D-dimer as a marker for early diagnosis of acute mesenteric ischemia

The Diagnostic Value of Coagulation Indicators and Inflammatory Markers in Distinguishing Between Strangulated and Simple Intestinal Obstruction

BACKGROUND

Intestinal obstruction with strangulation can be life-threating, and it is critical to make an accurate and timely diagnosis for emergency surgery.

OBJECTIVE

This was aimed to investigate the value of coagulation indicators and inflammatory markers in distinguishing between strangulated and simple intestinal obstruction.

MATERIALS AND METHODS

Fifty-four patients with intestinal obstruction were retrospectively studied. The correlation between coagulation indicators and inflammatory markers with intestinal obstruction was analyzed. Receiver operating characteristic curves were created to assess their ability in discriminative diagnosis.

RESULTS

Levels of fibrinogen (Fib), C-reactive protein (CRP), neutrophil ratio, and D-Dimer were significantly greater, while thrombin time was significantly shorter in strangulated intestinal obstruction compared with simple intestinal obstruction. Furthermore, Fib levels in the necrosis subgroup of strangulated intestinal obstruction were significantly higher than those in the ischemia subgroup and simple intestinal obstruction group. The areas under the receiver operating characteristic curve were 0.58 for white blood cells, 0.78 for CRP, and 0.80 for Fib. Using the optimal cutoff values of Fib (3.71 g/L) and CRP (14.54 mg/L), the sensitivity, specificity, positive predictive value, and negative predictive value in discriminating between strangulated intestinal obstruction and simple intestinal obstruction were 51.43%, 100%, 100%, and 52.78% for Fib, and 56.25%, 94.44%, 94.74%, and 54.84% for CRP, respectively.

CONCLUSIONS

Fib and CRP demonstrate good performance in predicting strangulation and are indicative of intestinal necrosis and ischemia. The combination of this coagulation indicator and inflammatory marker holds potential for better discrimination between strangulated and simple intestinal obstruction.

Acute type A aortic dissection with mesenteric malperfusion syndrome: a case report

BACKGROUND

Patients with acute type A aortic dissection and mesenteric malperfusion syndrome (mesMPS) have a high mortality rate. Therefore, the analysis of the timing of open aortic repair and intestinal operation is of great significance for the timely selection of clinical treatment.

CASE SUMMARY

The chief complaints of the patient were sudden chest and back bursting pain for 15 h. Emergency "ascending aorta replacement + total arch replacement (island flap anastomosis) + descending aorta stent implantation + coronary artery bypass grafting + autologous vascular access" was performed. The patient's postoperative occult blood test was positive. His blood stool was visible to the naked eye on the 11^th day after the open aortic repair. He had abdomen tenderness on the 12^th postoperative day. He had abdominal pain and was diagnosed by CT with intestinal obstruction on the 13^th postoperative day. Then, he underwent an emergency laparotomy for right hemicolectomy + partial resection of small intestine + cholecystectomy + ileostomy. He was discharged with diagnoses of aortic dissection (type A), coronary dissection, multiple perforations of the colon, congenital ectopic small bowel glands, and acute attack of chronic cholecystitis. More than a year later, he underwent "intestinal adhesion lysis + ileostomy closure + incisional hernia repair". The patient recovered well at the 1-year follow-up.

CONCLUSION

We have reported a case of acute type A aortic dissection with mesenteric malperfusion syndrome. In the early stage of mesenteric hypoperfusion syndrome, specific laboratory examination indexes and clinical manifestations are lacking, and mesenteric multidetector CT angiography is a first-line examination method for mesenteric malperfusion. Through the detailed analysis of the patient's condition and the review of the relevant literature, we hope to have a deeper understanding of this condition and provide evidence supporting the formulation of clinical treatment plan.

The value of potassium, pH and D-dimer levels in early diagnosis of acute mesenteric ischemia: an experimental study on rats

INTRODUCTION

The aim of this randomized controlled experimental study was to evaluate the efficacy of potassium, pH and D-dimer levels in blood, as well as potassium and pH levels in peritoneal lavage fluid, in the early diagnosis of acute mesenteric ischemia.

MATERIAL AND METHODS

This study was conducted at the Istanbul University Center of Experimental Medicine after having received approval from the Istanbul University animal testing ethics committee. Male albino Wistar rats (n = 24; 250 to 350 g) were divided into two control groups and two ischemic groups. Levels of potassium, pH, and D-dimer in blood and levels of potassium and pH in peritoneal lavage fluid were analyzed for 1 h and 2 h after the induced acute mesenteric ischemia procedure. The degree of ischemic injury was determined using the histopathological damage score in tissue samples taken from the terminal ileum.

RESULTS

Ischemic groups had statistically significant differences in potassium and pH in blood and peritoneal lavage fluid compared to non-ischemic groups (p < 0.05). There was no significant difference between control and ischemic groups in terms of D-dimer and histologic grading results after 1 h (p = 0.132, p = 0.475 respectively), while there was a significant difference between control and ischemic groups after 2 h (p < 0.05).

CONCLUSIONS

The levels of potassium, pH, and D-dimer could be useful in daily practice for the early diagnosis of acute mesenteric ischemia.

A Novel Approach for Repairing Superior Mesenteric Artery Injury During Left Nephrectomy-6-year Follow-up

OBJECTIVE

To describe a novel approach for reconstructing the superior mesenteric artery (SMA) during left nephrectomy and review the literature.

MATERIALS AND METHODS

The patient was a 57-year-old man with left back pain from an unknown cause for more than 3 hours. A computed tomography scan showed a 12- × 15-cm firm mass and a subcapsular hematoma in the left kidney. It was considered to be bleeding and rupture of the solid renal mass, and because of persistent pain and no documented distant metastatic disease, a transperitoneal laparoscopic nephrectomy was elected, but the procedure was converted to open surgery for SMA injury. We reconstructed the SMA with end-to-end anastomosis between the SMA and the left renal artery stump.

RESULTS

At the 6-year follow-up, the patient had no intestine-related sequelae.

CONCLUSION

Our novel approach of an end-to-end anastomosis between the SMA and the left renal artery stump is an option for SMA injury, especially when orthotopic anastomosis or repair of the SMA is not indicated.

