45.1% of the patients were male. Compared with OSR, EVR as the first treatment may not decrease short-term mortality (OR, 0.79; 95% CI, 0.50-1.25; P = .31; very low certainty) and second-look laparotomy (OR, 1.00; 95% CI, 0.30-3.36; P = .99; very low certainty). However, EVR may be associated with decreased bowel resection (OR, 0.42; 95% CI, 0.20-0.88; P = .022; very low certainty) and short bowel syndrome (OR, 0.39; 95% CI, 0.21-0.75; P = .005; very low certainty). The metaregression revealed that the mortality regarding EVR vs OSR was not impacted significantly by thrombotic etiology (-0.002; 95% CI, -0.027 to 0.022; P = .85), whereas it was impacted significantly by publication year (0.076; 95% CI, 0.069-0.145; P = .031).

CONCLUSIONS

Compared with OSR, EVR as the first treatment for arterial AMI may not decrease short-term mortality or second-look laparotomy. Future multicenter randomized controlled trials are needed urgently to confirm these results.

Small bowel neuroendocrine tumor presenting with chronic diarrhea and mesenteric ischemia: A case report

Key Clinical Message

The diagnosis of gastrointestinal neuroendocrine tumors is often challenging owing to the nonspecific presentation. This may lead to delayed diagnosis and serious, rare complications, such as acute mesenteric ischemia. This case highlights the importance of early recognition and the need for a multidisciplinary approach to managing such cases.

Abstract

Gastrointestinal (GI) neuroendocrine tumors (NETs) are rare neoplasms originating from neuroendocrine cells within the digestive tract. Despite their rarity, their incidence is increasing, necessitating a better understanding of their presentation and management. In the present report, we present a case of duodenal bulb NET that caused chronic diarrhea and unintentional weight loss for 2 years before manifesting as acute mesenteric ischemia. This case sheds light on the diagnostic challenges associated with GI NETs, particularly in cases with nonspecific symptoms. In addition, it underscores the importance of prompt recognition and management, as evidenced by the progression of the patient to acute mesenteric ischemia.

Surgical bypass of superior and inferior mesenteric arteries with Dacron graft in a patient with acute on chronic mesenteric ischaemia with atherosclerotic complete occlusion of the infrarenal aorta

A 67-year-old male presented to us with symptoms of postprandial abdominal pain for the last 3 months and was not able to take meals for the last month. The computed tomography (CT) angiogram showed complete occlusion in the coeliac artery (CA), superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) with complete occlusion of infrarenal aorta and bilateral iliac arteries. While waiting for elective surgical mesenteric bypass, patient suddenly developed signs of peritonitis for which emergency surgery was done using a Dacron bifurcated graft 12 × 6 mm size. Inflow was taken from the supra coeliac aorta. At 6 months follow-up, the patient was doing well and the CT angiogram showed a patent graft. In our case, the challenge was from where to take inflow, as the patient's aorta was atherosclerotic and infrarenal aorta was completely occluded, and he was also not suitable for endovascular stenting. So, we decided to take inflow from the supra coeliac aorta and a distally mesenteric bypass was done. Although mesenteric ischaemia has very high morbidity and mortality rates, prompt and well-planned mesenteric bypass surgery can save both bowel and patients life as well.

Mesenteric venous thrombosis in a young adult: A case report and review of the literature

BACKGROUND

Acute mesenteric vein thrombosis (MVT) accounts for only 2%-10% of all cases of acute mesenteric ischaemia, with an incidence rate of ~0.1% in Europe and the United States. It represents < 10% of mesenteric infarction cases and is seen predominantly in older adults. In younger individuals, MVT is uncommon, with 36% of cases having unidentified mechanisms and causes.

