The role of multislice computed tomography (MSCT) angiography in the diagnosis and therapy of non-occlusive mesenteric ischemia (NOMI): Could MSCT replace DSA in diagnosis?

Computed Tomography Imaging of Acute Mesenteric Ischemia for Interventional Radiology

Acute mesenteric ischemia is a life-threatening condition. A comprehensive approach involving a multidisciplinary team to review patient background, clinical history, physical examination, laboratory data, and imaging examination for respective diagnosis of superior mesenteric arterial occlusion, nonocclusive mesenteric ischemia, and superior mesenteric venous occlusion is essential. The most important imaging modality is computed tomography, which is used for diagnosis and for directing therapeutic strategy (e.g., endovascular revascularization, surgical bowel resection, or conservative management). Computed tomography image findings can support triaging of irreversible transmural bowel necrosis compared with reversible ischemic change with reperfusion. In this review article, the computed tomography imaging findings specifically associated with the pathophysiology of superior mesenteric arterial occlusion, nonocclusive mesenteric ischemia, and superior mesenteric venous occlusion are reviewed.

Nonocclusive Mesenteric Ischemia: A Review for Interventional Radiologists

Nonocclusive mesenteric ischemia (NOMI) is a condition characterized by segmental or discontinuous mesenteric ischemia and intestinal necrosis without an organic obstruction in the mesenteric vessels. Diagnosis is challenging, and early intervention is crucial for improving patient outcomes. Various factors such as background factors, symptoms, biomarkers, and imaging techniques contribute to the diagnosis. Ensuring an early diagnosis and prompt treatment is of paramount importance. Although studies reported on the effectiveness of intra-arterial vasodilator infusion therapy as an endovascular treatment, its future role remains uncertain. Therefore, this review primarily aimed to provide a comprehensive summary of the advancements in the current state of NOMI management, with a specific emphasis on the implementation of endovascular therapy.

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.

Diagnostic accuracy of abdominal contrast-enhanced multi-slice spiral CT after oral diluted iodide in a time segment for gastrointestinal fistula in patients with severe acute pancreatitis

PURPOSE

To evaluate the diagnostic accuracy of abdominal contrast-enhanced multi-slice spiral CT after oral diluted iodide in a time segment (post-ODI ACE-MSCT) for gastrointestinal fistula (GIF) in severe acute pancreatitis (SAP).

MATERIALS AND METHODS

Patients with SAP who underwent both post-ODI ACE-MSCT and endoscopy/surgery from 2017 to 2023 were continuously retrospectively involved. Their demographic information and clinical features were recorded prospectively in an in-hospital database. Using endoscopy/surgery results as the reference standard, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of post-ODI ACE-MSCT for diagnosing GIF in SAP were calculated by a four-cell table. The consistency of the two diagnostic methods was evaluated by the Kappa test and McNemar's test.

RESULTS

Using endoscopy/surgery as the reference standard, a total of 86 cases were divided into the GIF group (N = 52) and the non-GIF group (N = 34). Among the 52 cases of GIF, 88.5% (46/52) cases had a positive result and 11.5% (5/52) cases had a negative result of post-ODI ACE-MSCT for GIF. Among the 34 cases of non-GIF, 2.9% (1/34) case had a positive result and 97.1% (33/34) cases had a negative result of post-ODI ACE-MSCT for GIF. Post-ODI ACE-MSCT had a sensitivity of 88.5% (95% CI 75.9%-95.2%), a specificity of 97.1% (95% CI 82.9%-99.8%), a positive predictive value of 97.9% (95% CI 87.3%-99.9%), a negative predictive value of 84.6% (95% CI 68.8%-93.6%), and an accuracy of 91.9% (83.4%-96.4%). The kappa value was 0.834, and P < 0.001 by McNemar's test. There were no significant differences in diagnostic test characteristics between the two modalities.

CONCLUSION

Post-ODI ACE-MSCT can diagnose GIF in SAP in a simple, noninvasive, and accurate way, and can provide earlier imaging evidence for clinical diagnosis and treatment.