Amelioration of Coagulation Disorders and Inflammation by Hydrogen-Rich Solution Reduces Intestinal Ischemia/Reperfusion Injury in Rats through NF-κB/NLRP3 Pathway

Intestinal ischemia/reperfusion (I/R) injury often causes inflammatory responses and coagulation disorders, which is further promoting the deterioration of the disease. Hydrogen has anti-inflammatory, antioxidative, and antiapoptotic properties against various diseases. However, the effect of hydrogen on coagulation dysfunction after intestinal I/R and the underlying mechanism remains unclear. The purpose of this study was to explore whether hydrogen-rich solution (HRS) could attenuate coagulation disorders and inflammation to improve intestinal injury and poor survival following intestinal I/R. The rat model of intestinal I/R injury was established by clamping the superior mesenteric artery for 90 min and reperfusion for 2 h. HRS (10 or 20 mL/kg) or 20 mL/kg 0.9% normal saline was intravenously injected at 10 min before reperfusion, respectively. The samples were harvested at 2 h after reperfusion for further analyses. Moreover, the survival rate was observed for 24 h. The results showed that HRS improved the survival rate and alleviated serum diamine oxidase activities, intestinal injury, edema, and apoptosis. Interestingly, HRS markedly improved intestinal I/R-mediated coagulation disorders as evidenced by abnormal conventional indicators of coagulation and thromboelastography. Additionally, HRS attenuated inflammatory responses and the elevated tissue factor (TF) and inhibited nuclear factor kappa beta (NF-κB) and nucleotide binding and oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome activation in peripheral blood mononuclear cells. Moreover, inflammatory factors and myeloperoxidase were closely associated with TF level. This study thus emphasized upon the amelioration of coagulation disorders and inflammation by HRS as a mechanism to improve intestinal I/R-induced intestinal injury and poor survival, which might be partially related to inhibition of NF-κB/NLRP3 pathway.

Small-intestinal necrosis due to non-occlusive mesenteric ischemia with diabetic ketoacidosis after quetiapine treatment

We report a 66-year-old male who developed diabetic ketoacidosis (DKA) and necrosis of the small intestine due to non-occlusive mesenteric ischemia (NOMI), 3 months after starting quetiapine treatment. He was transferred to our hospital and diagnosed as diabetic for the first time, associated with DKA. Despite improvement in DKA, abdominal pain worsened gradually 10 h after hospitalization. Computed tomography (CT) revealed bowel emphysema, and gas out of the gut wall, in the mesenteric veins and the intrahepatic portal vein, suggesting intestinal necrosis. He survived because of resection of necrotic small-intestinal tissue and he finally required no diabetes treatment. Mesenteric arteries were patent with good palpitation without occlusion or thrombosis, and pathological findings showed ischemic enteritis, which is consistent with NOMI. DKA is a rare but serious side effect of second-generation antipsychotic medications (SGAMs) such as quetiapine, which can result in NOMI: a life-threatening complication. We must keep in mind that the plasma glucose concentration may increase in patients taking SGAMs, or that NOMI may occur concurrently if DKA develops.

Predictive Factors for Intestinal Transmural Necrosis in Patients with Acute Mesenteric Ischemia

BACKGROUND

Acute mesenteric ischemia (AMI) is a serious and potentially fatal condition. No definite parameter can predict transmural bowel necrosis in patients with AMI to justify early surgical intervention. The current study aimed to identify the clinical, laboratory, and radiologic parameters that can successfully predict the onset of intestinal transmural necrosis in patients with AMI.

PATIENTS AND METHODS

Records of patients with AMI in the period of January 2013 to October 2017 were reviewed. Clinical parameters as patients' symptoms, vital signs, and signs of peritonitis along with the results of laboratory and radiologic investigations were analyzed to identify predictive factors for intestinal transmural necrosis using binary logistic regression analysis.

RESULTS

One hundred and one patients (70 males) with mean age of 55 years were included. Venous occlusion was the cause of AMI in 78 (77.3%) patients and arterial occlusion in 23 (22.7%) patients. Twenty-two patients completed conservative treatment successfully, whereas 79 patients required exploratory laparotomy. On laparotomy, six patients were found to have viable bowel. Overall, 28 patients had viable bowel and 73 had bowel necrosis. The significant independent predictors for transmural bowel necrosis were mesenteric arterial occlusion (OR: 26.5, p = 0.02), leukocytosis (OR: 1.3, p < 0.0001), acidosis (OR: 3.8, p = 0.04), free intraperitoneal fluid (OR: 4.21, p = 0.005), and combined portal vein and SMV thrombosis in CT scan (OR: 3.4, p = 0.026).

CONCLUSION

The independent predictors for transmural bowel necrosis were mesenteric arterial occlusion, leukocytosis, acidosis, free intraperitoneal fluid, and combined portal vein and SMV thrombosis in CT scan.

In the Experimental Model of Acute Mesenteric Ischemia, The Correlation of Blood Diagnostic Parameters with the Duration of Ischemia and their Effects on Choice of Treatment

Purpose/Aim: Acute mesenteric ischemia is a syndrome characterized by sudden onset abdominal pain followed by intestinal necrosis. Morbidity and mortality increase with delayed diagnosis. Even with the latest radiological diagnostic methods, early diagnosis and initiation of treatment can be delayed. Using an experimental model, here we aim to determine the relationship between the laboratory parameters used to detect acute mesenteric ischemia and the duration of irreversible ischemia. Materials and Methods: A total of 30 male Wistar albino rats were divided into five groups, all of which underwent general anesthesia: (i) Superior mesenteric artery (SMA) dissection with laparotomy was performed, and blood samples and intestinal segment samples were taken after 2 hr (Sham group); (ii) volvulus of one-third of the small intestines was performed manually by laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (Volvulus group); (iii) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (SMA+ligated 2-hr group); (iv) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 4 hr (SMA+ligated 4-hr group); and (v) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 6 hr (SMA+ligated 6-hr group). Results: The mean lactate dehydrogenase (LDH) activities of the SMA+ligated 2-hr and SMA+ligated 6-hr groups were statistically higher than the control group (p = .004). Compared to the Sham and Volvulus groups, the mean lactate level of the SMA+ligated 6-hr group was significantly higher (p = .004). Compared to the Sham and Volvulus groups, the mean D-dimer levels of the SMA+ligated 4-hr and SMA+ligated 6-hr groups were significantly higher (p = .004 and .003, respectively). By histopathological evaluation, we found that pathological damage increased as the ischemia lengthened. Conclusions: Mesenteric ischemia leads to an irreversible loss of intestinal perfusion and an increase in parameters of ischemia. Irreversible tissue damage occurs after 4 hr of ischemia and peaks after 6 hr, whereas parameters of ischemia (D-dimer, LDH, and L-Lactate levels) are highest at 2 hr after the onset of ischemia.

