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Rajamanuri M, Garg M, Siddiqui H, Pannala S. Progesterone-Only Contraceptive-Induced Ischemic Colitis. ACG Case Rep J 2024; 11:e01313. [PMID: 38566974 PMCID: PMC10986904 DOI: 10.14309/crj.0000000000001313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/23/2024] [Indexed: 04/04/2024] Open
Abstract
Ischemic colitis (IC) occurs when there is a temporary lack of adequate blood supply to the intestines, particularly in vulnerable areas such as the splenic flexure and sigmoid colon, which lack sufficient collateral blood vessels. Although primarily seen in older individuals with atherosclerotic risk factors, IC can also be triggered by hormonal contraceptives in young women. Although estrogen-containing oral contraceptives are known to increase thromboembolic risk, the impact of progesterone is not well understood. We report a unique case of biopsy-confirmed IC in a previously healthy 30-year-old woman who presented with abdominal pain and bloody diarrhea 2 months after initiation of progesterone-only oral contraceptive. This occurrence, although rare, underscores the need for further research on the impact of progesterone on coagulation, especially concerning mesenteric arteries.
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Affiliation(s)
- Medha Rajamanuri
- Southern Illinois University-School of Medicine, Springfield, IL
| | - Meher Garg
- Springfield High School, Springfield, IL
| | - Harris Siddiqui
- Southern Illinois University-School of Medicine, Springfield, IL
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2
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Xu JJ, Ulriksen PS, Jawad S, Rohde YZ, Sejer M, Achiam MP, Resch TA, Lönn L, Hansen KL. Iodine density mapping for the diagnosis of acute bowel ischemia using fast kV-switching dual-energy CT. Abdom Radiol (NY) 2024; 49:312-319. [PMID: 37978076 PMCID: PMC10789852 DOI: 10.1007/s00261-023-04097-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE To evaluate the diagnostic capabilities of a supplementary color ramped iodine density map compared to virtual monoenergetic images (VMIs) at 74 keV in the diagnosis of acute bowel ischemia (ABI). METHODS Data for this study were prospectively gathered and retrospectively evaluated. Patients referred to the Department of Diagnostic Radiology between October 2020 and August 2022 on the suspicion of ABI and underwent surgery < 12 h following fast kV-switching venous phase abdominal dual-energy CT (DECT) were consecutively included. Images were evaluated by two board-certified radiologists and two radiology residents. First round included only 74 keV VMIs resembling conventional 120 kVp images, and the second round included a supplementary iodine density map. Readers were asked to register presence of ABI as well as their confidence in their diagnosis based on a 5-point Likert scale. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each observer with the surgical findings as the gold-standard. McNemar's and Wilcoxon signed-rank test were used to compare registrations and diagnostic confidence across assessment rounds. RESULTS A total of 29 patients resulting in 31 DECT scans were included. Fourteen cases of ischemic/necrotic bowel were reported following surgery. Sensitivity and NPV were decreased with the use of supplementary iodine map images compared to 120 kVp-like images without supplementary iodine map images for three of four observers (round 1 range: 71.4-92.9% and 78.0-94.8%; round 2 range: 57.1-78.6% and 70.1-83.3%, respectively), while specificity and PPV were increased for three of four observers (round 1 range: 64.7-94.1% and 67.4-93.1%; round 2 range: 88.2-94.1% and 73.8-91.1%, respectively). However, no significant difference in ABI diagnosis or diagnostic confidence was found (p-value range: 0.07-1.00 and 0.23-0.58, respectively). CONCLUSION No significant difference for the diagnosis of ABI was found using supplementary iodine mapping. Our study may suggest a trend of increased specificity and decreased sensitivity, hence, the use of supplementary iodine mapping should be carefully considered.
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Affiliation(s)
- Jack Junchi Xu
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark.
| | - Peter Sommer Ulriksen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark
| | - Samir Jawad
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Yecatarina Zincuk Rohde
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Morten Sejer
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Michael Patrick Achiam
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark
- Department of Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Timothy Andrew Resch
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark
- Department of Vascular Surgery, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Lars Lönn
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark
| | - Kristoffer Lindskov Hansen
- Department of Diagnostic Radiology, Copenhagen University Hospital, Rigshospitalet, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100, Copenhagen, Denmark
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3
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Castro A, Haq R, Gesner L. Small bowel obstruction with bowel ischemia due to ingestion of water-absorbing bead. Am J Emerg Med 2023; 73:235.e1-235.e3. [PMID: 37517873 DOI: 10.1016/j.ajem.2023.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 08/01/2023] Open
Abstract
Foreign body aspiration accounts for 7% of accidental deaths in children under age 4 (4). Children between the ages of 6 months and 3 years of age, adolescent boys and children with mental health issues are at the highest risk of foreign body ingestion. Coins are the most commonly swallowed foreign body in the United States (US) and in other countries those related food such as fish bones are most common (10). Most cases are accidental and pass harmlessly through the gastrointestinal tract with low mortality (10). The most common complication is esophageal obstruction particularly at the thoracic inlet. However, the object can become lodged anywhere in the gastrointestinal tract. We present an unusual case of small bowel obstruction and bowel ischemia secondary to superabsorbent polymer water bead ingestion in a pediatric patient.
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Affiliation(s)
- Alexandra Castro
- Cooperman Barnabas Medical Center, 94 Old Short Hills Rd, Livingston, NJ 07039, United States of America.
| | - Razi Haq
- Cooperman Barnabas Medical Center, 94 Old Short Hills Rd, Livingston, NJ 07039, United States of America
| | - Lyle Gesner
- Cooperman Barnabas Medical Center, 94 Old Short Hills Rd, Livingston, NJ 07039, United States of America
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4
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May C, Sodickson A. Leveraging Dual-Energy Computed Tomography to Improve Emergency Radiology Practice. Radiol Clin North Am 2023; 61:1085-1096. [PMID: 37758358 DOI: 10.1016/j.rcl.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Dual-energy computed tomography affords emergency radiologists with important tools to aid in the detection and discrimination of commonly encountered ED pathologies. In doing so, it can increase the speed of diagnosis and diagnostic certainty while sparing patients potentially unnecessary downsteam workups and radiation exposure. This article demonstrates these clinical benefits through a case-based approach.
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Affiliation(s)
- Craig May
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| | - Aaron Sodickson
- Department of Radiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Wongwaisayawan S, Krutsri C, Koosaksathaporn A, Choikrua P. Diagnosis and emergency surgical management of stercoral colitis-induced colonic ischemia: A case report and literature review. Int J Surg Case Rep 2023; 111:108864. [PMID: 37793237 PMCID: PMC10551616 DOI: 10.1016/j.ijscr.2023.108864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/06/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Stercoral colitis is an urgent complication of fecal impaction that requires aggressive management. The rare complicated with bowel ischemia requires a high index of suspicion for early diagnosis. This case report describes the detection and management of this rare and fatal complication of stercoral colitis. CASE PRESENTATION An 80-year-old man presented after 3 days of obstipation. Abdominal plain radiography revealed several air-fluid levels in the colon with centralized small bowel gas. Computed tomography revealed fecal impaction and stercoral colitis without evidence of bowel ischemia. CLINICAL DISCUSSION Fecal impaction and stercoral colitis without evidence of bowel ischemia was suspected. Owing to the development of refractory septic shock, we performed damage control surgery. Definitive surgery with end ileostomy was follow by 48 h later. The patient was discharged home safely. CONCLUSION Stercoral colitis-induced ischemia is rare but potentially fatal; ischemia should be highly suspected. CT can help diagnosed of stercoral colitis but no single parameters for diagnosed of bowel ischemia. Prompt resuscitation and surgical exploration with damage control surgery are recommended.
