Smooth muscle degeneration of the mesenteric and branching veins causing ischemic enteritis: a case report

Background

Ischemic bowel injuries are generally caused by arteriosclerosis, thromboembolism, or vasculitis. Ischemic enteritis is less common than ischemic colitis because of the rich collateral arteries of the small intestine. In the present case, smooth muscle degeneration of the mesenteric to the submucosal veins caused ischemic enteritis and small bowel obstruction.

Case presentation

An 85-year-old woman with recurrent enteritis eventually developed small bowel obstruction. We performed laparoscopic partial resection of the small intestine. The pathological findings revealed smooth muscle degeneration of the mesenteric veins that caused ischemic enteritis. Venous changes were detected not only in the injured region, but also in a part of the normal region of the resected specimen. She continued to experience some minor symptoms postoperatively; however, these symptoms subsided in a short period with medicine discontinuation.

Conclusion

This report shows the possibility that a disease causes ischemic enteritis with unique venous pathological changes and may recur postoperatively.

Oral administration of n-3 fatty acids positively affect the mucosal lesions after experimental ischemic enteritis in the rat

AIM

The purpose of the study was to evaluate the effect of oral administration of n-3 polyunsaturated fatty acids in experimental ischemic enteritis in rats.

METHODS

Forty Wistar rats were submitted to control narrowing of the superior mesenteric artery and were divided in two groups: N3 polyunsaturated fatty acids, which received a high-molecular polymer solution of artificial total enteral nutrition enriched with n-3 fatty acids and CONTROL which received a high-molecular polymer solution of artificial total enteral nutrition.

RESULTS

Reduction of the animals' body weight was observed in both groups, but there was no difference between the two groups. Regarding the level of cytokines interleukin (IL)-1b, IL-6, and tumor necrosis factor a (TNF-a) there was no statistically significant difference between the two groups. Ischemic lesions to the small bowel mucosa were observed in both groups. A statistically significant difference in the extent of intestinal lesions was observed between the two groups with the animals that received enteral nutrition enriched with n-3 fatty acid developing fewer lesions.

CONCLUSION

Enteral nutrition enriched with n-3 polyunsaturated fatty acids reduces the mucosal lesions caused by mesenteric ischemia compared to standard enteral nutrition, by modifying the local, but not the systemic, immune, and inflammatory response.

[Severe coagulation abnormality during treatment for ischemic enteritis in an older patient taking a direct oral anticoagulant]

An 85-year-old woman hospitalized for rehabilitation after cerebral infarction developed persistent bloody diarrhea and was transferred to our hospital (day 1). Contrast-enhanced computed tomography of the abdomen showed edematous thickening extending from the left side of the transverse colon to the rectum, with decreased mucosal enhancement. She was diagnosed with ischemic enteritis. She fasted and was treated with fluids and antibiotics. The bloody diarrhea stopped, and she was restarted on the direct oral anticoagulant (DOAC) edoxaban on day 5. Endoscopy on day 11 showed linear ulceration and severe mucosal edema in the rectum. The diarrhea was persistent, so fasting and fluid therapy were continued. A blood test on day 18 showed significant prolongation of the prothrombin time (≥100 s), International Normalized Ratio (14.03), and activated partial thromboplastin time (87.5 s), as well as a significant increase in protein induced by vitamin K absence-II (12,469 mAU/mL). Her condition was diagnosed as a coagulation abnormality due to vitamin-K deficiency. A vitamin-K preparation was administered immediately, and her coagulation abnormality improved rapidly. In general, DOACs do not require routine monitoring with blood tests. However, frequent monitoring of the coagulation function is required in fasting patients on DOACs because acute coagulation abnormalities can be induced rapidly by vitamin-K deficiency. Given that non-valvular atrial fibrillation and ischemic enteritis are among the most prevalent diseases affecting older people, the likelihood of encountering these diseases in daily clinical practice will increase with the aging of the population. We herein report this instructive case suggesting that a severe coagulation abnormality may develop during treatment for ischemic enteritis in older people taking a DOAC.