Therapeutic targeting of extracellular DNA improves the outcome of intestinal ischemic reperfusion injury in neonatal rats

Thrombosis and inflammation cooperate in the development of intestinal infarction. Recent studies suggest that extracellular DNA released by damaged cells or neutrophils in form of extracellular traps (NETs) contributes to organ damage in experimental models of ischemia-reperfusion injury. Here we compared the therapeutic effects of targeting fibrin or extracellular DNA in intestinal infarction after midgut volvulus in rats. Following iatrogenic midgut volvulus induction for 3 hours, we treated animals with a combination of tissue plasminogen activator (tPA) and low molecular weight heparin (LMWH) to target fibrin or with DNase1 to degrade extracellular DNA. The therapeutic effects of tPA/LMWH and DNase1 were analyzed after 7 days. We observed that both therapeutic interventions ameliorated tissue injury, apoptosis, and oxidative stress in the intestine. DNase1, but not tPA/LMWH, reduced intestinal neutrophil infiltration and histone-myeloperoxidase-complexes, a surrogate marker of NETs, in circulation. Importantly, tPA/LMWH, but not DNase1, interfered with hemostasis as evidenced by a prolonged tail bleeding time. In conclusion, our data suggest that the therapeutic targeting of fibrin and extracellular DNA improves the outcome of midgut volvulus in rats. DNase1 therapy reduces the inflammatory response including NETs without increasing the risk of bleeding. Thus, targeting of extracellular DNA may provide a safe therapy for patients with intestinal infarction in future.

The value of combined elevation of D-dimer and neopterin as a predictive parameter for early stage acute mesenteric ischemia: An experimental study

Background The diagnosis of acute mesenteric ischemia is variable. Early diagnosis is important for reducing the mortality and morbidity rates. Aim This experimental study aims to investigate the diagnostic utility of D-dimer and neopterin as a marker for the early stage of acute mesenteric ischemia caused by occlusion of superior mesenteric artery. Methods The levels of D-dimer and neopterin were measured using an animal acute mesenteric ischemia model in 21 male rabbits. Superior mesenteric artery occlusion (Group 1, n = 14) and control (Group 2, n = 7) groups were identified. Blood samples at different times are collected from each rabbits. Blood samples from superior mesenteric artery occlusion group were taken 30 min after anesthesia but before laparotomy, 1, 2, and 3 h after superior mesenteric artery ligation. Blood samples from control group were taken 1 h before, 1 and 3 h after anesthesia and laparotomy. The D-dimer and neopterin levels of each blood sample were measured. Results The probability of acute mesenteric ischemia was found to be 36 times higher when the D-dimer level was over 0.125 ng/L, whereas the probability was 19.2 times higher when the neopterin level was over 1.25 nmol/L. Conclusions In this experimental study, the combined elevation of two significant markers, D-dimer and neopterin, may be helpful for the early diagnosis of acute mesenteric ischemia.

Plasma citrulline measurement in the diagnosis of acute mesenteric ischaemia

BACKGROUND

The differential diagnosis in acute mesenteric ischaemia (AMI) is essential and sometimes life-saving. A marker for early diagnosis is lacking. Citrulline is an amino acid mainly synthesized by small bowel enterocytes from glutamine. In this study, we aimed to evaluate the diagnostic and prognostic values of citrulline with those of the D-dimer in patients with AMI.

METHODS

The patients were divided into two groups; group 1: patients with acute abdominal findings which were attributed preoperatively to AMI, and group 2: patients with acute abdominal findings which were attributed preoperatively to causes other than AMI. All patients underwent surgical exploration. Blood samples were taken before surgery. The demographic features, laboratory examinations, citrulline concentration, D-dimer level and surgical findings were evaluated.

RESULTS

Overall, 48 patients were enrolled in the study. AMI was diagnosed in 23 of the 48 patients. There was no significant difference between the groups with regard to gender, leucocyte count and creatinine levels but group 1 was significantly older than group 2. Citrulline, D-dimer and lactate levels were also significantly higher in group 1. Age, lactate, D-dimer and citrulline levels were statistically significant for mortality. The most significant factor was increased lactate level at admission.

CONCLUSION

Plasma citrulline level may be helpful in the diagnosis of patients with AMI.

Non-occlusive Mesenteric Ischemia with Diabetic Ketoacidosis and Lactic Acidosis Following the Administration of a Sodium Glucose Co-transporter 2 Inhibitor

We herein describe a patient with non-occlusive mesenteric ischemia (NOMI) potentially associated with the administration of a sodium glucose co-transporter 2 (SGLT2) inhibitor. A 60-year-old man with type 1 diabetes was transferred to our hospital due to vomiting and respiratory distress. He was treated with insulin, metformin and a SGLT2 inhibitor, which had recently been added. He was diagnosed with intestinal ischemia complicated by diabetic ketoacidosis and lactic acidosis. Urgent exploratory surgery was performed, and the gangrenous bowel was resected. Histological findings confirmed the diagnosis of NOMI. The administration of SGLT2 inhibitors therefore requires certain exceptions for type 1 diabetes and cautious monitoring for the occurrence of these possible adverse effects.

The Combination of D-Dimer and Peritoneal Irritation Signs as a Potential Indicator to Exclude the Diagnosis of Intestinal Necrosis

Intestinal necrosis is a life-threatening disease, and its prompt and accurate diagnosis is very important. This study aimed to evaluate the value of D-dimer as a marker for early diagnosis of bowel necrosis. From 2009 to 2013, patients undergoing operation due to acute intestinal obstruction were retrospectively analyzed. Clinicopathologic characteristics were compared among no ischemia group, reversible ischemia group, and bowel necrosis group. There were totally 274 patients being included for analyses. Patients with bowel necrosis had a significant highest level of D-dimer compared with other 2 groups (P =  .007) when FEU unit was applied. The optimal cutoff value of D-dimer levels as an indicator in diagnosing bowel necrosis was projected to be 1.965 mg/L, which yielded a sensitivity of 84.0%, a specificity of 45.6%, a positive predictive value of 60.7%, and a negative predictive value of 74.0%. And the sensitivity of 84.0% and specificity of 70.0% were detected, when 1.65 mg/L of D-dimer was set as the cutoff value to distinguish the reversible ischemia and bowel necrosis. The corresponding results in patients with no or slight peritoneal irritation signs were 85.2%, 44.7%, 35.4% and 89.5% respectively. The sensitivity and negative predictive value were 96.0% and 91.7%, respectively, when D-dimer and peritoneal irritation signs were combined to perform the parallel analysis. The combination of D-dimer and peritoneal irritation signs could generate a reliable negative predictive value, which is helpful to exclude the diagnosis of intestinal necrosis. However, it should also be proved in well-designed large-scale prospective study.