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Affiliation(s)
- Sirote Wongwaisayawan
- Emergency Radiology Unit, Department of Diagnostic and Therapeutic Radiology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonlada Krutsri
- Trauma, Acute Care Surgery and Surgical Critical Care Unit, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Arichaya Koosaksathaporn
- General Surgery, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Pattawia Choikrua
- Surgical Research Unit, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Cornelissen LGH, Carrière L, Hack KEA. Surgical complications in pregnancy after bariatric surgery; a case series. J Gynecol Obstet Hum Reprod 2023; 52:102614. [PMID: 37270105 DOI: 10.1016/j.jogoh.2023.102614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Obesity is a rising world-wide problem and bariatric surgery, also in the reproductive age, is increasingly performed. Bariatric procedures are associated with surgical complications during pregnancy, such as internal herniation. CASES In this case series three cases with severe surgical complications after Roux-Y gastric bypass are described. In all three cases surgery was needed to prevent further complications. In one case subtotal bowel resection had to be performed because of extensive necrosis and intra-uterine fetal death was found. CONCLUSION Though surgical complications after Roux-Y gastric bypass are not very common, complications can be very serious and lead to severe morbidity and even mortality for mother and fetus. Because of the severity of complications, delaying bariatric surgery or considering alternative bariatric techniques with fewer (severe) complications should be considered in obese women in childbearing age.
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Affiliation(s)
- Lisa G H Cornelissen
- Gelre Ziekenhuizen, Albert Schweitzerlaan 31, Apeldoorn, DZ 7334, the Netherlands.
| | - Laura Carrière
- Gelre Ziekenhuizen, Albert Schweitzerlaan 31, Apeldoorn, DZ 7334, the Netherlands
| | - Karien E A Hack
- Gelre Ziekenhuizen, Albert Schweitzerlaan 31, Apeldoorn, DZ 7334, the Netherlands
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Zanca KM, Marcantonio M, Pini R, Mongelli F, La Regina D, Cianfarani A. Intestinal ischemia due to internal hernia beneath the right external iliac artery after laparoscopic hysterectomy and lymphadenectomy: A case report. Int J Surg Case Rep 2023; 106:108187. [PMID: 37058801 PMCID: PMC10130623 DOI: 10.1016/j.ijscr.2023.108187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/08/2023] [Accepted: 04/10/2023] [Indexed: 04/16/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The occurrence of an internal hernia beneath the external iliac artery is rare but may occur after pelvic lymphadenectomy. The challenging treatment of this rare condition should be tailored to the patient's clinical and anatomical characteristics. CASE PRESENTATION We present the case of a 77-year-old woman with previous history of laparoscopic hysterectomy and adnexectomy with extended pelvic lymphadenectomy for endometrial cancer. The patient was admitted in the emergency department because of severe abdominal pain and a computed tomography scan showed signs of internal hernia. The laparoscopy confirmed such a finding below the right external iliac artery. A small bowel resection was deemed necessary and the defect was closed with an absorbable mesh. The post-operative course was uneventful. CLINICAL DISCUSSION Internal hernia beneath the iliac artery is a rare condition after pelvic lymphadenectomy. The first challenge is the hernia reduction, which can be safely carried out laparoscopically. Secondly, a patch or a mesh should be used to close the defect if a primary peritoneal suture is not feasible, but it requires to be fixed in the small pelvis. The use of absorbable material is a valuable option and should leave a fibrotic area that covers the hernia defect. CONCLUSION A strangulated internal hernia beneath the external iliac artery is a possible complication after extensive pelvic lymph node dissection. The laparoscopic approach to treat bowel ischemia and to close the peritoneal defect with a mesh, should reduce as much as possible the risk of internal hernia recurrence.
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Affiliation(s)
- Kostas Mario Zanca
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, EOC, 6500 Bellinzona, Switzerland.
| | - Maria Marcantonio
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, EOC, 6500 Bellinzona, Switzerland
| | - Ramon Pini
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, EOC, 6500 Bellinzona, Switzerland
| | - Francesco Mongelli
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, EOC, 6500 Bellinzona, Switzerland; Faculty of Biomedical Science, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Davide La Regina
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, EOC, 6500 Bellinzona, Switzerland; Faculty of Biomedical Science, Università della Svizzera Italiana, 6900 Lugano, Switzerland
| | - Agnese Cianfarani
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, EOC, 6500 Bellinzona, Switzerland
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8
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Li Y, Tian Z, Liu C, Li S, Bi W, Ji Q. Diagnostic nomogram for closed-loop small bowel obstruction requiring emergency surgery. Am J Emerg Med 2023; 63:5-11. [PMID: 36283292 DOI: 10.1016/j.ajem.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/30/2022] [Accepted: 10/11/2022] [Indexed: 12/07/2022] Open
Abstract
PURPOSE This study aimed to build a diagnostic model of closed-loop small bowel obstruction (CL-SBO) using clinical information, blood test results, and computed tomography (CT) findings. METHODS All patients who were diagnosed with small bowel obstruction (SBO) and underwent surgery between January 1, 2018, and October 31, 2021, in the affiliated hospital of Qingdao university were reviewed, and their relevant preoperative information was collected. All variables were selected using univariate analysis and backward stepwise regression to build a diagnostic nomogram model. K-fold cross-validation and bootstrap resampling techniques were used for internal validation, and data from Qingdao Central Hospital were used for external validation. We also evaluated the diagnostic performance of each CT finding and performed subgroup analysis according to bowel ischemia in the closed-loop small bowel obstruction (CL-SBO) group. RESULTS A total of 219 patients (95 in the CL-SBO group and 124 in the open-loop small bowel obstruction [OL-SBO] group) were included in our research. D-dimers (median 1085 vs. 690, P = 0.019), tenderness (77.9% vs. 59.7%, P = 0.004), more than one beak sign (65.3% vs. 30.6%, P < 0.001), radial distribution (18.9% vs. 6.5%, P = 0.005), whirl sign (35.8% vs. 8.9%, P < 0.001), and ascites (71.6% vs. 53.2%, P = 0.006) were selected as the predictive variables of the nomogram. This model's Harrell's C statistic was 0.786 (95% confidence interval (CI), 0.724-0.848), and the Brier score was 0.182. The Harrell's C statistic of external validation was 0.784 (95%CI, 0.664-0.905); the Brier score was 0.190. Regarding the CT findings, radial distribution, U/C-shaped loop, and whirl sign had high specificity (93.5%, 96.0%, and 91.1%, respectively), but low sensitivity (18.9%, 8.4%, and 35.8%, respectively). D-dimer levels and tenderness were also associated with bowel ischemia. CONCLUSION The nomogram accurately predicted CL-SBO in patients with SBO, and surgery should be considered when patients have a high risk for developing CL-SBO.
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9
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Bala M, Catena F, Kashuk J, De Simone B, Gomes CA, Weber D, Sartelli M, Coccolini F, Kluger Y, Abu-Zidan FM, Picetti E, Ansaloni L, Augustin G, Biffl WL, Ceresoli M, Chiara O, Chiarugi M, Coimbra R, Cui Y, Damaskos D, Di Saverio S, Galante JM, Khokha V, Kirkpatrick AW, Inaba K, Leppäniemi A, Litvin A, Peitzman AB, Shelat VG, Sugrue M, Tolonen M, Rizoli S, Sall I, Beka SG, Di Carlo I, Ten Broek R, Mircea C, Tebala G, Pisano M, van Goor H, Maier RV, Jeekel H, Civil I, Hecker A, Tan E, Soreide K, Lee MJ, Wani I, Bonavina L, Malangoni MA, Koike K, Velmahos GC, Fraga GP, Fette A, de'Angelis N, Balogh ZJ, Scalea TM, Sganga G, Kelly MD, Khan J, Stahel PF, Moore EE. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2022; 17:54. [PMID: 36261857 PMCID: PMC9580452 DOI: 10.1186/s13017-022-00443-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 06/17/2022] [Indexed: 02/08/2023] Open
Abstract
Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.