CASE SUMMARY

A 27-year-old man presented to the emergency department on February 29, 2024, with a chief complaint of intermittent abdominal pain for 3 day. He was previously in good health. As the abdominal pain was not alleviated by conventional treatment, an abdominal computed tomography (CT) scan was performed, which showed increased density in the portal and mesenteric veins. Further imaging, including portal vein ultrasound, mesenteric CT angiography, and enhanced abdominal CT, revealed widespread thrombosis of the portal vein system (including the main portal vein, left and right branches, proximal mesenteric vein, and splenic vein). After 10 day of thrombectomy and anticoagulation therapy, the patient's abdominal pain had improved significantly. Follow-up assessments indicated that portal venous blood flow had largely returned to normal. He was discharged on March 9, 2024. During a follow-up exam 2 months later, repeat abdominal enhanced CT showed that the previously detected thrombi were no longer visible.

CONCLUSION

Clinicians should remain vigilant for acute MVT in young patients presenting with abdominal pain, to prevent misdiagnosis of this fatal condition.

Germacrone ameliorates acute lung injury induced by intestinal ischemia-reperfusion by regulating macrophage M1 polarization and mitochondrial defects

Intestinal ischemia-reperfusion (I/R) injury severely affects the lungs. Germacrone (Ger) possesses anti-inflammatory and antioxidant properties. However, it is unclear whether it protects the lungs from I/R injury. In this study, we elucidate the mechanisms by which Ger protects lungs from I/R injury. C57BLKS/J male mice are subjected to I/R injury via complete clamping of the superior mesenteric artery. Ger is administered before intestinal I/R. Mitochondrial morphology is observed via electron microscopy. The histopathology of the lung tissues is monitored via hematoxylin-eosin and immunofluorescence staining. The mitochondrial oxygen consumption rate is measured via an XF96 extracellular flux analyzer. In the I/R mouse model, lung specimens present significant lung damage accompanied by increases in the levels of collagen III, vimentin, and α-SMA in lung tissues. After treatment with Ger, lung impairment and fibrosis in I/R-induced acute lung injury (ALI) model mice are restored, suggesting that Ger improves I/R-ALI. In addition, Ger administration decreases the release of inflammatory factors such as IL-1β, IL-6, and COX2, as well as the expressions of M1 macrophage markers, facilitating cell survival in the I/R-ALI model. Additionally, Ger (EC50: 47.16 μM) ameliorates mitochondrial dysfunction by increasing I/R-ALI-induced apoptosis, increasing the expression of SIRT1, and reducing the levels of HIF1-α, Nrf2, and OGG1 in MLE-12 cells. Ger may affect macrophage polarization and improve subsequent mitochondrial defects through the SIRT1-HIF1α-Nrf2 signaling pathway in MLE-12 cells, which ultimately improves lung function and lung inflammation in the I/R-ALI model.

Acute mesenteric ischemia secondary to complete AV block and acute systolic heart failure: a case report

BACKGROUND

Acute mesenteric ischemia (AMI) usually presents with abrupt and severe abdominal pain associated with nausea and vomiting. This case is notable due to the occurrence of AMI secondary to acute systolic heart failure caused by new onset complete heart block.

CASE PRESENTATION

A 65-year-old male presented with sudden onset epigastric pain. ECG showed complete AV block and acute ischemia, and a subsequent CTA revealed complete occlusion of the mid superior mesenteric artery. His emergent left heart catheterization showed non-occlusive coronary artery disease. The patient underwent emergent laparotomy and SMA thrombectomy. Postoperative complications included worsening congestive heart failure and persistent bradycardia, requiring a permanent pacemaker. The patient was discharged to a skilled nursing facility in stable condition.

CONCLUSIONS

This case highlights the diagnostic challenges of AMI in the setting of acute heart failure and new onset AV block mimicking acute cardiac events and emphasizes the importance of a multidisciplinary approach in managing such complex cases.

Probabilistic Prediction of Gastrointestinal Ischemia after Cardiothoracic Surgery

BACKGROUND

 Gastrointestinal ischemia (GIisch) is challenging to diagnose in patients after cardiothoracic surgery. Computed tomography angiography (CTA) carries substantial false-negative and false-positive rates. The aim of the study was to evaluate if a combination of readily available variables improves the diagnosis of GIisch after cardiothoracic surgery.