A Case of Nonocclusive Mesenteric Ischemia During Bioradiotherapy With Cetuximab

Nonocclusive mesenteric ischemia (NOMI) causes mesenteric ischemia and intestinal necrosis despite the absence of organic obstruction, such as thrombi and emboli in mesenteric blood vessels, and it has an extremely poor prognosis. We report a case of NOMI developed during bioradiotherapy (BRT) with cetuximab for cervical lymph node metastasis of tongue cancer. The patient was a 73-year-old man who underwent right radical neck dissection for neck lymph node metastasis after tongue cancer surgery. Postoperatively, the patient received BRT with cetuximab. On the 34th day after BRT, the patient had abdominal distension and a decreased level of consciousness. Contrast-enhanced computed tomography revealed mesenteric ischemia without thrombi and extensive intestinal emphysema. The patient was diagnosed with NOMI. Furthermore, he had septic shock and was treated with vasopressors and antibacterial agents; however, the condition of the patient did not improve, and he died on the same day.

Insights into acute mesenteric ischaemia: an up-to-date, evidence-based review from a mesenteric stroke centre unit

Radiologists play a central role in the diagnostic and prognostic evaluation of patients with acute mesenteric ischaemia (AMI). Unfortunately, more than half of AMI patients undergo imaging with no prior suspicion of AMI, making identifying this disease even more difficult. A confirmed diagnosis of AMI is ideally made with dynamic contrast-enhanced CT but the diagnosis may be made on portal-venous phase images in appropriate clinical settings. AMI is diagnosed on CT based on the identification of vascular impairment and bowel ischaemic injury with no other cause. Moreover, radiologists must evaluate the probability of bowel necrosis, which will influence the treatment options.AMI is usually separated into different entities: arterial, venous, non-occlusive and ischaemic colitis. Arterial AMI can be occlusive or stenotic, the dominant causes being atherothrombosis, embolism and isolated superior mesenteric artery (SMA) dissection. The main finding in the bowel is decreased wall enhancement, and necrosis can be suspected when dilatation >25 mm is identified. Venous AMI is related to superior mesenteric vein (SMV) thrombosis as a result of a thrombophilic state (acquired or inherited), local injury (cancer, inflammation or trauma) or underlying SMV insufficiency. The dominant features in the bowel are hypoattenuating wall thickening with submucosal oedema. Decreased enhancement of the involved bowel suggests necrosis. Non-occlusive mesenteric ischaemia (NOMI) is related to impaired SMA flow following global hypoperfusion associated with low-flow states. There are numerous findings in the bowel characterised by diffuse extension. An absence of bowel enhancement and a thin bowel wall suggest necrosis in NOMI. Finally, ischaemic colitis is a sub-entity of arterial AMI and reflects localised colon ischaemia-reperfusion injury. The main CT finding is a thickened colon wall with fat stranding, which seems to be unrelated to SMA or inferior mesenteric artery lesions. A precise identification and description of vascular lesions, bowel involvement and features associated with transmural necrosis is needed to determine patient treatment and outcome.

MDCT-findings in patients with non-occlusive mesenteric ischemia (NOMI): influence of vasoconstrictor agents

OBJECTIVES

To evaluate the influence of vasoconstrictor agents (VCAs) on signs of vasoconstriction and bowel ischemia on MDCT detected in patients with non-occlusive mesenteric ischemia (NOMI).

METHODS

This 8-year single-center retrospective study consecutively included all patients with histopathologically proven NOMI who underwent MDCT ≤ 48 h prior to surgical bowel resection. Two blinded radiologists jointly reviewed each examination for signs of bowel ischemia, abdominal organ infarct, mesenteric vessel size and regularity, and ancillary vascular findings. VCA administration (length and dosage), clinical and biochemical data, risk factors, and outcomes were retrieved from patients' medical records. Subgroup comparisons were performed.

RESULTS

Ninety patients were included (59 males, mean age 65 years); 40 (44.4%) had received VCAs before MDCT. Overall mortality was 32% (n = 29), with no significant difference between the two groups. In patients treated with VCAs, the calibre of the superior mesenteric artery (SMA) was smaller (p = 0.032), and vasoconstriction of its branches tended to be more important (p = 0.096) than in patients not treated with VCAs. The presence and extent of bowel ischemia did not significantly correlate with VCA administration, but abdominal organ infarcts tended to be more frequent (p = 0.005) and involved more organs (p = 0.088). The VCA group had lower mean arterial pressure (p = 0.006) and lower hemoglobin levels (p < 0.001). Several biomarkers of organ failure and inflammation, differed significantly with VCA use, proving worse clinical condition.