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Affiliation(s)
- Miklosh Bala
- Director of Acute Care Surgery and Trauma Unit, Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem Kiriat Hadassah, POB 12000, 91120, Jerusalem, Israel.
| | - Fausto Catena
- General and Emergency Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Jeffry Kashuk
- Tel Aviv Sackler School of Medicine, Tel Aviv, Israel
| | - Belinda De Simone
- Department of General, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Carlos Augusto Gomes
- Department of Surgery, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital Universitário Terezinha de Jesus, Juiz de Fora, Brazil
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | | | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Luca Ansaloni
- Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Marco Ceresoli
- Emergency and General Surgery Department, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Massimo Chiarugi
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- CECORC Research Center, Riverside University Health System, Loma Linda University, Loma Linda, USA
| | - Yunfeng Cui
- Department of Surgery, Nankai Clinical School of Medicine, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin, China
| | | | - Salomone Di Saverio
- General Surgery Department Hospital of San Benedetto del Tronto, Marche region, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Michael Sugrue
- Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sandro Rizoli
- Surgery Department, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ibrahima Sall
- General Surgery Department, Military Teaching Hospital, Dakar, Senegal
| | | | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chirika Mircea
- Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Giovanni Tebala
- Department of Digestive and Emergency Surgery, S.Maria Hospital Trust, Terni, Italy
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald V Maier
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Hans Jeekel
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ian Civil
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andreas Hecker
- Emergency Medicine Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kjetil Soreide
- HPB Unit, Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Matthew J Lee
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Luigi Bonavina
- Department of Surgery, IRCCS Policlinico San Donato, University of Milano, Milano, Italy
| | - Mark A Malangoni
- Case Western Reserve University School of Medicine, Cleveland, USA
| | | | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, PA, USA
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Andreas Fette
- Pediatric Surgery, Children's Care Center, SRH Klinikum Suhl, Suhl, Thueringen, Germany
| | - Nicola de'Angelis
- Unit of Digestive and HPB Surgery, Faculty of Medicine, University of Paris, Paris, France
| | - Zsolt J Balogh
- John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD, USA
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michael D Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Jim Khan
- University of Portsmouth, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip F Stahel
- College of Osteopathic Medicine, Rocky Vista University, Parker, CO, USA
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
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10
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Pavlidis ET, Pavlidis TE. Prediction factors for ischemia of closed-loop small intestinal obstruction. World J Gastrointest Surg 2022; 14:1086-1088. [PMID: 36185555 PMCID: PMC9521473 DOI: 10.4240/wjgs.v14.i9.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 02/07/2023] Open
Abstract
A closed-loop type of intestinal obstruction leads to ischemic necrosis. There have been indicators that may predict ischemia and its severity, such as biomarkers and computed tomography scans. In addition to the usual inflammation markers, such as white blood count-neutrophil count and c-reactive protein (CRP), the most accurate predictors that have been proposed are the CRP-to-albumin ratio, the neutrophil/lymphocyte ratio and the platelet/lymphocyte ratio. Endothelin 1 is another promising biomarker of ischemia that must be assessed in daily clinical practice. Advanced age and frailty status were assessed as predictors of mortality. A timely operative procedure without any delay ensures a better outcome.
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Affiliation(s)
- Efstathios Theodoros Pavlidis
- The Second Propedeutic Department of Surgery, Hippocration Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 54642, Greece
| | - Theodoros Efstathios Pavlidis
- The Second Propedeutic Department of Surgery, Hippocration Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki 54642, Greece
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11
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Toda Y, Komatsu S, Fukami Y, Saito T, Matsumura T, Osawa T, Kurahashi S, Uchino T, Kato S, Yasui K, Hanazawa T, Kaneko K, Sano T. Prognostic factors for the successful conservative management of nonocclusive mesenteric ischemia. World J Emerg Surg 2022; 17:32. [PMID: 35659015 PMCID: PMC9166604 DOI: 10.1186/s13017-022-00436-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/22/2022] [Indexed: 01/06/2023] Open
Abstract
Background The criteria for deciding upon non-operative management for nonocclusive mesenteric ischemia (NOMI) are poorly defined. The aim of this study is to determine the prognostic factors for survival in conservative treatment of NOMI. Methods Patients with bowel ischemia were identified by searching for “ICD-10 code K550” in the Diagnosis Procedure Combination database between June 2015 and May 2020. A total of 457 patients were extracted and their medical records, including the clinical factors, imaging findings and outcomes, were analyzed retrospectively. Diagnosis of NOMI was confirmed by the presence of specific findings in contrast-enhanced multidetector-row CT. Twenty-six patients with conservative therapy for NOMI, including four cases of explorative laparotomy or laparoscopy, were enrolled. Results Among the 26 cases without surgical intervention, eight patients (31%) survived to discharge. The level of albumin was significantly higher, and the levels of lactate dehydrogenase, total bilirubin, C-reactive protein, and lactate were significantly lower in the survivors than the non-survivors. Sepsis-related Organ Failure Assessment (SOFA) score was significantly lower in the survivors than the non-survivors. The most reliable predictor of survival for NOMI was SOFA score (cutoff value ≤ 3 points), which had the highest AUC value (0.899) with odds ratio of 0.075 (CI: 0.0096–0.58). Conclusions The SOFA score and several biological markers are promising predictors to determine a treatment plan for NOMI and to avoid unnecessary laparotomy. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00436-w.
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Affiliation(s)
- Yoko Toda
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Shunichiro Komatsu
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan.
| | - Yasuyuki Fukami
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Takuya Saito
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Tatsuki Matsumura
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Takaaki Osawa
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Shintaro Kurahashi
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Tairin Uchino
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Shoko Kato
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Kohei Yasui
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Takaaki Hanazawa
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Kenitiro Kaneko
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
| | - Tsuyoshi Sano
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi, 480-1195, Japan
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12
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Yamashita T, Iwakiri N, Kurebayashi E, Kimura H, Murata M. Superior Mesenteric Artery Embolism Complicating Transcatheter Aortic Valve Replacement. Struct Heart 2022; 6:100018. [PMID: 37273737 PMCID: PMC10236824 DOI: 10.1016/j.shj.2022.100018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/11/2021] [Accepted: 11/03/2021] [Indexed: 06/06/2023]
Affiliation(s)
- Takehiro Yamashita
- Department of Cardiology, Cardiovascular Center, Hokkaido Ohno Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Naoki Iwakiri
- Department of Cardiology, Cardiovascular Center, Hokkaido Ohno Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Eigo Kurebayashi
- Department of Cardiology, Cardiovascular Center, Hokkaido Ohno Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Hitoshi Kimura
- Department of Surgery, Hokkaido Ohno Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Masaki Murata
- Department of Pathology, Hokkaido Ohno Memorial Hospital, Sapporo, Hokkaido, Japan
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13
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Arabadzhieva E, Bulanov D, Shavalov Z, Yonkov A, Bonev S. Spontaneous transvaginal intestinal evisceration in case of long-standing uterine prolapse. BMC Surg 2022; 22:157. [PMID: 35509095 DOI: 10.1186/s12893-022-01615-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Transvaginal intestinal evisceration is an extremely rare surgical emergency with potentially fatal consequences. Only a few more than 100 cases with this pathology have been described in the literature. Aetiology is also unclear and multifactoral. Case presentation We report the case of an 80-year-old female who presented with sudden severe abdominal pain and spontaneous small bowel evisceration through the vagina along with associated high-grade uterine prolapse. The loops and their mesentery appeared edematous, thickened and dusky, but without apparent necrosis. An urgent laparotomy was performed with subsequent reduction of the prolapsed small bowel into the abdomen, hysterectomy, partial resection of the vagina and vaginal closure. Additional cholecystectomy was necessary because of the visible pathologic changes of the gallbladder. The postoperative period was uneventful. The unique feature of our case is that there was no trigger factor (trauma, constipation or a coughing episode that would increase the intra-abdominal pressure), provoking the vaginal rupture and intestinal evisceration through it in the context of pelvic floor weakness. Conclusions Early detection and surgical management are crucial for preventing bowel ischemia and abdominal sepsis. If the eviscerated intestine is ischaemic and non-viable, this requires resection and anastomosis. The approach should be individualized and performed by a multidisciplinary team.
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14
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Chen JV, Ohliger MA, Chung M, Sugi MD, Ye J, Nishimura SL, Choi HH. Diagnosis of acute mesenteric ischemia assisted by dual-energy CT: a case report. Emerg Radiol 2022; 29:611-614. [PMID: 35128620 DOI: 10.1007/s10140-022-02029-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/01/2022] [Indexed: 11/25/2022]
Abstract
In this case report, dual-energy CT was critical in the diagnosis of acute mesenteric ischemia by differentiating normal contrast-enhanced bowel and hemorrhagic necrosis. Iodine map showed a segment of small bowel with minimal contrast enhancement, and virtual non-contrast imaging revealed hyperattenuating bowel. This finding changed management for the patient and prevented complications from impending bowel perforation. Histopathological analysis confirmed hemorrhagic necrosis of the bowel segment. In cases of suspected bowel ischemia, dual-energy CT can distinguish bowel wall hemorrhage from contrast enhancement and allow for accurate diagnosis.