METHODS

 This retrospective study included patients receiving intensive care after cardiothoracic surgery. GIisch was confirmed by surgical and/or endoscopic findings. A GIisch prediction score was developed using the Spiegelhalter-Knill-Jones system in a training cohort then tested in a validation cohort (patients without obvious signs of GIisch on CTA).

RESULTS

 The training cohort comprised 125 consecutive patients with suspected GIisch in 2008 to 2019, including 85 with confirmed GIisch. CTA, performed in 92 patients, had a high false-negative rate of 17/60 (28%) and a lower false-positive rate of 7/32 (22%). The score included cardiopulmonary bypass, negatively associated with GIisch, and six variables positively associated with GIisch: intraoperative mean arterial pressure < 50 mm Hg, aspartate aminotransferase > 15 N, lactate increase in 24 hour > 20%, and 3 CTA findings, namely, bowel dilation, bowel wall thickening, and mesenteric vasoconstriction. The area under the receiver operating characteristic was 0.82 (95% confidence interval [CI], 0.51-0.93) in the training cohort and 0.82 (95% CI, 0.68-0.96) in the validation cohort (n = 34 patients). Reliability of the predicted probabilities was greatest for probabilities ≤ 30% or ≥ 70%.

CONCLUSION

 In patients receiving intensive care after cardiothoracic surgery, GIisch cannot be ruled out based solely on CTA findings. A scoring system combining CTA findings with other variables may improve the diagnosis of GIisch in this population.

CLINICAL APPLICATION OF EARLY POSTOPERATIVE NUTRITIONAL SUPPORT IN PATIENTS WITH HIGH-RISK VALVULAR HEART DISEASE

ABSTRACT

Background : The treatment strategy of early nutritional support after cardiac surgery has gradually been adopted. However, there are no scientific guidelines for the timing and specific programs of early nutritional support. Methods: A retrospective, single-center analysis (2021-2023) was carried out including elderly patients who were admitted for valvular heart disease and received open-heart valve replacement surgery. We designated patients who started the optimized nutritional support after surgery as the optimized enteral nutritional support strategy TN (EN) group and those who received traditional nutritional support as the traditional nutritional support strategy (TN) group. The nutritional and immune indexes, postoperative complications, length of hospital stay, and hospitalization cost of the two groups were compared and analyzed. Results: We identified 378 eligible patients, comprising 193 (51%) patients in the EN group and 185 (49%) patients in the TN group. There was no significant difference in hospital mortality between the two groups, but the proportion of nosocomial pneumonia was significantly lower in the EN group than in the TN group ( P < 0.001). In the Poisson regression analysis, EN was not associated with an increase in gastrointestinal complications ( P = 0.549). The EN group also seemed to have shorter hospital stays and lower hospitalization expenses ( P < 0.001). In the comparison of postoperative gastrointestinal complications, fewer patients experienced diarrhea ( P = 0.021) and abdominal distension ( P = 0.033) in the EN group compared with the TN group. Conclusion: The optimal nutritional support strategy could effectively improve the clinical outcome of high-risk patients with valvular heart disease.

First do no harm: Predicting futility of intervention in geriatric emergency general surgery

BACKGROUND

Emergent surgical conditions are common in geriatric patients, often necessitating major operative procedures on frail patients. Understanding risk profiles is crucial for decision-making and establishing goals of care.

METHODS

We queried NSQIP 2015-2019 for patients ≥65 years undergoing open abdominal surgery for emergency general surgery conditions. Logistic regression was used to identify 30-day mortality predictors.

