Acute mesenteric ischaemia, a highly lethal disease with a devastating outcome

Sonographically Detected Hepatic Portal Venous Gas - Prevalence, Causes, and Clinical Implications

PURPOSE

 Hepatic portal venous gas (HPVG) is a rare clinical finding, often caused by a severe underlying disease. In the literature as well as in clinical practice, HPVG is considered "signum malum" with a poor prognosis and bowel ischemia as the most common cause. Most studies are based on the results of computed tomography (CT) examinations. The aim of this retrospective study is to report on the prevalence, causes, and clinical course of HPVG in a monocentric cohort of abdominal ultrasound (US) investigations.

MATERIALS AND METHODS

 The US database of an academic teaching hospital was searched with specific keywords (timespan 01/2000 to 12/2020). Reports, pictures, and clinical data of all cases with HPVG were re-evaluated.

RESULTS

 Out of 134 804 US examinations, 8 HPVG cases were identified. There was a wide variety of underlying diseases, with mesenteric ischemia being seen in only 2 cases. 5 patients were discharged in stable condition, with 4 of them having undergone surgical treatment. 2 patients who had rejected further measures died, and one was lost to follow-up.

DISCUSSION

 HPVG is a rare phenomenon in clinical US. However, ultrasonographic prevalence is comparable to the prevalence in CT studies. Underlying diseases are mostly severe, and in nearly all cases an underlying cause can be found by thorough investigation. In some cases, US may even be superior to CT scans for the detection of HPVG. Despite its rarity, every sonographer should know the typical sonographic presentation of HPVG, and appropriate images should be included in US teaching modules.

Basic demographic characteristics and prevalence of comorbidities in acute mesenteric ischemia: a systematic review and proportional meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to examine and assess the basic demographic characteristics and prevalence of comorbidities in acute mesenteric ischemia (AMI) and its various subtypes.

PATIENTS AND METHODS

A literature search was conducted by using the databases PubMed, EMBASE, and Google Scholar (to June 1, 2022). Random-effects or fixed-effects models were selected to pool means and proportions and their corresponding 95% confidence intervals (CI), based on heterogeneity between studies. The results of meta-analyses for basic demographic characteristics and prevalence (proportions) of each specific comorbidities of acute mesenteric ischemia (AMI) and its various subtypes were described.

RESULTS

Ninety-nine studies were included in the meta-analysis, including 17,103 patients with AMI. Furthermore, 7941 patients with subclass diagnoses of AMI were identified, including 3,239 patients with arterial occlusive mesenteric ischemia (AOMI), 2,977 patients with nonocclusive mesenteric ischemia (NOMI), and 1,725 patients with mesenteric venous thrombosis (MVT). As a surgical emergency, AMI is associated with older patients and a high likelihood of multisystem comorbidities. Comorbidities of AMI involved multiple systemic diseases, including cardiovascular disease, endocrine and metabolic diseases, kidney diseases, digestive diseases, respiratory diseases, cerebrovascular diseases, vascular diseases, and cancer.

CONCLUSION

The basic demographic characteristics and the prevalence of comorbidities of different subtypes of AMI are different. The management of comorbidities should be an essential part of improving the prognosis of AMI patients and may contribute to precise prevention of AMI.

Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis

OBJECTIVE

To estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022.

ELIGIBILITY CRITERIA

Studies reporting data on the incidence and outcomes of AMI in adult populations.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment with modified Newcastle-Ottawa scale were performed using predeveloped standard forms. The outcomes were the incidence of AMI and its different forms in the general population and in patients admitted to hospital, and the mortality of AMI in its different forms.