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Affiliation(s)
- Joshua Vic Chen
- School of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Michael A Ohliger
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA.,Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Maggie Chung
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Mark D Sugi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Julia Ye
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
| | - Stephen L Nishimura
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA.,Department of Pathology, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Hailey H Choi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA.,Department of Radiology, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
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15
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Khan K, Bunajem F, Alkhan F. Post traumatic arterial occlusive mesenteric ischemia: a rare case report. Radiol Case Rep 2021; 17:473-476. [PMID: 34950276 PMCID: PMC8671805 DOI: 10.1016/j.radcr.2021.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022] Open
Abstract
Mesenteric ischemia is an uncommon condition with very high mortality rates characterized by inadequate blood supply, inflammatory injury, and subsequent necrosis of the bowel wall. Acute arterial mesenteric ischemia is usually caused by cardiac emboli, atherosclerotic vascular disease, aortic aneurysm, or dissection. We report a case of a 60-year-old male who presented to the accident and emergency department complaining of abdominal pain following blunt abdominal trauma. An urgent contrast enhanced computed tomography scan demonstrated superior mesenteric artery thrombosis with ischemic small bowel. Surgical intervention was carried out with resection of the necrotic bowel followed by anastomosis. Acute occlusive mesenteric ischemia needs to be considered in cases of blunt trauma presenting with abdominal pain. Proper early diagnosis and management is essential as it carries a high risk of morbidity and mortality.
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Affiliation(s)
- Khalid Khan
- Radiology Department, Salmaniya Medical Complex, Bahrain
| | - Fatema Bunajem
- Radiology Department, Salmaniya Medical Complex, Bahrain
| | - Fatema Alkhan
- Radiology Department, Salmaniya Medical Complex, Bahrain
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16
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Brillantino A, Lanza M, Antropoli M, Amendola A, Squillante S, Bottino V, Renzi A, Castriconi M. Usefulness of damage control approach in patients with limited acute mesenteric ischemia: a prospective study of 85 patients. Updates Surg 2021; 74:337-342. [PMID: 34686970 DOI: 10.1007/s13304-021-01192-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 10/10/2021] [Indexed: 02/03/2023]
Abstract
To evaluate the efficacy of the damage control approach by two-step surgical procedure in not critical patients (without sepsis or septic shock) with peritonitis from limited acute mesenteric ischemia. From April 2013 to April 2020, 85 patients [49 (57.7%) women and 36 (42.3%) men, median age 69.5 (range 38-92)] were enrolled in this study and underwent emergency surgery. After resection of ischemic bowel, basing on the individual decision of the single surgeon, the patients underwent primary end-to-end anastomosis (Group 1) or damage control approach (Group 2) including primary laparotomy with resection of ischemic bowel, temporary abdominal closure and a second-look procedure at 48 h with re-evaluation of bowel vitality. Forty-seven (55.3%) patients underwent one-stage surgical treatment and 38 (44.7%) patients received a two-step procedure. In the latter group, at second exploration, 8 (21%) patients required a further intestinal resection, due to mesenteric ischemia progression. Both anastomosis dehiscence rate and need for ileostomy in Group 1 patients were significantly higher than in Group 2 (23.4% vs 5.3%: p = 0.03 and 19.1% vs 2.6%: p = 0.03; Fisher's exact test). No significative differences in mortality and morbidity rate were found between the two groups. The damage control approach by two-step surgical procedure may represent a valid innovative option in the management of not critical patients with limited acute mesenteric ischemia, achieving a better clinical outcome if compared with surgical treatment by one-step procedure.
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Affiliation(s)
- Antonio Brillantino
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy.
| | - Michele Lanza
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Massimo Antropoli
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Alfonso Amendola
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Simone Squillante
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Vincenzo Bottino
- Department of Surgery, "Villa Betania" Hospital, Via Argine 604, 80147, Naples, Italy
| | - Adolfo Renzi
- Department of Surgery, "Buonconsiglio Fatebenefratelli" Hospital, Via Alessandro Manzoni 220, 80123, Naples, Italy
| | - Maurizio Castriconi
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
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17
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Snow DC, Colbenson K. Avoiding Misdiagnosis of Abdominal Vascular Catastrophes. Emerg Med Clin North Am 2021; 39:769-80. [PMID: 34600636 DOI: 10.1016/j.emc.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abdominal vascular emergencies are an uncommon entity in emergency medicine, but when they present, they are often catastrophic. These time-sensitive and life-threatening diagnoses are often hidden in nonspecific complaints such as nausea, vomiting, or flank pain, so the emergency physician must remain diligent and consider these in the differential diagnoses. The following is an overview of the more common of these abdominal vascular emergencies, in the hope that they help the Emergency Physician avoid the misdiagnosis and subsequent vascular catastrophe that would follow.
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18
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Metcalfe KHM, Stienstra R, McHoney M. NIRS as a biomarker of bowel ischaemia & surgical pathology: A meta-analysis of studies in newborns. Early Hum Dev 2021; 161:105437. [PMID: 34411803 DOI: 10.1016/j.earlhumdev.2021.105437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We performed a meta-analysis on Near-infrared Spectroscopy (NIRS) as a biomarker of bowel ischaemia. SUMMARY BACKGROUND DATA NIRS allows non-invasive assessment of gastrointestinal regional oxygen saturation (GrSO2). Studies to date have focused on the feasibility of NIRS in clinical practice and its reproducibility. GrSO2 can be used alone, or in conjunction with cerebral NIRS to give a Cerebral Splanchnic Oxygenation Ratio (CSOR). We assess published data on abdominal NIRS as a marker of bowel ischaemia. METHODS A literature review was conducted using the PRISMA method. Data on GrSO2 and CSOR in controls and patients with confirmed ischaemia was included in a meta-analysis, and used to identify a diagnostic threshold. RESULTS 14 studies were identified. Meta-analysis demonstrated that GrSO2 (p < 0.01) and CSOR (p < 0.01) were significantly lower in neonates with bowel pathology associated with ischaemia than controls. Area under the curve for GrSO2 was 0.80, with Youden's index highest (0.52) at a GrSO2 of 42% (specificity 91% and sensitivity 62%). For CSOR, area under the curve is 0.89, with Youden's index highest (0.69) at 0.76 (specificity of 80%, sensitivity 90%). CONCLUSIONS Splanchnic NIRS correlates with bowel ischaemia. Low GrSO2 is consistently associated with ischaemia, although a specific cut off level in each patient is hard to define. However, values below 42% correlate strongly with ischaemia while values above 52% are more suggestive of patients without bowel pathology. CSOR of below 0.76 is strongly suggestive of ischaemia. Trends within individuals are likely to be able to provide even more clinically correlatable and diagnostic data.
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Affiliation(s)
- Kiloran H M Metcalfe
- University of Edinburgh, College of Medicine, United Kingdom of Great Britain and Northern Ireland
| | - Roxane Stienstra
- Department Paediatric Surgery, Royal Hospital for sick Children Edinburgh, United Kingdom of Great Britain and Northern Ireland
| | - Merrill McHoney
- University of Edinburgh, College of Medicine, United Kingdom of Great Britain and Northern Ireland; Department Paediatric Surgery, Royal Hospital for sick Children Edinburgh, United Kingdom of Great Britain and Northern Ireland.
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19
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Della Seta M, Kloeckner R, Pinto Dos Santos D, Walter-Rittel TC, Hahn F, Henze J, Gropp A, Pratschke J, Hamm B, Geisel D, Auer TA. Pneumatosis intestinalis and porto-mesenteric venous gas: a multicenter study. BMC Med Imaging 2021; 21:129. [PMID: 34429069 PMCID: PMC8383372 DOI: 10.1186/s12880-021-00651-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/26/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Estimating the prognosis of patients with pneumatosis intestinalis (PI) and porto-mesenteric venous gas (PMVG) can be challenging. The purpose of this study was to refine prognostication to improve decision making in daily clinical routine. METHODS A total of 290 patients with confirmed PI were included in the final analysis. The presence of PMVG and mortality (90d follow-up) were evaluated with regard to the influence of possible risk factors. Furthermore, a linear estimation model was devised combining significant parameters to calculate accuracies for predicting death in patients undergoing surgery by means of a defined operation point (ROC-analysis). RESULTS Overall, 90d mortality was 55.2% (160/290). In patients with PI only, mortality was 46.5% (78/168) and increased significantly to 67.2% (82/122) in combination with PMVG (median survival: PI: 58d vs. PI and PMVG: 41d; p < 0.001). In the entire patient group, 53.5% (155/290) were treated surgically with a 90d mortality of 58.8% (91/155) in this latter group, while 90d mortality was 51.1% (69/135) in patients treated conservatively. In the patients who survived > 90d treated conservatively (24.9% of the entire collective; 72/290) PMVG/PI was defined as "benign"/reversible. PMVG, COPD, sepsis and a low platelet count were found to correlate with a worse prognosis helping to identify patients who might not profit from surgery, in this context our calculation model reaches accuracies of 97% specificity, 20% sensitivity, 90% PPV and 45% NPV. CONCLUSION Although PI is associated with high morbidity and mortality, "benign causes" are common. However, in concomitant PMVG, mortality rates increase significantly. Our mathematical model could serve as a decision support tool to identify patients who are least likely to benefit from surgery, and to potentially reduce overtreatment in this subset of patients.