CONCLUSIONS

MDCT demonstrates more severe SMA vasoconstriction and tends to show increased abdominal organ infarcts after VCA administration in NOMI patients compared to NOMI patients not treated with VCAs.

KEY POINTS

• In critically ill patients with NOMI, MDCT demonstrates VCA support via increased vasoconstriction of the main SMA and its branches. • VCA administration in NOMI patients tends to contribute to the development of organ infarcts, as shown on MDCT. • An important degree of vasoconstriction in NOMI patients may indicate insufficient resuscitation and, thus, help clinicians in further patient management.

Advances in the diagnosis of non-occlusive mesenteric ischemia and challenges in intra-abdominal sepsis patients: a narrative review

Non-occlusive mesenteric ischemia (NOMI) is a type of acute mesenteric ischemia (AMI) with a high mortality rate mainly because of a delayed or misdiagnosis. Intra-abdominal sepsis is one of the risk factors for developing NOMI, and its presence makes early diagnosis much more difficult. An increase in routine abdominal surgeries carries a corresponding risk of abdominal infection, which is a complication that should not be overlooked. It is critical that physicians are aware of the possibility for intestinal necrosis in abdominal sepsis patients due to the poor survival rate of NOMI. This review aims to summarize advances in the diagnosis of NOMI, and focuses on the diagnostic challenges of mesenteric ischemia in patients with intra-abdominal sepsis.

Non-occlusive mesenteric ischemia in critically ill patients

BACKGROUND

Non-occlusive mesenteric ischemia (NOMI) is a life-threatening acute condition that has an overall in-hospital mortality rate of up to 75%. Critically ill patients are often admitted to intensive care units (ICUs) due to shock, and these patients are frequently at risk of developing NOMI. The objective of this study was to determine the clinical features of critically ill patients with NOMI and evaluate the risk factors for in-hospital mortality among these patients.

METHODS

We reviewed the electronic medical records of 7,346 patients who underwent abdominal contrast-enhanced computed tomography during their ICU stay at Samsung Medical Center (Seoul, Korea) between January 1, 2010 and December 31, 2019. After reviewing each patient's computed tomography (CT) scans, 60 patients were diagnosed with NOMI and included in this analysis. The patients were divided into survivor (n = 23) and non-survivor (n = 37) groups according to the in-hospital mortality.

RESULTS

The overall sequential organ failure assessment (SOFA) score for the included patients upon admission to the ICU was 8.6 ± 3.1, and medical ICU admissions were most common (66.7%) among the patients. The SOFA score upon admission to the ICU was higher for the non-survivors than for the survivors (9.4 vs. 7.4; p = 0.017). Non-survivors were more often observed in the medical ICU admissions (39.1% vs. 83.8%) than in the surgical ICU admissions (47.8% vs. 10.8%) or the cardiac ICU admissions (13.0% vs. 5.4%). Laboratory test results, abdominal CT findings, and the use of vasopressors and inotropes did not differ between the two groups. In a multivariable analysis, SOFA scores >8 upon admission to the ICU (odds ratio [OR] 4.51; 95% 1.12-18.13; p = 0.034), patients admitted to the ICU with medical problems (OR 7.99; 95% 1.73-36.94; p = 0.008), and abdominal pain (OR 4.26; 95% 1.05-17.35; p = 0.043) were significant prognostic predictors for in-hospital mortality.

CONCLUSIONS

The SOFA score >8 upon admission to the ICU, admission to the ICU for medical problems, and abdominal pain at diagnosis are associated with increased mortality among patients with NOMI.

Understanding CT imaging findings based on the underlying pathophysiology in patients with small bowel ischemia

Because acute small bowel ischemia has a high mortality rate, it requires rapid intervention to avoid unfavorable outcomes. Computed tomography (CT) examination is important for the diagnosis of bowel ischemia. Acute small bowel ischemia can be the result of small bowel obstruction or mesenteric ischemia, including mesenteric arterial occlusion, mesenteric venous thrombosis, and non-occlusive mesenteric ischemia. The clinical significance of each CT finding is unique and depends on the underlying pathophysiology. This review describes the definition and mechanism(s) of bowel ischemia, reviews CT findings suggesting bowel ischemia, details factors involved in the development of small bowel ischemia, and presents CT findings with respect to the different factors based on the underlying pathophysiology. Such knowledge is needed for accurate treatment decisions.