Diagnostic Value of Procalcitonin Levels in Acute Mesenteric Ischemia

BACKGROUND

Acute mesenteric ischemia (AMI) is a potentially fatal disease. Difficulties in diagnosis make it essential to find early biomarkers.

AIMS

This study investigated the diagnostic value of procalcitonin (PCT) levels in AMI.

STUDY DESIGN

Animal experimentation.

METHODS

Rats were divided into six groups of six animals each. In the experimental group, an experimental ischemia model was established by clamping the superior mesenteric artery from the aortic outflow tract. Blood and tissue specimens were collected from rats in the experimental mesenteric ischemia model at 30 min and 2 and 6 h, and these were compared with specimens from the respective control groups. PCT levels were compared at 30 min and 2 and 6 h.

RESULTS

PCT levels were 185.3 pg/mL in the control group and 219.3 pg/mL in the study group, 199.6 pg/mL in the control group and 243.9 pg/mL in the study group, and 201.9 pg/mL in the control group and 286.9 pg/mL in the study group, respectively, at 30 minute, 2 and 6 hours. Significant differences were determined between 6-h control group and ischemia group PCT levels (p=0.005).

CONCLUSION

The absence of a significant increase in PCT levels in the early period, while a significant difference was detected in the later period (6 h), shows that PCT levels rise late in mesenteric ischemia and can be a marker in the late period.

Early diagnosis of testicular torsion in rats by measuring plasma d-dimer levels: comparative study with epididymitis

PURPOSE

To evaluate the differential diagnosis of testicular torsion and acute epididymo-orchitis by measuring the acute increase in plasma d-dimer levels in an experimental rat model.

METHODS

Thirty male Wistar rats were randomly divided into 5 groups, 1--sham operated group (acute term; 4 hours), 2--early torsion group (acute term; 4 hours), 3--late torsion group (long-term; 72 hours), 4--control of epididymitis group (vehicle injected; 0.1 ml physiologic saline injected into the left ductus deferens) (long term; 72 hours), 5--epididymitis group (0.1 ml Escherichia coli injected into the left ductus deferens), (n=6 for each group).

RESULTS

Serum d-dimer levels were significantly higher compared with the sham operated group with early torsion (p=0.002). This elevation remained mildly in the late torsion group compared with the control group (p<0.001), but there was no difference between 4 and 72 hours of the testis torsions (p=0.794). On the other hand, d-dimer levels were significantly higher in the torsion groups compared to the epididymitis group (p=0.042).

CONCLUSIONS

The present study demonstrated that testicular damage that occurs following testicular torsion shows a higher increase in d-dimer levels than epididymitis, suggesting that d-dimer level can be used as a diagnostic marker of testicular torsion.

Procalcitonin and intestinal ischemia: A review of the literature

Intestinal ischemia is common after emergency gastrointestinal or cardiovascular surgery. At present, there are no diagnostic tools for the early diagnosis of intestinal ischemia. In the last decade, procalcitonin (PCT) has been suggested as a marker of this condition. Here, we review the use of PCT as a diagnostic tool for intestinal ischemia. Two reviewers independently searched the PubMed and EMBASE databases for articles on intestinal ischemia and PCT. They then considered (1) the criteria applicable to preclinical and clinical data; and (2) PCT’s predictive value in the diagnosis of intestinal ischemia. Article quality was rated according to the STAndards for Reporting of Diagnostic accuracy. Between 1993 and 2014, seven studies (including two preclinical studies and five clinical studies) dealt with the use of PCT to diagnose intestinal ischemia. Procalcitonin’s sensitivity, specificity, positive predictive value and negative predictive value ranged between 72% and 100%; 68% and 91%; 27% and 90% and 81% and 100%, respectively. The area under the receiver operating characteristic curve ranged from 0.77 to 0.92. In view of the preclinical and clinical data, we consider that PCT can be used in daily practice as a tool for diagnosing intestinal ischemia.

D-dimer as an early marker of severity in patients with acute superior mesenteric venous thrombosis

No early serum marker of disease severity contributes to the treatment decision-making process of acute superior mesenteric venous thrombosis (ASMVT). This study aims to assess the value of serum D-dimer level in the first 3 days after admission as a severity marker of ASMVT patients. From May 2010 to June 2014, 50 consecutive patients of ASMVT were enrolled in this observational study. The serum D-dimer level was measured on a daily basis during the first 3 days after admission as well as other laboratory-testing parameters, clinical score, and outcome variables recorded during the same period. The maximum and mean D-dimer values were analyzed and compared with other potential markers for prediction of multiple-organ dysfunction syndrome (MODS) and short-bowel syndrome (SBS). The correlation of D-dimer level with other potential severity markers and inflammation parameters were also studied. Both maximum and mean D-dimer level during the first 3 days of admission were significantly higher in patients with several clinical variables such as death within 30 days, bowel resection, sepsis, abdominal compartment syndrome, MODS, and SBS. In addition, serum D-dimer level showed precise prediction for MODS and SBS, greater than L-lactate and intestinal-type fatty acid-binding protein (I-FABP). The D-dimer level was correlated well with L-lactate, I-FABP, and APACHE II score on the first 3 days of admission. Poor correlation of D-dimer level and inflammation parameters, white blood cell count, and C-reactive protein level, was detected. D-dimer level could be an effective, early, and specific serum marker indicating the clinical evolution and outcome of ASMVT.

Value of the serum I-FABP level for diagnosing acute mesenteric ischemia

PURPOSE

This study examined the feasibility of using the serum intestinal fatty acid binding protein (I-FABP) level for the early diagnosis of acute mesenteric ischemia, and investigated whether it contributes to the clinical decision-making process.

METHOD

Thirty patients diagnosed with acute mesenteric ischemia, 27 patients with other types of acute abdomen who presented with acute abdomen symptoms but were not diagnosed with acute mesenteric ischemia, and 20 healthy people were included in the study. Mesenteric ischemia was confirmed by a pathological evaluation in patients who underwent intestinal resection due to detection of mesenteric ischemia during surgery.

RESULTS

There was no significant difference in the leukocyte counts and D-dimer levels between subjects with mesenteric ischemia and acute abdomen due to other causes (p > 0.05). There was a significant difference in the serum I-FABP level between these groups (p < 0.001).