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Affiliation(s)
- Marta Della Seta
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Roman Kloeckner
- Department for Radiology, University Hospital Mainz, Mainz, Germany
| | | | - Thula Cannon Walter-Rittel
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Hahn
- Department for Radiology, University Hospital Mainz, Mainz, Germany
| | - Jörn Henze
- Department for Radiology, University Hospital of Cologne, Cologne, Germany
| | - Annika Gropp
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of General, Visceral and Transplant Surgery, Charité - University Medicine Berlin, Berlin, Germany
| | - Bernd Hamm
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Dominik Geisel
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Timo Alexander Auer
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany. .,Berlin Institute of Health (BIH), Berlin, Germany.
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20
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Buso G, Becchetti C, Berzigotti A. Acute splanchnic vein thrombosis in patients with COVID-19: A systematic review. Dig Liver Dis 2021; 53:937-949. [PMID: 34120860 PMCID: PMC8149197 DOI: 10.1016/j.dld.2021.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/07/2021] [Accepted: 05/16/2021] [Indexed: 02/08/2023]
Abstract
There is increasing evidence that coronavirus disease 2019 (COVID-19) is associated with a significant risk of venous thromboembolism. While information are mainly available for deep vein thrombosis of the lower limb and pulmonary embolism, scarce data exist regarding acute splanchnic vein thrombosis (SVT) in this setting. PubMed, EMBASE and Google Scholar English-language articles published up to 30 January 2021 on SVT in COVID-19 were searched. Overall, 21 articles reporting equal number of patients were identified. 15 subjects presented with portal vein thrombosis, 11 with mesenteric vein thrombosis, four with splenic vein thrombosis, and two with Budd-Chiari syndrome. Male sex was prevalent (15 patients), and median age was 43 years (range 26-79 years). Three patients had a history of liver disease, while no subject had known myeloproliferative syndrome. Clinical presentation included mainly gastrointestinal symptoms. Anticoagulation was started in 16 patients. Three patients underwent bowel resection. Ten subjects developed gastric or bowel ischemia, seven of whom underwent bowel resection, and four died after SVT diagnosis. Although rare, SVT should be seen as a complication of COVID-19. Patients with severe gastrointestinal symptoms should be screened for SVT, as rapid recognition and correct management are essential to improve the outcome of these patients.
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Affiliation(s)
- Giacomo Buso
- Angiology Division, Heart and Vessels Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Chiara Becchetti
- Hepatology, Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Switzerland,Hepatology, Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Annalisa Berzigotti
- Hepatology, Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Switzerland,Hepatology, Department of Biomedical Research, University of Bern, Bern, Switzerland,Corresponding author at: Hepatology, Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Switzerland
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21
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de Kok BM, Toneman MK, Oei S, Westerterp M, van Acker GJD, van der Pool AEM, Zijta FM, Bipat S. Correlation of CT findings with intra-operative outcome in closed-loop small bowel obstruction (CL-SBO). Eur J Radiol 2021; 142:109844. [PMID: 34252868 DOI: 10.1016/j.ejrad.2021.109844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/31/2021] [Accepted: 06/30/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To correlate CT-findings in patients with closed-loop small bowel obstruction (CL-SBO) with perioperative findings, to identify patients who require immediate surgical intervention. Secondary purpose was to substantiate the role of radiologists in predicting perioperative outcome. METHODS Data were retrospectively obtained from patients with surgically confirmed CL-SBO, between September 2013 and September 2019. Three radiologists reviewed CTs to assess defined CT features and predict patient outcome for bowel wall ischemia and necrosis using a likelihood score. Univariate statistical analyses were performed and diagnostic performance parameters and interobserver agreement were assessed for each feature. RESULTS Of 148 included patients, 28 (19%) intraoperatively had viable bowel and 120 (81%) had bowel wall ischemia or necrosis. Most CT characteristics, as well as the likelihood of ischemia and necrosis, found fair or moderate multirater agreement. Increased attenuation of bowel wall and mesenteric vessels on non-contrast-enhanced CT had a specificity for bowel ischemia or necrosis of 100% (sensitivity respectively 48% (p < 0.001) and 21% (p = 0.09)). Mesenteric edema had high sensitivity for ischemia or necrosis (90%), but specificity of only 26% (p < 0.001). For mesenteric fluid, sensitivity was 60% and specificity 57% (p = 0.004). Decreased enhancement of bowel wall in both arterial and PV-phase showed significant correlation, respectively a sensitivity of 58% and 42%, and specificity of 88% and 79% (both p < 0.001). Likelihood of both ischemia and necrosis were significantly correlated with perioperative outcome (p < 0.001). CONCLUSION CT findings concerning mesenteric and bowel wall changes, as well as radiologists' judgement of likelihood of ischemia and necrosis are significantly correlated with perioperative outcome of bowel wall ischemia and necrosis in patients with CL-SBO.
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22
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Tirumani SH, Rahnemai-Azar AA, Pierce JD, Parikh KD, Martin SS, Gilkeson R, Ramaiya NH. Are asymptomatic gastrointestinal findings on imaging more common in COVID-19 infection? Study to determine frequency of abdominal findings of COVID-19 infection in patients with and without abdominal symptoms and in patients with chest-only CT scans. Abdom Radiol (NY) 2021; 46:2407-14. [PMID: 33394096 DOI: 10.1007/s00261-020-02920-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE To identify incidence of abdominal findings in COVID-19 patients with and without abdominal symptoms on various imaging modalities including chest-only CT scans and to correlate them with clinical, laboratory and chest CT findings. MATERIALS AND METHODS In this retrospective study, we searched our clinical database between March 1st, 2020 and May 22nd, 2020 to identify patients who had positive real-time reverse transcriptase polymerase chain reaction (RT-PCR) on throat swabs for COVID-19, had availability of clinical, laboratory information and had availability of CT scan of chest or abdominal radiograph, abdominal ultrasound or CT scan within 2 weeks of the diagnosis. Abdominal imaging findings on all imaging modalities were documented. Chest CT severity score (CT-SS) was assessed in all patients. Clinical and laboratory findings were recorded from the electronic medical record. Statistical analysis was performed to determine correlation of abdominal findings with CT-SS, clinical and laboratory findings. RESULTS Out of 264 patients with positive RT-PCR, 73 patients (38 males and 35 females; 35 African American) with mean age of 62.2 (range 21-94) years were included. The median CTSS was 13.5 (IQR 75-25 18-8). Most common finding in the abdomen on CT scans (n = 72) were in the gastrointestinal system in 13/72 patients (18.1%) with fluid-filled colon without wall thickening or pericolonic stranding (n = 12) being the most common finding. Chest-only CT (n = 49) found bowel findings in 3 patients. CTSS did not differ in terms of age, sex, race or number of comorbidities but was associated with longer duration of hospitalization (p = 0.0.0256), longer intensive care unit stay (p = 0.0263), more frequent serum lactate dehydrogenase elevation (p = 0.0120) and serum C-reactive protein elevation (p = 0.0402). No statistically significant correlation of occurrence of bowel abnormalities with CTSS, clinical or laboratory features. Deep venous thrombosis was seen in 7/72 patients (9.8%) with three patients developing pulmonary embolism CONCLUSION: Abnormal bowel is the most common finding in the abdomen in patients with COVID-19 infection, is often without abdominal symptoms and occurs independent of severity of pulmonary involvement, other clinical and laboratory features.