RESULTS

From 3064 records, 335 full texts were reviewed and 163 included in the quantitative analysis. The mean incidence of AMI was 6.2 (95% CI 1.9 to 12.9) per 100 000 person years. On average 5.0 (95% CI 3.3 to 7.1) of 10 000 hospital admissions were due to AMI. Occlusive arterial AMI was the most common form constituting 68.6% (95% CI 63.7 to 73.2) of all AMI cases, with similar proportions of embolism and thrombosis.Overall short-term mortality (in-hospital or within 30 days) of AMI was 59.6% (95% CI 55.5 to 63.6), being 68.7% (95% CI 60.8 to 74.9) in patients treated before the year 2000 and 55.0% (95% CI 45.5 to 64.1) in patients treated from 2000 onwards (p<0.05). The mid/long-term mortality of AMI was 68.2% (95% CI 60.7 to 74.9). Mortality due to mesenteric venous thrombosis was 24.6% (95% CI 17.0 to 32.9) and of non-occlusive mesenteric ischaemia 58.4% (95% CI 48.6 to 67.7). The short-term mortality of revascularised occlusive arterial AMI was 33.9% (95% CI 30.7 to 37.4).

CONCLUSIONS

In adult patients, AMI is a rarely diagnosed condition with high mortality, although with improvement of treatment results over the last decades. Two thirds of AMI cases are of occlusive arterial origin with potential for better survival if revascularised.

PROSPERO REGISTRATION NUMBER

CRD42021247148.

Outcomes of different acute mesenteric ischemia therapies in the last 20 years: A meta-analysis and systematic review

OBJECTIVE

Acute mesenteric ischemia is a disease with high morbidity and mortality, and it is traditionally treated with open surgery. Endovascular therapy and hybrid techniques are alternative treatments that are also currently available. We performed a meta-analysis to evaluate the outcomes of the different treatment approaches in the last 20 years.

METHODS

Studies on acute mesenteric ischemia that were indexed in PubMed, Embase, and MEDLINE databases (from January 1, 2000, to April 1, 2021) were reviewed. All related retrospective observational studies and case series were included. A random-effects model was used to calculate pooled estimates, and the results were reported as proportions and 95% confidence intervals (CIs).

RESULTS

In our study, a total of 2369 patients (in 39 studies) underwent endovascular, open surgery, or retrograde open mesenteric stenting. The pooled mortality estimates for open surgery, endovascular therapy, and retrograde open mesenteric stenting were 40% (95% CI, 0.33-0.47; I² = 84%), 26% (95% CI, 0.19-0.33; I² = 33%), and 32% (95% CI, 0.21-0.44; I² = 26%), respectively.

CONCLUSIONS

The mortality associated with open surgical treatment, endovascular therapy, and retrograde open mesenteric stenting tend to be similar in the last 20 years.

Synergistic Effect of β-alanine and Aprotinin on Mesenteric Ischemia

BACKGROUND

Acute mesenteric ischemia arises through sudden interruption of mesenteric blood flow, mostly due to an occlusion of the superior mesenteric artery and is associated with a high mortality of approximately 50% to 90%. In previous studies, the single application of β-alanine or aprotinin caused an ameliorated intestinal damage but without any systemic effects.

METHODS

To analyze the combined effect of β-alanine and aprotinin on acute ischemia and reperfusion of the small intestine, a model with anesthetized rats was used. Ischemia and reperfusion were initiated by occluding and reopening the superior mesenteric artery. After 120 min of ischemia and 180 min of reperfusion, the intestine was analyzed for tissue damage, the activity of the saccharase, and accumulation of granulocytes. In addition, systemic and metabolic as well as inflammatory parameters were measured in blood at certain points in time.

RESULTS

The combination of β-alanine and aprotinin resulted in a clearly stabilized mean arterial blood pressure and blood glucose level during the reperfusion period. Furthermore, the combined administration resulted in significantly reduced tissue damage parameters, cytokine and cell-free hemoglobin concentrations in blood plasma. In addition, the damage to the small intestine was significantly attenuated, so that the animals ultimately survived the entire test period because of the administration of both substances.

CONCLUSIONS

Overall, the simultaneous application of both substances leads to a synergistic protection without the occurrence of undesirable side effects. The combined usage of β-alanine and aprotinin can be seen as a promising approach to inhibit the onset of acute mesenteric ischemia.