CONCLUSION

The I-FABP level is a more reliable parameter for diagnosing acute mesenteric ischemia compared to leukocytosis and D-dimer elevation.

The value of signal peptide-CUB-EGF domain-containing protein 1 and oxidative stress parameters in the diagnosis of acute mesenteric ischemia

OBJECTIVES

This study investigated the diagnostic value of signal peptide-CUB-EGF domain-containing protein 1 (SCUBE-1) and other oxidative stress parameters in the early diagnosis of acute mesenteric ischemia, which has high mortality and morbidity if not identified and treated in the early period.

METHODS

Thirty-six female Sprague-Dawley rats were used in this randomized, controlled study. Rats were divided into six groups: three control groups (Groups I, III, and V) and three ischemia groups (Groups II, IV, and VI). In the control groups, blood and tissue specimens were sampled at 30 minutes (Group I), 2 hours (Group III), and 6 hours (Group V), following a simple laparotomy. In the ischemia groups, the superior mesenteric artery (SMA) was ligated following laparotomy, and blood and tissue samples were sampled at 30 minutes (Group II), 2 hours (Group IV), and 6 hours (Group VI).

RESULTS

When comparing the ischemia and control groups, the differences in SCUBE-1, malondialdehyde (MDA), and total antioxidant status (TAS) levels in the 30-minute period were not significant (p > 0.05); at 2 hours, SCUBE-1 levels rose rapidly, and although the desired level of significance could not be obtained with Bonferroni correction, the level was significantly higher compared to the control group at the same time interval (for SCUBE-1, Group III vs. Group IV, p = 0.006). In these periods (30 minutes and 2 hours), only total oxidative status (TOS) and oxidative stress index (OSI) values were significantly higher in the ischemia group compared to the control group (for both, p = 0.004). A pronounced rise in SCUBE-1 levels was determined with 6-hour ischemia (for SCUBE-1, Group V vs. Group VI, p = 0.004). The changes in MDA, TAS, TOS, and OSI levels were not significant (p = 0.025, p = 0.321, p = 0.006, and p = 0.037, respectively).

CONCLUSIONS

SCUBE-1 levels have the potential to be used as a marker of early period injury in acute mesenteric ischemia, although it is impossible to state explicitly that they can be used for early diagnosis. The same can be said for plasma MDA and TAS levels. The authors believe that TOS and OSI levels, however, can be used in early diagnosis and as an injury marker. Moreover, OSI also exhibits a medium-strong correlation with histopathologic injury.

Current status on plasma biomarkers for acute mesenteric ischemia

Clinical diagnosis of acute mesenteric ischemia is difficult. The aim of this review is to provide current status on the search for an accurate plasma biomarker for acute mesenteric ischemia. A search using the medical subject heading terms marker and mesenteric ischemia or intestinal ischemia or superior mesenteric artery occlusion or mesenteric venous thrombosis in the Medline and Embase databases from 1980 to 2011. Studies without a control group or a control group consisted of healthy individuals (human studies), or studies on intestinal reperfusion were excluded. Twenty animal and twelve human studies were identified. In human studies, the studied series of patients had a control group that had a need of laparotomy (n = 2), suspected acute mesenteric ischemia (n = 7), acute abdomen (n = 2) or systemic inflammatory response syndrome (n = 1). D: -dimer has been found to be the most consistent highly sensitive early marker, but specificity was low. The follow-up study on α-glutathione S-transferase yielded inferior sensitivity and accuracy than the preliminary study, clearly questioning the value of this marker. Intestinal fatty acid binding globulin (I-FABP) and D: -lactate are both interesting markers, but the results were conflicting. Different cut-off levels have been used in the studies on I-FABP. The encouraging preliminary result of cobalt-albumin and urinary FABP as an accurate marker needs to be addressed in other study populations. The early clinical and laboratory diagnosis of intestinal ischemia remains a challenge. None of the proposed plasma-derived tests for acute mesenteric ischemia has as yet entered routine clinical practice. The proposed biomarkers need to be evaluated in a prospective clinical research project in patients with acute abdomen.

Peritoneal fluid analysis in dairy cows with left displaced abomasum and abomasal volvulus

Peritoneal fluid (PF) was evaluated in 40 cows with left displaced abomasum (LDA) and 15 cows with abomasal volvulus (AV). PF was obtained by abdominocentesis at the right ventral abdomen at admission. Simultaneously, a blood sample was taken from the jugular vein. Biochemical and cytological variables in blood and PF specific for ischaemia, inflammation and cell damage were compared. Total protein, albumin, glucose and cholesterol were normal in PF of cows with LDA and AV. Although L-lactate increased in both groups, cows with AV had significantly higher values (LDA: 1.47/0.69/2.68 mmol/l; AV: 6.45/4.55/12.89 mmol/l (median/1. quartile/3. quartile)). D-dimer (LDA: 0.50/0.22/0.88 mg/l; AV: 1.11/0.40/1.85 mg/l) and LDH (LDA: 663/437/943 U/l; AV: 1099/750/1439 U/l) were only increased in PF of cows with AV. The number of leucocytes was normal; however, significantly more peritoneal neutrophils appeared necrotic or apoptotic after AV. PF of cows with abomasal displacement showed distinctive features of ischaemia and inflammation. Characteristics of haemostatic dysfunction and cell damage were mainly evident in PF of cows with AV. The results suggest that anti-inflammatory therapy is indicated in each cow with abomasal displacement. Additionally, medical treatment should be directed to prevent complications of ischaemia and reperfusion in cows with AV.

Acute abdominal pain in the older adult

Abdominal pain in older adults is a concerning symptom common to a variety of diagnoses with high morbidity and mortality. Organizing the differential into categories based on pathology (inflammatory, obstructive, vascular, or other causes) provides a framework for the history, physical, and diagnostic studies. An organized approach and treatment and considerations specific to the geriatric population are discussed.

The diagnostic value of ischemia-modified albumin in a rat model of acute mesenteric ischemia

OBJECTIVES

Previous studies have demonstrated that ischemia-modified albumin (IMA) is a useful marker for the diagnosis of ischemic events. This study aimed to determine the value of ischemia-modified plasma albumin in the early diagnosis of acute mesenteric ischemia in an experimental model.

METHODS

The study was performed on 32 Wistar albino rats divided into control (n = 8), sham (n = 8), 2-hour (n = 8), and 6-hour (n = 8) ischemia groups. Mesenteric ischemia was created by arterial occlusion, and then blood samples (2 mL) were collected and centrifuged. Serum levels of IMA were measured by a rapid calorimetric test that determined the reduced cobalt binding to albumin. For histopathologic evaluation, samples of the small intestine were obtained from the animals after they were euthanized at the end of the experiment.