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Negrete JR, Molina GA, Sanchez AC, Caiza E, Acosta C, Alvear MDL, Gonzalez H, Zavalza JF. Transvaginal evisceration of the small bowel a rare and potentially lethal event, a case report. Ann Med Surg (Lond) 2021; 65:102352. [PMID: 34026097 PMCID: PMC8120864 DOI: 10.1016/j.amsu.2021.102352] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/14/2021] [Accepted: 04/24/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction and Importance Evisceration of the small bowel through the vagina is an extremely rare condition and a life-threatening surgical emergency. Complications associated with this condition include bowel ischemia, abdominal sepsis, and deep vein thrombosis. Therefore, prompt surgical consultation and treatment are crucial as delay in treatment can lead to a grim outcome. Case presentation We report the case of a 50-year-old female obese patient with a past medical history of uterine surgery. During a cough episode, she experienced sudden transvaginal evisceration that required emergent surgery. Thankfully she fully recovered and is doing well. Discussion and conclusions Transvaginal evisceration is a life-threatening and extremely rare pathology; it requires urgent diagnosis and surgical intervention since bowel viability can be compromised. During these rare events, interdisciplinary surgical cooperation is vital to obtain the best possible outcome for patients. Transvaginal evisceration is a life-threatening and extremely rare pathology. Prompt surgical consultation is crucial as delay in treatment can lead to sever complications. Complications associated with this condition include bowel ischemia, abdominal sepsis, and deep vein thrombosis.
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Affiliation(s)
- Jose R. Negrete
- Hospital Vozandes Quito, Department of General Surgery, Quito, Ecuador
| | - Gabriel A. Molina
- Hospital Iess Quito Sur, Department of General Surgery & Universidad San Francisco de Quito (USFQ), Quito, Ecuador
- Corresponding author.
| | - Andrea C. Sanchez
- Hospital Vozandes Quito, Department of General Surgery, Quito, Ecuador
| | - Edwin Caiza
- Hospital Vozandes Quito, Department of General Surgery, Quito, Ecuador
| | - Cesar Acosta
- Hospital Vozandes Quito, Department of Urology, Quito, Ecuador
| | | | - Hernán Gonzalez
- Hospital de Especialidades Carlos Andrade Marin, Department of General Surgery, Quito, Ecuador
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Khetarpal A, Khetarpal A. Bowel ischemia and gangrene-primary true enterolith. Int J Surg Case Rep 2021; 80:105562. [PMID: 33592410 PMCID: PMC7893413 DOI: 10.1016/j.ijscr.2021.01.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 02/07/2023] Open
Abstract
Enterolithiasis, or presence of stone concretions in the gastrointestinal tract, is an important but relatively uncommon clinical condition that has recently gained significant attention with advances in the gastrointestinal field. Here, we present a case of an old male having features of bowel Ischemia and gangrene formation. Patient underwent exploratory laparotomy and there was a presence of inflamed Gut with a perforation just one and half feet away from IC junction and an obstruction was also identified by following the dilated bowel loops distally, palpation revealed a hard stone and enterotomy incision at the site delivered a stone. Following it, resection of thickened mesentery was done and loop ileostomy was made. The most important prognostic factor in such cases relies on time interval between onset of symptoms and definitive treatment. By improving the awareness and early recognition of mesenteric ischemia will lead to improved survival in the condition.
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Fujii M, Yamashita S, Tanaka M, Tashiro J, Takenaka Y, Yamasaki K, Masaki Y. Clinical features of patients with hepatic portal venous gas. BMC Surg 2020; 20:300. [PMID: 33246462 PMCID: PMC7694268 DOI: 10.1186/s12893-020-00973-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 11/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hepatic portal venous gas (HPVG) is a rare clinical condition that is caused by a variety of underlying diseases. However, the factors that would permit accurate identification of bowel ischemia, requiring surgery, in patients with HPVG have not been fully investigated. METHODS Thirty patients that had been diagnosed with HPVG using computed tomography between 2010 and 2019 were allocated to two groups on the basis of clinical and intraoperative findings: those with (Group 1; n = 12 [40%]) and without (Group 2; n = 18 [60%]) bowel ischemia. Eleven patients underwent emergency surgery, and bowel ischemia was identified in eight of these (73%). Four patients in Group 1 were diagnosed with bowel ischemia, but treated palliatively because of their general condition. We compared the characteristics and outcomes of Groups 1 and 2 and identified possible prognostic factors for bowel ischemia. RESULTS At admission, patients in Group 1 more commonly showed the peritoneal irritation sign, had lower base excess, higher lactate, and higher C-reactive protein, and more frequently had comorbid intestinal pneumatosis. Of the eight bowel ischemia surgery patients, four (50%) died, mainly because of anastomotic leak following bowel resection and primary anastomosis (3/4, 75%). All except one patient in Group 2, who presented with aspiration pneumonia, responded better to treatment. CONCLUSIONS Earlier identification and grading of bowel ischemia according to the findings at admission should benefit patients with HPVG by reducing the incidence of unnecessary surgery and increasing the use of safer procedures, such as prophylactic stoma placement.
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Affiliation(s)
- Manato Fujii
- Department of Surgery, Ome Municipal General Hospital, 4-16-5, Higashi Ome, Ome-shi, Tokyo, 198-0042, Japan.
| | - Suguru Yamashita
- Department of Surgery, Ome Municipal General Hospital, 4-16-5, Higashi Ome, Ome-shi, Tokyo, 198-0042, Japan
| | - Mayuko Tanaka
- Department of Radiology, Ome Municipal General Hospital, 4-16-5, Higashi Ome, Ome-shi, Tokyo, 198-0042, Japan
| | - Jo Tashiro
- Department of Surgery, St. Luke's International Hospital, 9-1 Akashicho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Yoshiharu Takenaka
- Department of Surgery, Ome Municipal General Hospital, 4-16-5, Higashi Ome, Ome-shi, Tokyo, 198-0042, Japan
| | - Kazuki Yamasaki
- Department of Surgery, Ome Municipal General Hospital, 4-16-5, Higashi Ome, Ome-shi, Tokyo, 198-0042, Japan
| | - Yukiyoshi Masaki
- Department of Surgery, Ome Municipal General Hospital, 4-16-5, Higashi Ome, Ome-shi, Tokyo, 198-0042, Japan
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Dombert L, Hussain A, Bullock B, Liu X, Faughnan P, Pigneri D, May A, Mathews T, Semenza K, Granet J, Behm R. Impact of Protocol Utilizing Water-Soluble Contrast for Adhesive Small Bowel Obstruction. J Surg Res 2021; 259:487-92. [PMID: 33127063 DOI: 10.1016/j.jss.2020.09.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 09/20/2020] [Accepted: 09/25/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Adhesive small bowel obstruction (ASBO) has classically been managed with nasogastric tube decompression and watchful waiting. Our group developed an evidence-based protocol to manage ASBO utilizing a water-soluble contrast (WSC) agent. We hypothesized the protocol would decrease the length of stay (LOS) for patients admitted with ASBO along with the time interval from admission to surgery. METHOD From 2010 to 2018, a retrospective review was performed, including all patients admitted with a diagnosis of ASBO. These patients were divided into two groups: the preprotocol group included years 2010-2013 and the postprotocol group included years 2015-2018. A Student t-test and a two-proportion z-test were used for statistical analysis. RESULT We captured 767 patients; 296 in the preprotocol group and 471 in the postprotocol group. We found a significant decrease in overall LOS between the preprotocol and postprotocol groups (6.56 d versus 4.08 d; P < 0.001) along with decreases in LOS for patients managed nonoperatively (5.36 d versus 3.42 d; P < 0.001) and operatively (16.09 d versus 9.47 d; P < 0.001). Time interval from admission to the operation was significantly decreased in the postprotocol group (3.79 d versus 2.10 d; P < 0.050). We identified a trend toward decreased rates of bowel ischemia and resections with our protocol. CONCLUSIONS These results reaffirm previous reports of WSC's impact on overall LOS in ASBO while showing a similar impact on both operative and nonoperative groups. The decreased time interval between admission and operation may impact the incidence of bowel ischemia and resections.