RESULTS

Of 41,029 patients, 5589 (13.6 ​%) died within 30 days of admission. The highest predictors of mortality were ASA status 5 (aOR 9.7, 95 ​% CI,3.5-26.8, p ​< ​0.001), septic shock (aOR 4.9, 95 ​% CI,4.5-5.4, p ​< ​0.001), and dialysis (aOR 2.1, 95 ​% CI,1.8-2.4, p ​< ​0.001). Without risk factors, mortality rates were 11.9 ​% after colectomy and 10.2 ​% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4 ​% and 100 ​% following colectomy and small bowel resection, respectively.

CONCLUSIONS

In older adults undergoing emergent open abdominal surgery, septic shock, ASA status, and dialysis were strongly associated with futility of surgical intervention. These findings can inform goals of care and informed decision-making.

Safety, Efficacy and Outcome of Rotational Thrombectomy assisted Endovascular Revascularisation of the Superior Mesenteric Artery in Acute Thromboembolic Mesenteric Ischaemia

PURPOSE

To evaluate the efficacy and safety of percutaneous rotational thrombectomy-assisted endovascular revascularization of acute thromboembolic superior mesenteric artery occlusions in acute mesenteric ischemia.

MATERIALS AND METHODS

Fifteen cases of percutaneous rotational thrombectomy- assisted (Rotarex S, BD, USA) revascularization were retrospectively analyzed. The etiology was embolic in 40 % of cases and thrombotic in 60 %. A "Thrombectomy in Visceral Ischemia" (TIVI) 5-point score determined vessel patency at presentation, after percutaneous rotational thrombectomy, and after adjunctive technologies. TIVI 3 indicated nearly complete revascularization (minimal residual side branch thrombus). TIVI 4 indicated complete revascularization. Technical success was defined as successful device application and a final TIVI score of 3/4 after adjunctive technologies. Safety and outcome were also analyzed.

RESULTS

Device application via femoral access was feasible in 100 % of cases and improved flow in 86.7 % of cases (1 × TIVI 0→1, 11 × TIVI 0→2, 1 × TIVI 1→2). There was no change in 13.3 % of cases (2 × TIVI 2→2). Additional devices resulted in further flow improvement in 93.3 % of cases (8 × TIVI 3, 6 × TIVI 4). One recanalization failed (TIVI 2→2→2). After adjunctive technologies (10 × manual aspiration, 11 × angioplasty, 9 × stenting), the technical success rate was 93.3 %. The mean procedure time was 40.5(± 14) minutes for embolism and 72.1(± 20) minutes for thrombosis. There was one device-related major complication (catheter tip fracture) resulting in a device-related safety rate of 93.3 %. The overall major complication rate was 20 %. Surgical exploration (13 ×), bowel resection (9 ×) and Fogarty embolectomy/bypass (3 ×) were also performed. The 30-day mortality rate was 40 %.

CONCLUSION

Percutaneous rotational thrombectomy is an effective adjunct for rapid endovascular recanalization of acute thromboembolic superior mesenteric artery occlusions with an acceptable rate of major procedural complications.

KEY POINTS

· Percutaneous rotational thrombectomy-assisted superior mesenteric artery revascularization in acute occlusive mesenteric ischemia is feasible and effective.. · Percutaneous rotational thrombectomy facilitates rapid flow restoration in native and stented superior mesenteric artery segments.. · Brachial access should be considered in the case of steep take-off angles of the superior mesenteric artery..

Mesenteric Ischemia after Cardiac Surgery

BACKGROUND

 Mesenteric ischemia (Me-Is) after cardiac surgery is underreported in present literature but has still earned the bad reputation of a dismal prognosis. This study adds clinical outcomes in a large patient cohort.

METHODS

 Between 2009 and 2019 of the 22,590 patients undergoing cardiac surgery at our facility 106 (0.47%) developed Me-Is postoperatively. Retrospective patient data was analyzed. Additionally, patients were stratified by outcome-survivors and nonsurvivors.

