Littérature scientifique sur le sujet « Acute mesenteric ischemia, superior mesenteric artery obstruction, mesenteric ischemia mangement »

Mesenteric ischemia is one of the most mortal diseases of the gastrointestinal system causing acute abdomen. In most of the patients, the etiological factor is the obstructive embolism or thrombosis of superior mesenteric artery. In the literature, there have been reports regarding also celiac trunk occlusion in rare situations. The gold standard treatment relies on early diagnosis. The originality of our report relies on the concurrent obstruction of both vascular structures.

Abstract Objectives: Partial or total necrosis of the bowel is a frequent cause of obstruction of the mesenteric artery or vein. Mesenteric infarction is usually the consequence of other associated pathologies of the patient and most often revealed by acute intestinal obstruction. Thus, it is of utmost importance to recognize the risk factors and treat all conditions that might have a link with a hypercoagulability state. Acute mesenteric ischemia is pathology difficult to treat due to the nonspecific symptomatology and late diagnosis consequently. Moreover, the majority the patients have other comorbidities resulting a mortality in over 50% of the cases. Methods and results: Identified risk factors in our patient’s case for the thrombus formations were oral contraceptive medication, hypertension, and obesity. Other secondary causes of Superior Mesenteric Vein (SMV) and Portal Vein (PV) thrombosis were investigated but all tests were negative leading to the incrimination of obesity and chronic use of oral contraceptives for over two decades. Conclusion: Rare, life-threatening complications of associated pathologies such as venous mesenteric thrombosis and bowel obstruction are unanticipated. Thus, it is of utmost importance to diagnose complications and risk factors as soon as possible whose resolutions will make it possible to prolong survival of many patients. Identification of populations at risk and screening of asymptomatic patients are therefore crucial imperatives.

Background: Acute mesenteric ischemia consists of the sudden, partial or complete, interruption of the blood ow in superior or inferior mesenteric vessels that result in intestinal ischemia. The incidence was exponentially increasing with age and no difference has been observed between sexes. Aim: The Aim of this case series was to highlight clinical presentation, the difculty in diagnosis and importance of early intervention and the prognosis of superior mesenteric vessel thrombosis with bowel ischemia. This article presented a case series of intestinal infarction through obstruction of superior mesenteric vessels – three cases of acute mesenteric artery thrombosis, two case of acute mesenteric vein thrombosis. Materials and methods: The materials for this case series was collected from patients diagnosed and admitted as acute superior mesenteric vessel thrombosis in various surgical units in Department of General Surgery, Govt. Kilpauk Medical College & Hospital & Govt Royapettah Hospital,Chennai. All 5 cases have been analyzed for this study during period of 18 months from March 2020 to Augest 2021. All Cases with superior mesenteric vessels thrombosis were included.No exclusion criteria. Results: This case series consisted of 5 cases, three cases of acute mesenteric artery thrombosis and two case of acute mesenteric vein thrombosis. In this case series, superior mesenteric artery thrombosis was more common with male preponderance. 4 out of 5 cases were male in which Superior mesenteric artery was more common when compared to vein thrombosis. Out of 5 cases, 2 cases were asymptomatic with mild abdominal discomfort. Most common complaints of 5 cases were sudden onset of abdominal pain with or without vomiting. Abdominal distension/ Constipation were not seen in all cases. Out of 5 cases, 2post- operative stay and no complications after surgery. 2 cases developed postop complications.1 case had deceased because of late presentation. Conclusion: The diagnosis of AMI is difcult and mostly delayed resulting in irreversible bowel ischemia which requires emergency intervention. Mortality and morbidity for AMI remains high, and in patients requiring extensive bowel resection the survival rate was low. As AMI mostly affects the elderly population physicians have to be aware of the possibility of this condition when facing the elderly patient even with mild sudden onset of abdominal pain complaints. An interdisciplinary collaboration is must, since patients are not initially evaluated by surgeons.

Abstract 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.