Acute Mesenteric Ischaemia

Acute mesenteric ischaemia (AMI) is a surgical emergency, and has a high mortality. The term AMI covers arterial embolism, arterial thrombosis, non-occlusive mesenteric ischaemia and venous thrombosis which all lead to ischaemia/reperfusion syndrome of the bowel. Multi-detector row helical CT (MDCT) technology has dramatically improved the performance of CT by allowing rapid volumetric data acquisition to provide increased resolution, leading to better identification of the site, level and cause of ischaemia. CT angiography for diagnosing mesenteric ischaemia is now highly sensitive and specific, and should be used as first line when AMI is suspected. The aim of management is to restore intestinal blood flow in a timely manner. Therapeutic decisions are based on the presence of peritonitis, the presence of irreversible ischaemia or infarcted segments of the bowel, the general condition of the patient and the pathophysiological process underlying the ischaemia. AMI remains a challenging condition with high mortality. There is a need for good general surgical cover on the intensive care unit, with continuing care and clinical review by experienced senior surgeons with an interest in this condition.

Acute mesenteric ischemia after cardiac surgery: an analysis of 52 patients

OBJECTIVE

Acute mesenteric ischemia (AMI) is a rare but serious complication after cardiac surgery. The aim of this retrospective study was to evaluate the incidence, outcome, and perioperative risk factors of AMI in the patients undergoing elective cardiac surgery.

METHODS

From January 2005 to May 2013, all patients who underwent cardiac surgery were screened for participation, and patients with registered gastrointestinal complications were retrospectively reviewed. Univariate analyses were performed.

RESULTS

The study included 6013 patients, of which 52 (0.86%) patients suffered from AMI, 35 (67%) of whom died. The control group (150 patients) was randomly chosen from among cases undergoing cardiopulmonary bypass (CPB). Preoperative parameters including age (P = 0.03), renal insufficiency (P = 0.004), peripheral vascular disease (P = 0.04), preoperative inotropic support (P < 0.001), poor left ventricular ejection fraction (P = 0.002), cardiogenic shock (P = 0.003), and preoperative intra-aortic balloon pump (IABP) support (P = 0.05) revealed significantly higher levels in the AMI group. Among intra- and postoperative parameters, CPB time (P < 0.001), dialysis (P = 0.04), inotropic support (P = 0.007), prolonged ventilator time (P < 0.001), and IABP support (P = 0.007) appeared significantly higher in the AMI group than the control group.

CONCLUSIONS

Prompt diagnosis and early treatment should be initiated as early as possible in any patient suspected of AMI, leading to dramatic reduction in the mortality rate.

Mesenteric Vascular Thrombosis Associated with Disseminated Abdominal Visceral Hemangiosarcoma in a Cat

An adult castrated male cat was evaluated because of a 4 day history of lethargy and partial anorexia. Physical examination revealed abdominal pain with a palpable fluid wave. Cytologic and biochemical analyses of peritoneal effusion were suggestive of septic peritonitis. On surgical exploration of the abdomen, the mesenteric vessels had no palpable pulses and they contained gross thromboses. The intestines were white with no visible peristalsis. Necropsy findings included disseminated, poorly differentiated hemangiosarcoma throughout the abdomen. Mesenteric arterioles contained fibrin thrombi. To the author's knowledge, no previous reports exist of complete mesenteric vascular thrombosis associated with disseminated abdominal visceral hemangiosarcoma in a cat.

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.