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Twohig PA, Desai A, Skeans J, Waghray N. Quantifying risk factors for ischemic colitis: A nationwide, retrospective cohort study. Indian J Gastroenterol 2020; 39:398-404. [PMID: 32797386 DOI: 10.1007/s12664-020-01049-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite identifying numerous factors associated with colonic ischemia, the relative risk has been variable and not thoroughly evaluated. Hence, we aimed to quantify the risk of diseases and medications associated with ischemic colitis (IC). METHODS A population-based retrospective analysis in International Business Machines (IBM) Explorys (1999-2018), a pooled, de-identified database of 57 million patients in the USA, was performed. Odds ratios (OR) were calculated between IC and other diseases/medications. IC patients were also stratified by age to assess trends of IC in different age groups. RESULTS A total of 1560 patients had IC in the database. Hyperlipidemia had the highest association with IC (OR 15.3), consistent with prior reports of atherosclerosis being a major risk factor for IC. Hypertension, congestive heart failure, constipation, prior abdominal surgery, and atrial fibrillation all conferred odds greater than 10, which is consistent with prior reports. Novel findings of our study include that beta blockers (OR 9.6) and pro-inflammatory disease states such as vasculitis, rheumatoid arthritis, and malignancy all increase the risk of IC. CONCLUSION Early identification of IC is critical for minimizing morbidity and mortality. Epidemiologic information could be integrated with current clinical algorithms to more rapidly identify patients at risk.
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Affiliation(s)
- Patrick A Twohig
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
| | - Aakash Desai
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
| | - Jacob Skeans
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, OH, 43210, USA
| | - Nisheet Waghray
- Department of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA
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Gonzalez-Urquijo M, Espino-Rodriguez M, Romero-Davila A, Rodarte-Shade M, Gil-Galindo GA. Persistence of a vitelline artery on a Meckel's diverticulum as a cause of bowel infarction. Clin J Gastroenterol 2020; 13:386-92. [PMID: 31705374 DOI: 10.1007/s12328-019-01062-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/24/2019] [Indexed: 10/25/2022]
Abstract
Meckel's diverticulum is a congenital anomaly, resulting from incomplete obliteration of the most proximal portion of the omphalomesenteric duct. It generally remains silent, but life-threatening complications may arise in 4-6% of the patients. We present a case of a 16-year-old male, who arrived at the emergency room with crampy abdominal pain, nausea, and vomiting, suggestive of acute appendicitis. Surgical exploration revealed 150 cm of infarcted small bowel, secondary to a mesodiverticular band of a Meckel's diverticulum at the site of obstruction. The ischemic small bowel with Meckel's diverticulum was resected, and an ileo-ileal anastomosis was carried out. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. He was seen 12 months after his initial surgery, with a favorable outcome.
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Abstract
Acute mesenteric ischemia (AMI) is a life-threatening condition that often presents with abdominal pain. Early diagnosis with contrast-enhanced computed tomography and revascularization can reduce the overall mortality in AMI. This article reviews practical etiological classification, pathophysiology of imaging manifestations and common pitfalls in intestinal ischemia.
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Affiliation(s)
| | | | - Prashant Nagpal
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Differences in effect of early enteral nutrition on mortality among ventilated adults with shock requiring low-, medium-, and high-dose noradrenaline: A propensity-matched analysis. Clin Nutr 2019; 39:460-467. [PMID: 30808573 DOI: 10.1016/j.clnu.2019.02.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/18/2019] [Accepted: 02/09/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Despite extensive research on early enteral nutrition (EEN), it remains unclear whether EEN is effective for patients with shock requiring vasopressors. This study aimed to compare outcomes between EEN and late enteral nutrition (LEN) in ventilated patients with shock requiring low-, medium-, or high-dose noradrenaline. METHODS Using a national inpatient database in Japan, we identified ventilated patients admitted to intensive care units who had shock requiring catecholamines (noradrenaline or dobutamine) from July 2010 to March 2016. We defined patients who started enteral nutrition within 2 days after starting mechanical ventilation as EEN group and the others as LEN group. Propensity score matching was performed between patients undergoing EEN and LEN in each of the low- (<0.1 μg/kg/min), medium- (0.1-0.3 μg/kg/min), and high-dose (≥0.3 μg/kg/min) noradrenaline groups. RESULTS We identified 52,563 eligible patients during the 69-month study period, including 38,488, 11,042, and 3033 patients in the low-, medium-, and high-dose noradrenaline groups, respectively. One-to-two propensity score matching created 5,969, 2,162, and 477 one-to-two matched pairs in the low-, medium-, and high-dose noradrenaline groups, respectively. The 28-day mortality rate was significantly lower in the EEN than LEN group in the low-dose noradrenaline group (risk difference, -2.9%; 95% confidence interval [CI], -4.5% to -1.3%) and in the medium-dose noradrenaline group (risk difference, -6.8%; 95% CI, -9.6% to -4.0%). In the high-dose noradrenaline group, 28-day mortality did not differ significantly between the EEN and LEN groups (absolute risk difference, -1.4%; 95% CI, -7.4%-4.7%). CONCLUSIONS Although the size of the subgroup requiring high-dose noradrenaline may have been too small to demonstrate a significant difference, the results suggest that EEN was associated with a reduction in mortality in ventilated adults treated with low- or medium-dose noradrenaline but not in those requiring high-dose noradrenaline.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Abstract
AIM OF THE STUDY The aim of the study was to identify major gastrointestinal complications associated with direct jejunal feeding. We hypothesized that jejunal feeding may cause life-threatening surgical complications in a minority of patients. METHODS All patients undergoing jejunal feeding between 1/2008 and 1/2018 at a pediatric surgical unit were identified retrospectively. Data sought from records included demographics, comorbidities, indications, feeding strategies, adverse events, and follow-up. Major surgical complications were defined by Clavien-Dindo grade ≥ IIIb and involving the GI tract (excluding changes of jejunal tube). MAIN RESULTS 197 patients were identified (110 female). Median age (IQR) at initiation of jejunal feeding months was 5.6 (6-164) months. 122 were neurologically impaired. The most frequent indications were: GERD/gastroparesis (n = 114), prophylaxis/treatment of Superior Mesenteric Artery (SMA) syndrome (N.B. our center is a national spinal deformity unit) (n = 47), congenital anomalies of aerodigestive anatomy (n = 17), and malignancy (n = 7). 125 patients were managed with nasojejunal feeding alone: gastrojejunal tube (n = 51) and via Roux-en-Y jejunostomy (n = 21). There were 14 significant gastrointestinal complications (n = 11 grade > IIIb) identified among 12 patients, of whom 8 required bowel resections, and 2 died as a result: nonmechanical bowel ischemia (n = 7), intussusception (n = 4), and volvulus (n = 3). CONCLUSION This series highlights the major complications of jejunal feeding, including a significant yet underreported risk of gut compromise. Patients undergoing jejunal feeding had a 6.1% risk of developing major surgical complications (of note, 3.6% developed bowel ischemia of unknown etiology). Susceptible children were comorbid, fragile, and neurologically impaired. These findings should influence parental discussions and informed consent before embarking upon jejunal feeding. LEVEL OF EVIDENCE Level IV prognosis study.
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Affiliation(s)
- Conor McCann
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK
| | - Paul S Cullis
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK
| | - Amanda J McCabe
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK
| | - Fraser D Munro
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK.