RESULTS

 Patients were predominantly male (n = 68, 64.2%), mean age was 71.2 ± 9.3 years. Most procedures were elective (n = 85, 80.2%) and comprised of more complex combined procedures (50.9%) and redos (17.9%). Mean EuroSCORE II averaged 10.9 ± 12.2%. Survival at 30 days was 49.1% (n = 52). Clinical baseline and procedural characteristics did not differ significantly between survivors and nonsurvivors. The median postoperative interval until symptom onset was 5 days in both groups. Survivors were more frequently diagnosed by computed tomography and nonsurvivors based on clinical symptoms. Me-Is was predominantly nonocclusive (n = 84, 79.2%). Laparotomy was the main treatment in both groups (n = 45, 78.8% vs. n = 48, 88.9%, p = 0.94). Predictors of mortality were maximum norepinephrine doses (hazard ratio [HR] 8.29, confidence interval [CI] 3.39-20.26, p < 0.0001), lactate levels (HR 1.06, CI 1.03-1.09), and usage of inotropes (HR 2.46, CI 1.41-4.30).

CONCLUSION

 The prognosis of Me-Is following cardiac surgery is poor-independently from diagnostic or treatment patterns. There exists a significant asymptomatic time period postoperatively, in which pathophysiologic processes seem to cross the Rubicon. After clinical demarcation, the further course can almost no longer be influenced.

Association between periodic variation of air temperature, humidity, atmospheric pressure and hospital admissions for acute occlusive mesenteric ischaemia

Referring to the intestinal ischemic injury caused by sudden interruption of the blood supply, acute mesenteric ischemia (AMI) is a highly fatal emergency with mortality rates varying from 58 to 80%. The aim of this study was to explore the effect of temperature on AMI admission. This was a retrospective, multicentric study. The medical records of 1477 patients with verified AMI who were consecutively admitted to 3 hospitals anytime between January 2010 and December 2020 were included in the study. Distributed lag non-linear model was applied, the model was adjusted for temperature, atmospheric pressure, relative humidity, year, holiday, day of the week, time and seasonality. AMI exhibited obvious sex preference, AMI patients tended to be male (M/F ratio = 2.3:1) and in their late 50 s. Hospital admissions of acute mesenteric arterial thromboembolism (AMAT) increased significantly with high temperatures on day of exposure and lag 0-14 day. The effect curve of daily average temperature on acute mesenteric venous thromboembolism (AMVT) admission was J-shaped, and the duration of cold effect was longer, while the duration of heat effect was shorter. An increase in hospital admissions of AMVT was found above 20 °C at lag 0-30. For the first time, our study indicated that temperature is significantly associated with the risk of AMI. Although it is not possible to always avoid exposure to extreme temperatures, one should be aware of dramatic temperature fluctuations and take appropriate precautions.

Acute mesenteric ischaemia: a rare complication mimicking necrotising enterocolitis in a premature infant

Acute mesenteric ischaemia (AMI) is a life-threatening gastrointestinal complication uncommonly described in premature infants. The diagnosis of AMI is challenging and may be delayed due to the limitation of accurate diagnostic imaging and non-specific clinical signs. Furthermore, AMI can be misdiagnosed as necrotising enterocolitis (NEC) due to the overlapping clinical and radiological features. Though known to be associated with high mortality rates, early recognition and intervention can improve the survival rates in infants with AMI. We describe a case of a premature infant who presented with an acute abdomen and haemodynamic collapse, initially treated for NEC but later diagnosed with AMI intraoperatively. Due to the extensive bowel necrosis, surgical intervention was rendered futile and the infant finally succumbed to the disease.