Nonocclusive mesenteric ischemia caused by type B aortic dissection: a case report

Background

Nonocclusive mesenteric ischemia (NOMI) is defined as acute intestinal ischemia because of decreased blood flow in mesenteric vessels. Only a few cases of NOMI that occur secondary to aortic dissection (AD) have been reported, resulting in the lack of sufficient knowledge of diagnosis and treatment.

Case presentation

We aimed to report a case of NOMI caused by type B Aortic Dissection. A 26-year-old male patient was transferred to our hospital with the diagnose of NOMI and aortic dissection in April 2018. The abdominal computed tomography (CT) assists the diagnosis of paralytic intestinal obstruction, intestinal wall pneumatosis, and perforation. Emergency laparotomy revealed that the bowel wall supplied by the superior mesenteric artery (SMA) was pale with the palpable but weak pulsation of the parietal artery. The small intestine was extremely dilated with a paper-thin, fragile wall that was ruptured easily and could not be sutured. In this case, extensive resection and segmental drainage were done. Postoperatively, the digestive tract was reconstructed. However, the patient suffered from iron deficiency anemia and short bowel syndrome eight months later, and unfortunately died from long-term complications.

Conclusion

Aortic dissection leads to continuous decrease in blood pressure and blood flow to the SMA, considering as a predisposing factor for NOMI. During the treatment, extensive resection and segmental drainage are the optimal surgical strategy, which can make benefit in emergencies especially.

Non-occlusive mesenteric ischemia (NOMI) and prognostic signs at CT: reperfusion or not reperfusion that is the question!

PURPOSE

Non-occlusive mesenteric ischemia (NOMI) is a misdiagnosed and dangerous condition. To our knowledge, a comprehensive evaluation of CT parameters that can predict the outcome of patients suffering from NOMI is still missing.

MATERIALS AND METHODS

Contrast-enhanced CT examination of 84 patients with a confirmed diagnosis of NOMI (37 with clinical and laboratory confirmation and 47 biopsy or surgery proven) was retrospectively reviewed by assessing vessels, mesentery, bowel, and peritoneal cavity CT quantitative and dichotomous parameters, and data were analyzed with Fisher's test. Diameter of superior mesenteric artery (SMA), celiac trunk (CT), inferior vena cava (IVC), superior mesenteric vein (SMV), and differences in CT HU (Delta HU) of the bowel wall before and after intravenous contrast media (ICM) administration were correlated to the patients' outcome using ANOVA test. Receiver operating characteristic (ROC) curves were elaborated after a binary logistic regression was performed.

RESULTS

Increased number and diameter of vessels, bowel wall thickening, and hypervascularity were more frequent in patients with good prognosis. Conversely, pale mesentery, paper thin, hypovascularity, and aeroportia were more frequent in patients with bad prognosis. A significant correlation between diameters of SMA, CT, IVC, IMA, and SMV and outcome was found at univariate analysis. Also Delta HU resulted to be correlated with the outcome. At multivariate analysis only IVC and Delta HU were significant (p = 0.038 and 0.01) and the combined AUC resulted in 0.806 (CI 0.708-0.903).

CONCLUSION

Dichotomous signs of reperfusion and quantitative CT parameters can predict the outcome of patients with NOMI. In particular the combination of IVC diameter and Delta HU of bowel wall allows to predict the prognosis with the highest accuracy.

Diagnostic performance of CT for the detection of transmural bowel necrosis in non-occlusive mesenteric ischemia

OBJECTIVES

To evaluate the diagnostic performance of CT for transmural necrosis (TN) in non-occlusive mesenteric ischemia (NOMI) according to the bowel segment involved.

METHODS

From January 2009 to December 2019, all patients admitted to the intensive care unit (ICU) and requiring laparotomy for NOMI were retrospectively studied. CT had to have been performed within 24 h prior to laparotomy and were reviewed by two abdominal radiologists, with a consensus reading in case of disagreement. A set of CT features of mesenteric ischemia were assessed, separating the stomach, jejunum, ileum, and right (RC) and left colon (LC). Univariate and multivariate analyses were performed to identify features associated with TN. Its influence on overall survival (OS) was assessed.