RESULTS

Histopathologic damage of the intestinal wall correlated with the duration of ischemia. While the mean pathology scores of the 2- and 6-hour ischemia groups were different from each other, IMA levels (mean ± SD) in the four groups were not significantly different from each other: 0.55 ± 0.07 absorbance units (ABSU) in the control group, 0.62 ± 0.09 ABSU in the sham group, 0.60 ± 0.07 ABSU in the 2-hour ischemia group, and 0.64 ± 0.12 ABSU in the 6-hour ischemia group (p = 0.153).

CONCLUSIONS

Serum IMA values were not useful in the early diagnosis of acute mesenteric ischemia. Further studies to investigate ischemic and nonischemic conditions that affect IMA levels are needed.

Serum markers and intestinal mucosal injury in chronic gastrointestinal ischemia

BACKGROUND

Diagnosing chronic gastrointestinal ischemia (CGI) is a challenging problem in clinical practice. Serum markers for CGI would be of great diagnostic value as a non-invasive test method.

AIMS

This study investigated serum markers in patients with well-defined ischemia. Furthermore, intestinal mucosal injury was also evaluated in CGI patients.

METHODS

Consecutive patients suspected of CGI were prospectively enrolled and underwent a diagnostic work-up consisting of gastrointestinal tonometry and either CT or MR angiography. Blood samples for analysis of intestinal fatty acid-binding protein (I-FABP), D-dimer, lactate dehydrogenase (LDH), leucocyte counts, C-reactive protein (CRP), and L-lactate were drawn before and after a standard meal. Intestinal mucosal injury was assessed with glutamine, citrulline and arginine in blood samples and compared to a sugar absorption test (SAT). Test reproducibility was validated in healthy subjects.

RESULTS

Forty patients and nine healthy subjects were included. Ischemia was diagnosed in 32 patients (80%). I-FABP, leucocyte counts, LDH, CRP, glutamine, citrulline, arginine and SAT levels did not differ between patients with and without ischemia. L-lactate concentration showed a significant elevation in ischemia patients as compared to non-ischemia patients. In ischemia patients, D-dimer levels showed a significant elevation postprandially as compared to D-dimer levels at baseline. However, these ischemia patients did not show intestinal mucosal injury.

CONCLUSIONS

I-FABP, leucocyte counts, LDH and CRP levels are not clinically useful for the diagnosis of CGI. However, postprandial rises in L-lactate and D-dimer serum levels can serve as non-invasive indicators of CGI.

Altered mRNA expression due to acute mesenteric ischaemia in a porcine model

INTRODUCTION

Messenger RNA (mRNA) changes in the small intestine in response to acute mesenteric ischaemia (AMI) could offer novel diagnostic possibilities, but have not been described. The aim was to characterize the mRNA response to experimental AMI.

MATERIALS AND METHODS

Twelve pigs underwent catheterisation of the superior mesenteric artery with injection of polivinylalcohol embolisation particles or sodium chloride. Laparotomy and intestinal tissue sampling were performed. Microarray analysis was performed using the GeneChip(®) whole porcine genome array.

RESULTS

Seven down-regulated cellular pathways were associated with protein, lipid and carbohydrate metabolism. Seventeen up-regulated pathways were associated with inflammatory and immunological activity, regulation of extracellular matrix and decreased cellular proliferation. Thrombospondin (THS), monocyte chemoattractant protein 1(MCP-1) and gap junction alpha 1(GJA-1) were consistently up-regulated in all embolised pigs. Genes encoding earlier proposed biomarkers for AMI were up-regulated, such as lactate dehydrogenase and creatine kinase, or down-regulated, such as intestinal fatty acid binding protein and glutathione S-transferase.

CONCLUSION

This study describes the intestinal tissue response on a gene expression level to AMI. THS, MCP-1 and GJA-1 were consistently up-regulated by ischaemia, whereas earlier proposed biomarkers for AMI were not. Gene expression may not be directly linked to the use of the corresponding proteins as potential clinical biomarkers.

Acute mesenteric ischemia: diagnostic approach and surgical treatment

Mortality related to acute mesenteric arterial occlusion remains very high. Patient survival is dependent on prompt recognition and revascularization before ischemia progresses to intestinal gangrene. Biphasic computed tomography angiography has surpassed angiography as the diagnostic test of choice due to its ability to define the arterial anatomy and to evaluate secondary signs of mesenteric ischemia. Unlike chronic mesenteric ischemia, the treatment of acute arterial mesenteric ischemia, either embolic or thrombotic, remains largely surgical. This is due to the emergent need for revascularization combined with a careful evaluation of the intestines. Endovascular techniques remain useful, however, and can save precious time in the treatment of these challenging patients if integrated into a treatment pathway combined with definitive surgical treatment. A new hybrid endovascular-surgical treatment for the treatment of acute mesenteric thrombosis is described.

Biochemical constituents of peritoneal fluid in cows

Samples of peritoneal fluid and jugular venous blood were taken simultaneously from 95 clinically healthy Holstein-Friesian cows. The concentrations of total protein, albumin, glucose, cholesterol, fibrinogen, L-lactate and D-dimer, the activities of lactate dehydrogenase (LDH), alkaline phosphatase and creatine kinase, and the white blood cell count were determined in the samples. Light's criteria, the serum-ascites albumin gradient (SAAG) and the ratios of the concentration of each parameter in peritoneal fluid to its concentration in blood were calculated. The mean concentrations of total protein, albumin and D-dimer, the activity of LDH and the SAAG were different from the reference values for monogastric animals and human beings.

D-dimer in patients with suspected acute mesenteric ischemia

OBJECTIVES

The aims of this study were to assess the diagnostic value of D-dimer in patients with suspected acute mesenteric ischemia (AMI) and to evaluate the correlation between D-dimer levels and the severity of bowel necrosis.

METHODS

A prospective, noninterventional study of 67 patients with clinical suspicion of AMI was performed. Measurement of D-dimer levels was performed using a latex turbidimetric method.