Endovascular Intervention for Acute Superior Mesenteric Artery Occlusion Following COVID-19 Pneumonia: Two Case Reports

COVID-19 patients may experience acute mesenteric ischaemia. Identifying acute mesenteric ischaemia is challenging, particularly as initial symptoms are often vague and easily overlooked. Early detection and immediate intervention to restore blood flow can prevent these severe consequences. Presented in this report are two cases of superior mesenteric artery (SMA) thrombosis following severe acute respiratory syndrome coronavirus 2 infection. CT scans demonstrated SMA thrombosis in both patients, with no evidence of bowel necrosis. Endovascular intervention with self-expanding stent placement was performed after angiographic confirmation of the diagnosis. At 6-month follow-up, both patients remained asymptomatic on dual antiplatelet therapy. Atypical gastrointestinal manifestations in COVID-19 patients should raise suspicion for uncommon complications, such as SMA thrombosis. For SMA occlusion without associated bowel necrosis, endovascular therapy represents a viable treatment approach.

Successful Recanalization of the Superior Mesenteric Artery in Acute Mesenteric Ischemia

   The article describes a clinical case of recanalization of the superior mesenteric artery during acute mesenteric ischemia in an 81-year-old patient who was admitted to the emergency hospital in Ryazan with a clinic for “acute” abdomen. As a result of a diagnostic study, collection of anamnestic data and clinical picture, a diagnosis was made: “Embolism of mesenteric vessels.” Taking into account the early diagnosis (less than 4 hours from the onset of the disease), as well as the extremely complicated somatic status, selective angiography with mesentericography was performed, which revealed the patency of the main trunk of the superior mesenteric artery and complete occlusion of the distal segment of the intestine. Revascularization was performed ischemic area of the superior mesenteric artery. In the postoperative period, positive dynamics was observed, with complete relief of the clinical manifestations of mesenteric ischemia. On the 12th day, the patient was discharged for outpatient treatment under the supervision of a surgeon at her place of residence in satisfactory condition.

Extracorporeal Elimination of Pro- and Anti-inflammatory Modulators by the Cytokine Adsorber CytoSorb® in Patients with Hyperinflammation: A Prospective Study

INTRODUCTION

The release of pro-inflammatory cytokines in critically ill patients with sepsis leads to endothelial dysfunction resulting in cardiocirculatory insufficiency. Their extracorporeal elimination using the cytokine adsorber CytoSorb® (CS) (adsorption of especially hydrophobic molecules < 60 kDa) might be promising, but data about the adsorption capacity as well as a potential harmful adsorption of anti-inflammatory cytokines are missing so far.

METHODS

The prospective Cyto-SOLVE-study included 15 patients with sepsis or other hyperinflammatory conditions (interleukin 6 > 500 pg/ml), continuous kidney replacement therapy, and the application of CS. Various cytokines and chemokines were measured pre- and post-CS as well as in patients' blood at predefined timepoints. Significant changes in the concentrations were detected with the Wilcoxon test with associated samples. Clearance of the adsorber (ml/min) was calculated with: b l o o d f l o w ∗ c o n c e n t r a t i o n p r e - p o s t c o n c e n t r a t i o n pre . RESULTS: Most of the inflammatory mediators showed a high initial extracorporeal clearance of 70-100 ml/min after CS installation, which dropped quickly to 10-30 ml/min after 6 h of treatment. No difference in clearance was observed between pro- and anti-inflammatory cytokines. Despite extracorporeal adsorption, a significant (p < 0.05) decrease in the blood concentration after 6 h was only observed for the pro-inflammatory cytokines tumor necrosis factorα (TNF-α) (median 284 vs. 230 pg/ml), vascular endothelial growth factor (VEGF) (median 294 vs. 252 pg/ml), macrophage inflammatory protein 1a (MIP-1a) (median 11.1 vs. 9.0 pg/ml), and regulated upon activation, normal T cell expressed and secreted (RANTES) (median 811 vs. 487 pg/ml) as well as the anti-inflammatory cytokines interleukin 4 (median 9.3 vs. 6.4 pg/ml), interleukin 10 (median 88 vs. 56 pg/ml), and platelet-derived growth factor (PDGF) (median 177 vs. 104 pg/ml). A significant (p < 0.05) decrease in patients' blood after 12 h was only detected for interleukin 10.