An 85yo woman presented with diffused colicky abdominal pain and vomiting for 12hr. Patient still had bowel movement and passed flatus. Patient was otherwise healthy without past medical or surgical history, and taking no medications. PE: no distress, afebrile, vitals are stable. Cardiopulmonary exam only revealed tachycardia; Abdomen: soft, non-tender, no distension, bowel sounds hyperactive; there was an 8[[Unable to Display Character: ]]6 cm irreducible, firm but non-tender right inguinal hernia. Labs: leukocytosis, bicarbonate 20. CT abdomen with oral contrast suggested small bowel obstruction secondary to right inguinal hernia. The hernia was then reduced manually. Post the reduction patient had one foul smell watery bowel movement. However, patient deteriorated quickly. Repeat labs: bicarbonate 8, anion gap 23, lactic acid 11, ABG: 7.01/29/246/7/99%. EKG: A-fib with tachycardia. Patient’s blood pressure dropped necessitating IV fluid and vasopressor support. Strangulated hernia with septic shock was suspected and emergency laparotomy was performed. Ascending, transverse and descending colon past the splenic curve were found necroses with foul-smelling turbid fluid intraperitoneally; the small bowel was minimally dilated with a kink 25cm beyond the ileocelcal valve with evidence of previous incarceration. Subtotal colectomy and partial small bowel resection with ileostomy was performed. Pathology confirmed terminal ileum and colonic gangrene; recent mesentery venous thrombi. Despite appropriate therapy, patient continued to be in septic shock and developed multiple organ failure, a stroke, and then brain death. Acute mesenteric ischemia (AMI) is a rare abdominal emergency with high mortality, which could be caused by direct strangulation of the SMA by the inguinal hernia (Tiwary SK et al 2008) or thromoboembolism, e.g., emboli from A-fib, septic emboli, local thrombosis. Since there is no evidence that the incarcerated portion of small bowel had necrosis, this case is mostly likely caused by the paroxysmal A-fib-derived emboli. Due to the lack of typical clinical expression, a high index of suspicion is essential for prompt diagnosis. CT angiography is the current cornerstones for diagnosis of AMI, so treatment can be initiated expeditiously.

Background: Intestinal malrotation refers to the partial or complete failure of rotation of midgut around the superior mesenteric vessels in embryonic life. Arrested midgut rotation results due to narrow-based mesentery and increases the risk of twisting midgut and subsequent obstruction and necrosis. Midgut volvulus secondary to intestinal malrotation is a rare presentation in adults more so in the elderly. Its rarity portends a diagnostic dilemma for both the surgeon and radiologist, and CT scan showed dilated large and small intestine segments with air-fluid levels and twisted mesentery around superior mesenteric artery and vein indicating "whirlpool sign". In our patient Case presentation: 42 years old male who presented to the emergency department with acute onset of pain in the RUQ, vomiting, and absolute obstipation for the last 2 days. This patient had a history of similar two episodes of sub-acute intestinal obstruction in the last 6 months which has been managed conservatively. The patient underwent an elective exploratory laparotomy after 2 days of failed conservative management. Operative findings included the presence of adhesive bands in the RUQ (Ladd's Band), volvulus of the mid-portion of the small bowel in a clockwise fashion, and multiple intraabdominal adhesions and empty RIF and caecum pulled up in RUQ. We subsequently performed a Ladd's procedure, multiple adhesiolysis, and caecopexy and the patient had an uneventful recovery with eventual discharge on postoperative day 12. This case report reviews the incidence of malrotation in adults. It also high Conclusion: lights the difficulty in diagnosing midgut volvulus in the adult population given the nonspecific, insidious symptoms, therefore, prompting awareness of its existence and a high degree of clinical suspicion. Malrotation should be considered in the differential diagnosis in patients presented with acute abdomen and intestinal ischemia.

Acute mesenteric ischemia is still characterized by a high mortality since it is difficult to recognize the proper diagnosis. Unfortunately there are no guidelines based on the evidence of randomized controlled trials. Our study, like the most in literature, is a retrospective review based on the findings of ten years in patients treated at the Surgical Division of Policlinic-Vittorio Emanuele Hospital of the Catania s University for acute mesenteric ischemia. It is a typical disease affecting elderly since it s often consequence of atherosclerosis, of thromboembolism from cardiac arrhythmias and, in the nonocclusive form, of hypoperfusion caused by a low cardiac output characteristic of myocardial infarction, congestive heart failure or aortic insufficiency. Our patients with acute mesenteric ischemia were 42 but only 3 were younger than 65-year old. Habitually, the diagnosis is made intraoperatively when the bowel is already necrotic. Patients should be treated before 24 hours the onset of symptoms to improve the prognosis. CT angiography, used more and more frequently for abdominal syndromes even in small hospitals , has led to an earlier diagnosis. Moreover new endovascular techniques have to led to improved outcomes, especially when they are used in combination with open surgery techniques. Despite these advances the overall mortality remains high, in our study it was about 64% probably because our emergency operating theatres are not angio-equipped and every diagnostic and management step made in different places probably delays the appropriate successful treatment.