RESULTS

Acute mesenteric ischemia was diagnosed in 23 patients (34.3%) and non-AMI in 44 patients (65.7%). Median D-dimer levels on admission were 6.24 microg fibrinogen equivalent units (FEU)/mL (range, 0.96-53.48 microg FEU/mL) in patients with AMI and 3.45 microg FEU/mL (range, 0.50-44.69 microg FEU/mL) in non-AMI patients (P = .064). D-dimer had poor discriminative value to differentiate the presence from the absence of AMI with an area under the receiver operating characteristic curve of 0.64 (95% confidence interval, 0.50-0.78). A serum D-dimer cutoff value of 1.0 microg FEU/mL had a sensitivity of 96%, a specificity of 18%, a positive likelihood ratio of 1.17, and a negative likelihood ratio of 0.24. Among patients with AMI verified at operation, 8 had resectable bowl necrosis and 9 had unresectable bowel necrosis. There was no difference in serum D-dimer levels between resectable and unresectable bowel necrosis (P = .665).

CONCLUSIONS

Detection of serum D-dimer could not help to differentiate patient with AMI from those with non-AMI. We did not find a correlation between serum D-dimer levels and the severity of AMI. However, measurement of D-dimer levels can be of value for a small decrease in the likelihood of AMI, when the result is low.

Time-dependent variations in ischemia-modified albumin levels in mesenteric ischemia

OBJECTIVES

The objective was to determine the value of ischemia-modified albumin (IMA) in the diagnosis of mesenteric embolism. The authors investigated whether or not plasma IMA levels rose in the acute period in a rat model of mesenteric ischemia and the related time-dependent changes.

METHODS

In this randomized, controlled, nonblinded trial, 36 mature female Wistar rats were divided into six groups: three control (Groups I, III, and V) and three ischemia (Groups II, IV, and VI). In the control groups, blood was sampled at 30 minutes (Group I), 2 hours (Group III), and 6 hours (Group V) following a simple laparotomy. In the ischemia groups, following laparotomy, the superior mesenteric artery (SMA) was clamped using a bulldog clamp, and blood samples were taken at 30 minutes (Group II), 2 hours (Group IV), and 6 hours (Group VI).

RESULTS

Plasma IMA levels in the ischemia groups were significantly higher compared to those of the control groups (p < 0.004). In addition, levels were higher in the 6-hour blood samples of the ischemia group than in the 2-hour and 30-minute samples (p < 0.001). Serum IMA was also higher in the 2-hour blood samples of the ischemia group than in the 30-minute samples (p < 0.001).

CONCLUSIONS

These preliminary findings suggest that serum IMA levels may represent a significant parameter in the early diagnosis of acute mesenteric ischemia and that further studies are necessary.

Intestinal ischemia/reperfusion injury: defining the role of the gut microbiome

Intestinal ischemia/reperfusion (I/R) injury initiates a systemic inflammatory response syndrome with a high associated mortality rate. Early diagnosis is essential for reducing surgical mortality, yet current clinical biomarkers are insufficient. Metabonomics is a novel strategy for studying intestinal I/R, which may be used as part of a systems approach for quantitatively analyzing the intestinal microbiome during gut injury. By deconvolving the mammalian–microbial symbiotic relationship systems biology thus has the potential for personalized risk stratification in patients exposed to intestinal I/R. This review describes the mechanism of intestinal I/R and explores the essential role of the intestinal microbiota in the initiation of systemic inflammatory response syndrome. Furthermore, it analyzes current and future approaches for elucidating the mechanism of this condition.

Mesenteric ischemia: still a deadly puzzle for the medical community

The main goal of this article is to update etiology, epidemiology, diagnosis, treatment and outcome of the various causes of mesenteric ischemia in order to elucidate its labyrinthine clinical riddle, by reviewing the current English medical literature. Mesenteric ischemia is a quite uncommon disorder, observed in the emergency department. It is a life-threatening vascular emergency that requires early diagnosis and intervention to restore mesenteric blood flow and to prevent bowel necrosis and patient death. Consequently, it is a vital diagnosis to make because of its high mortality rate and its thorny complications. The underlying causes vary, and the prognosis depends on the specific findings during clinical examination. Vague and nonspecific clinical findings and limitations of diagnostic studies make the diagnosis a significant challenge. The prognosis of acute mesenteric ischemia of any type is grave. The complications following this medical jigsaw puzzle are also severe. Patients in whom the diagnosis is missed until infarction occurs have a mortality rate of 90%. Even with good treatment, up to 50-80% of patients die. Survivors of extensive bowel resection face lifelong disability. Despite the progress in understanding the pathogenesis of mesenteric ischemia and the development of treatment modalities, the entity remains a diagnostic challenge for clinicians. Delay in diagnosis contributes to a high mortality rate. Early diagnosis and adequate treatment can improve the clinical outcome. Even if diagnostic modalities have improved since the first successful attempts to confront effectively this clinical entity, mesenteric ischemia still remains a lethal diagnostic enigma for the medical community.

Acute mesenteric ischemia after cardio-pulmonary bypass surgery

Acute mesenteric ischemia (AMI) is a highly-lethal surgical emergency. Several pathophysiologic events (arterial obstruction, venous thrombosis and diffuse vasospasm) lead to a sudden decrease in mesenteric blood flow. Ischemia/reperfusion syndrome of the intestine is responsible for systemic abnormalities, leading to multi-organ failure and death. Early diagnosis is difficult because the clinical presentation is subtle, and the biological and radiological diagnostic tools lack sensitivity and specificity. Therapeutic options vary from conservative resuscitation, medical treatment, endovascular techniques and surgical resection and revascularization. A high index of suspicion is required for diagnosis, and prompt treatment is the only hope of reducing the mortality rate. Studies are in progress to provide more accurate diagnostic tools for early diagnosis. AMI can complicate the post-operative course of patients following cardio-pulmonary bypass (CPB). Several factors contribute to the systemic hypo-perfusion state, which is the most frequent pathophysiologic event. In this particular setting, the clinical presentation of AMI can be misleading, while the laboratory and radiological diagnostic tests often produce inconclusive results. The management strategies are controversial, but early treatment is critical for saving lives. Based on the experience of our team, we consider prompt exploratory laparotomy, irrespective of the results of the diagnostic tests, is the only way to provide objective assessment and adequate treatment, leading to dramatic reduction in the mortality rate.

D-dimer levels in the prediction of the degree of intestinal necrosis of etrangulated hernias in rats

PURPOSE

The aim of this study was to investigate the time-dependent relation between plasma D-dimer levels and the degree of intestinal necrosis and to compare these parameters with leukocyte counts in an experimental etrangulated hernia model in rats.