CONCLUSIONS

CS can adsorb pro- as well as anti-inflammatory mediators with no relevant difference regarding the adsorption rate. A fast saturation of the adsorber resulted in a rapid decrease of the clearance. The potential clinical benefit or harm of this unspecific cytokine adsorption needs to be evaluated in the future.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04913298, registration date June 4, 2021.

A decade's experience with retrograde open mesenteric stenting for acute mesenteric ischemia

OBJECTIVE

Retrograde open mesenteric stenting (ROMS) is an alternative to mesenteric bypass in patients with acute mesenteric ischemia (AMI) with variable reported 30-day mortality rates. Large studies evaluating patient outcomes following ROMS are scarce. Our study aims to assess the results of this approach among patients presenting with AMI.

METHODS

We reviewed all the patients with AMI who were treated with ROMS (2011-2022). Patient demographics, presentation, operative details, and outcomes were analyzed. Primary end points were in-hospital, 30-day, and 1-year mortality. Kaplan-Meier estimate for 1-year mortality and primary patency loss were generated. Secondary end points included postoperative 30-day complications.

RESULTS

Between 2011 and 2022, ROMS was attempted on a total of 42 patients. The median age was 70 ± 15 years and the majority of patients were female. Pain out of proportion to the physical examination was the most common presenting symptom (n = 18, 42.9%) followed by peritonitis (n = 14, 33.4%). All patients underwent preoperative intravenous contrast computed tomography imaging. In situ thrombosis was identified as the etiology of AMI in 36 patients (85.7%). Technical success was achieved in 40 patients (95.2%). Conventional, non-hybrid operating rooms were used for the majority of cases. Revascularization of all 40 patients involved angioplasty and stenting of superior mesenteric artery. A single stent was placed in 35 patients (87.5%) and the reminder had more than one stent. Eighty percent of patients required bowel resection. A second-look laparotomy was required in 34 patients (85.0%). The mean operative time, including both the general surgery and vascular surgery portions of the index procedure, was 192 ± 57 minutes. Sepsis was the most common complication observed within 30 days, occurring in 8 patients (20.0%). In terms of mortality, 13 patients (32.5%) died during their index hospitalization, and 9 died (22.5%) within 30 days. On Kaplan-Meier analysis, the 1-year overall patient survival rate was 58.6%, and the primary patency rate for stents was 51.4%.

CONCLUSIONS

ROMS has an excellent technical success rate in management of AMI with lower than traditionally reported mortality rates for AMI. The dual benefits of rapid revascularization and bowel evaluation should make this surgical modality an alternative approach for treatment of AMI.

Atypical Infective Endocarditis Presenting With Euthermia and Right Lower Quadrant Abdominal Pain

Infectious endocarditis (IE) is an infection of the heart's endothelial lining, often stemming from an underlying bacteremia. High-risk populations include intravenous substance users, individuals with structural heart disease, those with intravascular devices, and those with prosthetic heart valves. In the emergency department, IE is often suspected in patients with a fever, known risk factors, and unexplained systemic symptoms due to systemic thromboemboli. We present a case of atypical IE occurring in an afebrile 38-year-old woman with a remote history of intravenous drug use. The patient's clinical presentation was characterized by systemic inflammatory response syndrome, stabbing-like right lower quadrant abdominal pain radiating to the right lower back and the rest of the abdomen, malaise, fatigue, and an absence of a fever. A CT scan revealed a right renal embolism and an infarcted right kidney, prompting a bedside point-of-care echocardiogram that showed a large vegetation on the mitral valve, suggestive of IE with systemic thromboembolic disease. The patient received broad-spectrum antibiotics and antipyretics and ultimately underwent mitral valve replacement, with good recovery upon discharge. Patients with IE are at high risk for life-threatening complications due to tissue damage from systemic microemboli and sepsis. It is important to identify IE's atypical presentation and risk factors for early recognition, prompt point-of-care echocardiogram, and initiation of treatment. This is particularly important in the era of increased opioid use among our patient population which could potentially conceal an underlying fever.