Surgical management of mesenteric occlusive disease: a contemporary review of invasive and minimally invasive techniques

Mesenteric ischemia (MI) is caused by compromised blood flow to the arteries supplying the small and large intestine. Acute occlusive mesenteric ischemia (AMI) presents with the abrupt onset of severe abdominal pain, which if not diagnosed and treated immediately can cause bowel necrosis and prove fatal. Chronic occlusive mesenteric ischemia (CMI) is usually a longstanding process characterized by postprandial abdominal pain, progressive food intolerance, and weight loss. If untreated, CMI can lead to progressive disability and failure to thrive. This review article highlights the clinical and radiologic diagnosis of acute mesenteric ischemia and CMI and compares their treatment with surgical revascularization and the less invasive alternative of mesenteric artery angioplasty and stenting.

Short bowel syndrome: amelioration of diarrhea after vagotomy and pyloroplasty for peptic hemorrhage

Acute mesenteric ischemia is a rare symptomatic manifestation of arteriosclerosis. Prognosis crucially depends on rapid diagnosis and surgical management to prevent or at least minimize the bowel infarction. The length of the small bowel is considered to be between 3 and 8 m, and a normal bowel function can be maintained even after resection of its one third. But loss of a major part (> 60%) can lead to malnutrition and death. However, patients, who survived an extended intestinal resection due to improved postoperative care (intensive care unit and parenteral nutrition), develop short bowel syndrome. This phenomenon is a medical problem, and several surgical techniques have been used to slow down intestinal transit time or to increase the area of absorption. All these procedures have controversial outcomes and are still on different experimental levels; namely, they cannot be recommended for routine use. In our report of a patient suffering from short bowel syndrome, vagotomy and pyloroplasty were performed to repair a sudden peptic hemorrhage. This operation cured bleeding peptic ulcer and also palliated the diarrhea, a main clinical manifestation of short bowel syndrome. In this study, our aim is to emphasize the favorable clinical outcome of vagotomy concerning a principal manifestation of short bowel syndrome, such as diarrhea. To the best of our knowledge, the present study is the first report showing the vagotomy as a possible procedure for the treatment of diarrhea, although this occurrence has no clear explanation. We also discuss the management of short bowel syndrome.

Unchanged high mortality rates from acute occlusive intestinal ischemia: six year review

OBJECTIVE

Acute intestinal ischemia (AII) is an uncommon surgical emergency that has been increasing in incidence and remains a highly lethal condition with a difficult diagnosis. We undertook this study to evaluate our experience in treating this condition with a view to expand the cumulative information in the literature.

MATERIALS AND METHODS

Between January 2000 and December 2006, 60 patients with AII caused by thrombotic vascular event underwent surgery at our surgical center. The patients' medical records including data covering demographic features, comorbid medical conditions, medical risk factors, clinical symptoms, history and physical examination findings, and biochemical and radiologic examinations were reviewed. Operative records, the American Society of Anesthesiology physical status classification (ASA-PS), postoperative complications, duration of hospital stay, and final outcome were also considered.

RESULTS

Of the 60 patients with primary thrombotic vascular event, 20 patients had embolism and 19 patients arterial thrombosis. In 21 patients, mesenteric venous thrombosis was the etiology of AII. The median age was 73 years (range, 43-96). Higher ASA classification, age >70 years, late presentation, and high serum lactate levels were predictors of adverse outcome. The overall death rate was 60% (36/60), which was within the range of that observed in the published series.

CONCLUSION

AII remains a highly lethal condition. Mortality rates remain as high as they did decades ago due in part to advanced presentation and advanced age with multiple associated conditions and risk factors, all of which are independent predictors of adverse outcome.

Cardioembolic stroke followed by isolated celiac artery thromboembolism

A 78-year-old man with Parkinson's disease, paroxysmal atrial fibrillation, and congestive heart failure was admitted to our hospital due to global aphasia and right-sided hemiparesis. A cardioembolic stroke from a left ventricular thrombus was diagnosed; several days later, anticoagulants were started. On the seventh day, the patient suddenly developed severe acidosis and kidney and liver dysfunction. He died the following afternoon. Autopsy revealed an isolated celiac artery embolism from the left ventricular thrombus. This is the first reported case of isolated celiac artery embolism occurring after acute ischemic stroke.