RESULTS

When the duration of intestinal ischemia was prolonged, serum D-dimer levels increased relative to the control group, with the difference being statistically significant at hour 2 (P = 0.027). In contrast, leukocyte counts in the 2- and 4-h strangulation group were higher that those of the control group, but the difference was not statistically significant (P = 0.625 and P = 0.846, respectively). However, in the 6-h strangulation group the levels of leukocytes were significantly higher that those of the control group (P = 0.015).

CONCLUSION

Serum D-dimer measurements may be used as a more valuable diagnostic parameter than leukocyte count in the early diagnosis of intestinal ischemia, including strangulated hernia.

Ischemia-modified albumin in the diagnosis of acute mesenteric ischemia: a preliminary study

Ischemia-modified albumin (IMA) is a sensitive marker of myocardial ischemia, skeletal muscle ischemia, pulmonary embolism, and stroke. However, there are no studies showing whether IMA increases in mesenteric ischemia. The aim of this study was to determine whether IMA was elevated in acute mesenteric ischemia. This case-controlled study was performed in an emergency department of a university hospital. The measurement of IMA levels in patient plasma yielded means of 0.264 +/- 0.057 absorbance units (ABSU) in the thromboembolic occlusion of the superior mesenteric artery (SMA) group and 0.163 +/- 0.025 ABSU in the control group. When plasma IMA levels in the thromboembolic occlusion SMA group were compared with those in the control group, statistically significant increases in IMA were observed in the occlusion group (P = .003). Findings indicating that IMA may have a place in the diagnosis of acute mesenteric embolism were obtained in this preliminary study. Further prospective studies are needed to see if IMA is clinically useful in the early detection of thromboembolic occlusion of the SMA.

Mesenteric ischemia in the elderly

Intestinal ischemia is a relatively common disorder in the elderly and, if not treated promptly, still carries a high morbidity and mortality rate. High degree of clinical suspicion is of paramount importance in diagnosis, because there is no specific laboratory test available and physical examination findings may be subtle. Once the diagnosis is made, management relies on early resuscitation, identification, and treatment of the predisposing conditions, along with careful planning of the therapeutic invasive interventions, which altogether may help reduce the mortality and morbidity associated with this condition.

Determinants of mortality and treatment outcome following surgical interventions for acute mesenteric ischemia

BACKGROUND

Acute mesenteric ischemia (AMI) is associated with high morbidity and mortality due in part to its diagnostic difficulty and operative challenges. The purpose of this study was to review our experience of surgical management in patients with this condition and to identify variables associated with adverse outcomes following surgical interventions.

METHODS

Hospital records and clinical data of all patients undergoing surgical interventions for AMI were reviewed during a recent 12-year period. Clinical outcomes as well as factors influencing mortality were analyzed.

RESULTS

A total of 72 patients (41 females, overall mean age 65 years, range 34 to 83 years) were included in the study. Thrombosis and embolism were the cause of AMI in 48 patients (67%) and 24 patients (33%), respectively. Abdominal pain was the most common presenting symptom (96%), followed by nausea (56%). Preoperative angiogram was performed in 61 patients (85%). All patients underwent operative interventions, which included thromboembolectomy (n = 22, 31%), mesenteric bypass grafting (n = 33, 46%), patch angioplasty (n = 9, 12%), reimplantation (n = 5, 7%), and endarterectomy (n = 3, 4%). Bowel resection was necessary in 22 patients (31%) during the initial operation, and second-look operation was performed in 38 patients (53%). Perioperative morbidity and 30-day mortality rates were 39% and 31%, respectively. Univariate analysis showed renal insufficiency (P < .02), age >70 (P < .001), metabolic acidosis (P < .02), and symptom duration (P < .005), and bowel resection in second-look operations (P < .01) were associated with mortality. Logistic regression analysis showed age >70 (P = .03) and prolonged symptom duration (P = .02) were independent predictors of mortality.

CONCLUSIONS

Elderly patients and those with a prolonged duration of symptoms had worse outcomes following surgical intervention for AMI. A high index of suspicion with prompt diagnostic evaluation may reduce time delay prior to surgical intervention, which may lead to improved patient survival. Aggressive surgical intervention should be performed as promptly as possible in patients once the diagnosis of AMI is made.

Is D-dimer a predictor of strangulated intestinal hernia?

BACKGROUND

The goal of this study was to assess the relevance of serum D-dimer measurement as a possible reliable marker for the diagnosis of strangulated intestinal hernia.

METHODS

Consecutive patients admitted with nontraumatic acute abdominal gastrointestinal disorders were recruited prospectively in a tertiary referral hospital. The study was conducted in 159 patients between August 2002 and April 2004. D-dimer, lactate dehydrogenase, serum amylase, and international normalized ratio (INR) levels were tested in the emergency room prior to surgical intervention. For each patient, 15 variables, including D-dimer, were available for analysis.

RESULTS

Thirty-three (20.7%) of the 159 patients had intestinal ischemia, and 28 (85%) of these 33 patients had D-dimer level > 300 ng/ml. Plasma levels of D-dimer in patients with intestinal ischemia were significantly higher than in patients without ischemia (P < 0.05). There were 29 (18.2%) patients in the hernia group with incarceration (n = 22) or strangulation requiring resection (n = 7). D-dimer levels in patients requiring intestinal resection were insignificantly higher than in patients without resection (P > 0.05). Six (85%) of the 7 hernia patients requiring resection had D-dimer levels > 360 ng/ml. The D-dimer variable correlated best with the leukocyte count in patients with hernia requiring resection. Levels of lactate dehydrogenase, serum amylase, and INR did not show any correlation with D-dimer levels.

CONCLUSIONS

To help predict ischemic events, the increasing use of the D-dimer assay in clinical practice could be extended to patients presenting with intestinal emergencies. An elevated D-dimer level on admission had a high sensitivity for identifying patients with intestinal ischemia, although it had a low specificity. Whether it is predictive or preventive for resection in strangulated intestinal hernia patients still remains a question.

Update in management of mesenteric ischemia

Mesenteric ischemia disorders are precipitated by a circulation insufficiency event that deprives one or several abdominal organs of adequate respiration to meet metabolic demands. Although mesenteric ischemia occurs infrequently, the mortality rate is from 60% to 100%, depending on the source of obstruction. The successful outcome is dependent upon a high index of suspicion and prompt management. We briefly review the pathophysiology and presentation of the various ischemic entities and review the current state of the art in diagnosis and treatment. Despite advances in both diagnosis and treatment, prompt diagnosis and supportive care remain critical for successful outcome. New imaging techniques, endovascular therapy and emerging research may improve our approach to this deadly condition.