RESULTS

Among 145 patients, 95 (66%) had ≥ 1 bowel segment with TN, including 7 (5%), 31 (21%), 43 (29%), 45 (31%), and 52 (35%) in the stomach, jejunum, ileum, RC, and LC, respectively. Overall inter-reader agreement of CT features was significantly lower in the colon than in the small bowel (0.59 [0.52-0.65] vs 0.74 [0.70-0.77] respectively). The absence of bowel wall enhancement was the only CT feature associated with TN by multivariate analysis, whatever the bowel segment involved. Proximal TN was associated with poorer OS (p < 0.001).

CONCLUSIONS

The absence of bowel wall enhancement remains the most consistent CT feature of transmural necrosis, whatever the bowel segment involved in NOMI. Inter-reader agreement of CT features is lower in the colon than in the small bowel. Proximal TN seems to be associated with poorer OS.

KEY POINTS

• The absence of bowel wall enhancement is the most consistent CT feature associated with transmural necrosis in NOMI, whatever is the bowel segment involved. • Inter-reader agreement is lower in the colon than in the small bowel in NOMI. • In NOMI, the more proximal the bowel necrosis, the worse the prognosis.

Clinical characteristics of pneumoperitoneum with pneumatosis intestinalis detected using computed tomography: A descriptive study

Pneumoperitoneum has always been considered a surgical emergency as it represents a perforation of the gastrointestinal tract. Although several cases of pneumoperitoneum with pneumatosis intestinalis (PI) have been reported, the characteristics of such cases remain unclear. The current study aimed to clarify the clinical characteristics of pneumoperitoneum cases with PI detected using computed tomography (CT).This descriptive study was conducted at a single center. In a total of 18,513 abdominal CT scans obtained between January 2010 and February 2017, extraluminal free air was detected in 254 examinations of 182 cases. The medical records and CT images of these 182 patients were retrospectively analyzed.Pneumoperitoneum with PI was detected through 23 examinations in 21 cases, and the average age of the patients was 80.1 years. The frequency was 0.12% in all abdominal CT examinations, but 24.7% in the 85 cases with extraluminal free air, excluding iatrogenic air. PI was classified as benign in 20 cases and as life-threatening in 1 case. The majority of cases with benign PI showed good general and local findings and little leukocytosis, while the case with life-threatening PI showed severe conditions. No evidence of bowel wall discontinuity, segmental bowel-wall thickening, perivisceral fat stranding, and abscesses were observed. Ascites were detected less frequently in the cases with PI than in the other pneumoperitoneum cases (P < .01). Pneumoperitoneum and PI occasionally recurred, and PI and/or extraluminal free air generally disappeared quickly.Pneumoperitoneum with PI is a relatively common condition in older patients, and the majority of cases are caused by benign PI. The characteristics of pneumoperitoneum cases with benign PI include well-maintained physical conditions, normal laboratory data, absence of CT findings indicative of peritonitis, and infrequent ascites. In pneumoperitoneum cases with PI, predicting whether the PI is benign or life-threatening is clinically very important, whereas the presence of extraluminal free air is considered to be insignificant.

Non-occlusive mesenteric ischemia (NOMI): evaluation of 2D-perfusion angiography (2D-PA) for early treatment response assessment

Purpose

To evaluate the feasibility of 2D-perfusion angiography (2D-PA) for the analysis of intra-procedural treatment response after intra-arterial prostaglandin E1 therapy in patients with non-occlusive mesenteric ischemia (NOMI).

Methods

Overall, 20 procedures in 18 NOMI patients were included in this retrospective case–control study. To evaluate intra-procedural splanchnic circulation changes, post-processing of digital subtraction angiography (DSA) series was performed. Regions of interest (ROIs) were placed in the superior mesenteric artery (SMA; reference), the portal vein (PV; ROI_PV), as well as the aorta next to the origin of the SMA (ROI_Aorta). Peak density (PD), time to peak (TTP), and area under the curve (AUC) were assessed, and parametric ratios ‘target ROI_{PD, TTP, AUC}/reference ROI’ were computed and compared within treatment and control group. Additionally, a NOMI score was assessed pre- and post-treatment compared to 2D-PA.