A Rat Model of Ischemic Enteritis: Pathogenic Importance of Enterobacteria, iNOS/NO, and COX-2/PGE2

BACKGROUND

We introduced a rat model of ischemic enteritis and investigated the roles of enterobacteria, Nitric Oxide (NO), and Prostaglandins (PGs) in its pathogenesis.

METHODS

Male rats were used after 18 h of fasting. Ischemic enteritis was induced by partial ligation of the superior mesenteric artery (SMA). Under ether anesthesia, SMA was isolated, and a stenosis was made by placing a needle (23 guage) on the vessel and ligating both the vessel and needle, and then a needle was removed from the ligature. Animals were then fed normally after surgery. Various drugs such as antibiotics, cyclooxygenase (COX) inhibitors, NO synthase (NOS) inhibitors and PGE2 were administered for 2 days after surgery.

RESULTS

Stenosis of the SMA caused mucosal ischemia and damaged the small intestine, particularly the ileum, within 3 days. The development of enteritis was accompanied by mucosal invasion of enterobacteria, with the bacterial count being significantly increased 8 h after surgery. The severity of enteritis was prevented by the prior administration of ampicillin, L-NAME, or aminoguanidine, but aggravated by that of indomethacin or rofecoxib. The deleterious effects of indomethacin were antagonized by the co-administration of PGE2; these effects were mimicked by AE1-329, an EP4 agonist, and abrogated by AE3-208, an EP4 antagonist. The expression of iNOS and COX-2 was up-regulated in the small intestine in a time-dependent manner after ischemia caused by stenosis of the SMA, with increases in the mucosal contents of NO and PGE2.

CONCLUSION

These results suggest that enterobacteria played a major pathogenic role in this model of ischemic enteritis, and that iNOS/NO was deleterious in the pathogenesis of these lesions, while COX-2/PGE2 prevented the development of ischemic enteritis by activating EP4 receptors.

Ischemic necrosis of the tongue in surgical patients with septic shock: a case report

Background

As the tongue is a well-vascularized organ, ischemic necrosis of the tongue is a rare disease entity. Critically ill patients with profound shock may experience end-organ hypoperfusion, which might result in tongue necrosis. However, to our best knowledge, there are no reports regarding ischemic necrosis of the tongue in surgical patients with septic shock.

Case presentation

Two patients recently developed ischemic necrosis of the tongue in our surgical intensive care unit. Both patients had undergone emergent surgery for ischemic enteritis and developed postoperative septic shock. The first patient responded to critical treatment with a short period of circulatory shock, and the delivered dose of the vasopressor seemed to be acceptable. In contrast, the second patient developed postoperative refractory shock, and high-dose vasopressor treatment was required to maintain adequate tissue perfusion. Both patients developed ischemic necrosis of the tongue and died shortly after its emergence, despite vigorous resuscitation.

Conclusions

We suggest that ischemic necrosis of the tongue is an under-reported manifestation of any type of circulatory shock, which may have a complex pathogenic mechanism. Clinicians should be aware of the possibility of ischemic necrosis of the tongue in patients with circulatory shock, even if the patient exhibits clinical improvement, as this awareness may facilitate estimation of their prognosis and preparation for clinical deterioration.

Modification of end-loop ileostomy for the treatment of ischemic or radiation enteritis

AIM: To evaluate a new technique of temporary ileal anastomotic stoma, following small bowel resection, in patients where the anastomosis is anticipated to have borderline margins with dubious viability.

METHODS: Five patients underwent enterectomy and partially anastomosed end-loop ileostomy at the University Hospital of Larissa between 2000 and 2006. Enterectomy was performed because of conditions such as mesenteric vascular occlusive disease, radiation entritis and small bowel injury.

RESULTS: Postoperatively, none of the patients developed any stoma-related or anastomotic complications. There were no major complications. All patients were discharged between the 8th and 15th day after the procedure, and the stoma was closed 3 wk to 4 wk later.

CONCLUSION: We believe that our proposed modification of end-loop ileostomy is a simple, quick and safe technique with minimal stoma-related morbidity, and with simple and safe reversion. This technique can be considered as a useful option in the treatment of ischemic or radiation-induced enteritis, and in the management of severe intestinal trauma.