Results

Vasodilator therapy leads to a significant decrease of the 2D-PA-derived values PD_Aorta (p = 0.04) and AUC_Aorta (p = 0.03). These findings correlated with changes of the simplified NOMI score, both for overall (4 to 1, p < 0.0001) and for each category. Prostaglandin application caused a significant increase of the AUC_PV (p = 0.04) and TTP_PV was accelerated without reaching statistical significance (p = 0.13). When compared to a control group, all 2D-PA values in the NOMI group (pre- and post-intervention) differed significantly (p < 0.05) with longer TTP_Aorta/PV and lower AUC_Aorta/PV and PD _Aorta/PV.

Conclusion

2D-PA offers an objective approach to analyze immediate flow and perfusion changes following vasodilatory therapies of NOMI patients and may be a valuable tool for assessing treatment response.

Three cases of non-occlusive mesenteric ischemia that developed after head and neck cancer therapy

Non-occlusive mesenteric ischemia (NOMI) causes intestinal necrosis due to irreversible ischemia of the intestinal tract despite the absence of organic obstruction in the mesenteric blood vessels. The disease has extremely poor prognosis. We report three cases of NOMI hypothesized to have developed after head and neck cancer therapy; thus, we report these cases considering the available literature. Case 1: A 74-year-old man with T2N0M0 stage Ⅱ oropharyngeal carcinoma complained of abdominal pain 5 days after chemoradiotherapy. The patient was diagnosed with NOMI, and an emergency surgery was performed. Case 2: A 69-year-old man with T2N2bM0 stage IVA hypopharyngeal carcinoma complained of abdominal pain during TPF chemotherapy. The patient was diagnosed with NOMI, and he died on the same day. Case 3: A 82-year-old man with T2N2bM0 stage IVA hypopharyngeal carcinoma complained of abdominal pain with reduced level of consciousness, 5 days after total laryngopharyngectomy. The patient was diagnosed with NOMI, and an emergency surgery was performed on the same day. We therefore suggest that ENT physicians must be aware of NOMI as a complication that can develop after head and neck cancer therapy.

Mesenteric vascular disease: A population-based cohort study

OBJECTIVES

Mesenteric vascular disease carries a high risk of mortality and morbidity; however, due to obscure clinical presentation, it can be under-recognized. Currently, epidemiology of mesenteric vascular disease remains poorly defined. The aim of this study is to analyze changes in Scottish mortality rates from mesenteric vascular disease overtime.

METHODS

This is a retrospective, longitudinal population-based cohort study using data extracted from death certificates and Scottish Index of Multiple Deprivation. All deaths related to a vascular disorder of the intestines recorded as an underlying cause of death between 1979 and 2014 were identified using International Classification of Disease-9 or International Classification of Disease-10 code groups. Data included demographics and location of death. The residence postcodes were used to classify socio-economic status using the Scottish Index of Multiple Deprivation.

RESULTS

From 2,142,921 deaths over 36 years, 14,530 (0.7%) were due to mesenteric vascular disease with a median (interquartile range) age of 77 and a 2:1 female to male gender ratio. The mean ± standard deviation age significantly increased from 72.6 ± 12.1 in 1979 to 76.8 ± 11.1 in 2014 (p < 0.001, R² = 0.772). Males were consistently younger than females at the time of death. The two lowest Scottish Index of Multiple Deprivation categories accounted for half of the cohort, throughout the study period (p = 0.068). The adjusted death rate per 100,000 population increased from 7.6 in 1979 to 12.1 in 2014.

CONCLUSIONS

The reported death rates of mesenteric vascular disease in Scotland between 1979 and 2014 have nearly doubled. Mesenteric vascular disease affects twice as many women as men and is associated with social deprivation. The increased reporting of mesenteric vascular disease is likely due to increased recognition and incidence. These implications should be considered when planning healthcare provision in Scotland.

What affects the prognosis of NOMI patients? Analysis of clinical data and CT findings

BACKGROUND

Non-occlusive mesenteric ischemia (NOMI) is a mesenteric ischemic disease with considerably high mortality rate, although little has been known about what factors affect the patients' prognosis. The purpose of this study was to investigate prognostic factors of clinical data and computed tomography (CT) findings in patients with NOMI.

METHODS

This was a single institutional, retrospective study, reviewing 21 consecutive patients diagnosed with NOMI on angiography. Patients were divided into either ''survivor'' group or ''non-survivor'' group based on their clinical courses 1 month after diagnosis. Clinical information such as laboratory data, Charlson Comorbidity Index, and time from CT to injecting vasodilator was obtained from patients' medical records. Contrast-enhanced CT images were assessed in following items: defect of mural enhancement, pneumatosis intestinalis, hepatic portal venous gas, paralytic bowel dilatation, bowel wall thinning, and diameters of the relevant vessels.

RESULTS

Eight patients belonged to ''survivor'' group, whereas eleven were allocated to ''non-survivor'' group. None of CT findings showed significant difference between survivor group and non-survivor group [defect of mural enhancement: 75% and 100% (p = 0.16), pneumatosis intestinalis: 50% and 45.5% (p = 1.00), hepatic portal venous gas: 37.5% and 45.5% (p = 1.00), paralytic bowel dilatation: 12.5% and 63.6% (p = 0.06), and bowel wall thinning: 50% and 45.5% (p = 1.00)]. The diameters of the relevant vessels did not have significant difference either. Time from CT to injecting vasodilator was revealed to be significantly shorter in survivor group [187.5 (122.5-294) min and 310 (187-925.5)] (p = 0.048). None of the other clinical information had significant difference between each group.

CONCLUSION

Prompt angiography may be a key to improve the prognosis of NOMI patients.

[Vascular causes of clinically unclear acute abdomen]

CLINICAL ISSUE

Vascular abnormalities are a rare cause of an acute abdomen. They include arterial bleeding and ischemia, the latter being either in the arterial or venous system. The most common cause of an acute ischemic abdomen is acute mesenteric ischemia caused by a thromboembolic occlusion of the superior mesenteric artery, followed by thrombotic occlusion of the portal vein, the mesenteric vein as well as the hepatic veins and the suprahepatic part of the inferior vena cava. In the case of an acute abdomen due to internal bleeding, all abdominal arteries can be the source but most common are ruptures of aortic aneurysms and inflammatory-driven bleeding from the superior mesenteric artery.

PRACTICAL RECOMMENDATIONS

Due to the high mortality, vascular causes should be diagnosed as soon as possible. For this purpose, computed tomography (CT) has evolved into the preferred tool due to its high availability and speed. To differentiate various vascular causes of an acute abdomen, it is important to incorporate a CT protocol without contrast media as well as contrast-enhanced series in arterial and venous phases. Conventional angiography has been replaced by CT for the diagnosis of vascular pathologies causing an acute abdomen; however, it plays an increasing role in the treatment of these pathologies.

A Retrospective Analysis of Nonocclusive Mesenteric Ischemia in Medical and Surgical ICU Patients: Clinical Data on Demography, Clinical Signs, and Survival

Background:

To analyze demography, clinical signs, and survival of intensive care patients diagnosed with nonocclusive mesenteric ischemia (NOMI) and to evaluate the effect of a local intra-arterial prostaglandin therapy.

Methods:

Retrospective observational study screening 455 intensive care patients with acute arterial mesenteric perfusion disorder in a tertiary care hospital within the past 8 years. Lastly, 32 patients with NOMI were enrolled, of which 11 received local intra-arterial prostaglandin therapy. The diagnosis of NOMI was based on the clinical presentation and established biphasic computed tomography criteria. Clinical and biochemical data were obtained 24 hours before, at the time, and 24 hours after diagnosis.

Results:

Patients were 60.5 (49.3-73) years old and had multiple comorbidities. Most of them were diagnosed with septic shock requiring high doses of norepinephrine (NE: 0.382 [0.249-0.627] μg/kg/min). The Sequential Organ Failure Assessment (SOFA) score was 18 (16-20). A decrease in oxygenation (Pao₂/Fio₂), pH, and bicarbonate and an increase in international normalized ratio, lactate, bilirubin, leucocyte count, and NE dose were early indicators of NOMI. Median SOFA score significantly increased in the last 24 hours before diagnosis of NOMI (16 vs 18, P < .0001). Overall, 28-day mortality was 75% (81% nonintervention vs 64% intervention cohort; P = .579). Median SOFA scores 24 hours after intervention increased by +5% in the nonintervention group and decreased by 5.5% in the intervention group (P = .0059).

Conclusions:

Our data suggest that NOMI is a detrimental disease associated with progressive organ failure and a high mortality. Local intra-arterial prostaglandin application might hold promise as a rescue treatment strategy. These data encourage future randomized controlled trials are desirable.