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Jalalzadeh H, van Leeuwen CF, Indrakusuma R, Balm R, Koelemay MJW. Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2018; 68:900-915. [PMID: 30146037 DOI: 10.1016/j.jvs.2018.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/14/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Outcomes after repair of ruptured abdominal aortic aneurysm (RAAA) have improved in the last decade. It is unknown whether this has resulted in a reduction of postoperative bowel ischemia (BI). The primary objective was to determine BI prevalence after RAAA repair. Secondary objectives were to determine its major sequelae and differences between open repair (OR) and endovascular aneurysm repair (EVAR). METHODS This systematic review (PROSPERO CRD42017055920) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. MEDLINE and Embase were searched for studies published from 2005 until 2018. The methodologic quality of observational studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) tool. The quality of the randomized controlled trials (RCTs) was assessed with the Cochrane Collaboration's tool for assessing risk of bias. BI prevalence and rates of BI as cause of death, reoperation, and bowel resection were estimated with meta-analyses with a random-effects model. Differences between OR and EVAR were estimated with pooled risk ratios with 95% confidence intervals (CIs). Changes over time were assessed with Spearman rank test (ρ). Publication bias was assessed with a funnel plot analysis. RESULTS A total of 101 studies with 52,670 patients were included; 72 studies were retrospective cohort studies, 14 studies were prospective cohort studies, 12 studies were retrospective administrative database studies, and 3 studies were RCTs. The overall methodologic quality of the RCTs was high, but that of observational studies was low. The pooled prevalence of BI ranged from of 0.08 (95% CI, 0.07-0.09) in database studies to 0.10 (95% CI, 0.08-0.12) in cohort studies. The risk of BI was higher after OR than after EVAR (risk ratio, 1.79; 95% CI, 1.25-2.57). The pooled rate of BI as cause of death was 0.04 (95% CI, 0.03-0.05), and that of BI as cause of reoperation and bowel resection ranged between 0.05 and 0.07. BI prevalence did not change over time (ρ, -0.01; P = .93). The funnel plot analysis was highly suggestive of publication bias. CONCLUSIONS The prevalence of clinically relevant BI after RAAA repair is approximately 10%. Approximately 5% of patients undergoing RAAA repair suffer from severe consequences of BI. BI is less prevalent after EVAR than after OR.
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Affiliation(s)
- Hamid Jalalzadeh
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands.
| | - Carlijn F van Leeuwen
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Reza Indrakusuma
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Mark J W Koelemay
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
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Hansraj N, Pasley AM, Pasley JD, Harris DG, Diaz JJ, Bruns BR. "Second-look" laparotomy: warranted, or contributor to excessive open abdomens? Eur J Trauma Emerg Surg 2018; 45:705-711. [PMID: 29947847 DOI: 10.1007/s00068-018-0968-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 05/31/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The overuse of temporary abdominal closure and second look (SL) laparotomy in emergency general surgery (EGS) cases has been questioned in the recent literature. In an effort to hopefully decrease the number of open abdomen (OA) patients, we hypothesize that reviewing our cases, many of these SL patients could be managed with single-stage operative therapy and thus decrease the number of OA patients. METHODS This is a retrospective review of prospectively collected data from Jun 2013-Jun 2014, evaluating EGS patients managed with an OA who required bowel resection in either index or SL laparotomy. Demographics, clinical variables, complications and mortality were collected. Fisher's exact t test was used for statistical analysis. RESULTS During this time frame, 96 patients were managed with OA and 59 patients required a bowel resection. 55 (57%) of those required one bowel resection at the index operation with 4 (4.2%) only requiring one bowel resection at the second operation. In the patients requiring bowel resections, 18 (30%) required a resection at SL. At SL laparotomy, resection was required for questionably viable bowel at the index operation 60% (11), whereas 39% (7) had normal appearing bowel. Indications for resection at SL laparotomy included evolution of existing ischemia, new onset ischemia, staple line revision, and "other". 23 patients (39%) were hemodynamically unstable, contributing to the need for temporary abdominal closure. In the multivariate analysis, preoperative shock was the only predictor of need for further resection. Complications and mortality were similar in both groups. CONCLUSION Almost one-fifth of the patients undergoing SL laparotomy for open abdomen required bowel resections, with 6.8% of those having normal appearing bowel at index operation, therefore in select EGS patients, SL laparotomy is a reasonable strategy.
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Affiliation(s)
- Natasha Hansraj
- Division of Acute Care Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street S10B00, Baltimore, MD, 21201, USA.
| | - Amelia M Pasley
- Division of Acute Care Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street S10B00, Baltimore, MD, 21201, USA
| | - Jason D Pasley
- Division of Acute Care Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street S10B00, Baltimore, MD, 21201, USA
| | - Donald G Harris
- Division of Acute Care Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street S10B00, Baltimore, MD, 21201, USA
| | - Jose J Diaz
- Division of Acute Care Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street S10B00, Baltimore, MD, 21201, USA
| | - Brandon R Bruns
- Division of Acute Care Surgery, Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street S10B00, Baltimore, MD, 21201, USA
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Abidali H, Cole L, Seetharam AB. Rapid reversal of colonic pneumatosis with restoration of mesenteric arterial supply. Clin J Gastroenterol 2018; 11:461-464. [PMID: 29881954 DOI: 10.1007/s12328-018-0872-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 06/01/2018] [Indexed: 12/25/2022]
Abstract
Pneumatosis cystoides intestinalis (PCI) is characterized by gas-filled cystic lesions within the wall of the large intestine and presents along a spectrum of clinical severity ranging from benign to life threatening. Etiopathogenesis is multifactorial and postulated to result from either mechanical or bacterial causes. In this report, we present a patient with chronic abdominal pain evaluated with colonoscopy revealing segmental PCI isolated to the distal colon. Further investigation revealed an abdominal aortic aneurysm (AAA) compromising the inferior mesenteric artery takeoff. Endovascular repair of the AAA resulted in clinical resolution of abdominal pain and endoscopic resolution of PCI. To our knowledge, this is the first report to document endoscopic resolution of PCI with restoration of mesenteric arterial supply, highlighting vascular insufficiency as a predisposing and reversible pathogenic mechanism.
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Affiliation(s)
- Hussein Abidali
- Gastroenterology, Banner University Medical Center, Phoenix, AZ, USA
| | - Lauren Cole
- Internal Medicine, Banner University Medical Center, University of Arizona College of Medicine-Phoenix, 1111 E McDowell Rd, Phoenix, AZ, 85006, USA.
| | - Anil Bellur Seetharam
- Banner Transplant and Advanced Liver Disease Center, Phoenix, AZ, USA.,University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Abstract
Midgut volvulus can result in gangrene and loss of large segments of intestine. After correction of volvulus the viability of intestine may improve and if given sufficient time a large portion of intestine may be saved. A planned second look laparotomy in babies with volvulus and doubtful gut viability can be helpful in saving large bowel segment. We present a case of a newborn baby admitted with bilious vomiting, abdominal distension and melena. An urgent exploratory laparotomy showed midgut volvulus with near gangrene of about 35 cm of proximal jejunum and bluish discoloration of the rest of the small bowel. After de-rotation and warm packs, the vascularity of ileum & distal jejunum returned to normal, however the proximal jejunum remained dusky and bruised. Ladd’s procedure was done and a decision was made to close the abdomen with a plan for a 2nd look laparotomy after 24 hours. A relook laparotomy performed after 24 hours showed, a well vascularized small bowel. No bowel resection was required and abdomen was closed. The baby improved and was discharged in stable condition with no long-term ischemic complications. This case indicates that a second look laparotomy may provide time for revascularization of the intestine with doubtful vascularity and avoid unnecessary bowel resection.
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Affiliation(s)
- Iftikhar Ahmad Jan
- Iftikhar Ahmad Jan, Department of Paediatric Surgery, Al Mafraq Hospital, Abu Dhabi, UAE
| | - Mishail Ziaullah
- Mishail Ziaullah, Department of General Paediatrics, Al Mafraq Hospital, Abu Dhabi, UAE
| | - Laila Obaid Obaid
- Laila Obaid Obaid, Department of Neonatology, Al Mafraq Hospital, Abu Dhabi, UAE
| | - Mokhatar Ali Hassan
- Mokhatar Ali Hassan, Department of Paediatric Surgery, Al Mafraq Hospital, Abu Dhabi, UAE
| | - Mona Al Shehhi
- Mona Al Shehhi, Department of Paediatric Surgery, Al Mafraq Hospital, Abu Dhabi, UAE
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Zogheib E, Cosse C, Sabbagh C, Marx S, Caus T, Henry M, Nader J, Fumery M, Bernasinski M, Besserve P, Trojette F, Renard C, Duhaut P, Kamel S, Regimbeau JM, Dupont H. Biological scoring system for early prediction of acute bowel ischemia after cardiac surgery: the PALM score. Ann Intensive Care 2018; 8:46. [PMID: 29671149 DOI: 10.1186/s13613-018-0395-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 04/12/2018] [Indexed: 02/07/2023] Open
Abstract
Background Bowel ischemia is a life-threatening emergency defined as an inadequate vascular perfusion leading to bowel inflammation resulting from impaired colonic/small bowel blood supply. Main issue for physicians regarding bowel ischemia diagnosis lies in the absence of informative and specific clinical or biological signs leading to delayed management, resulting in a poorer prognosis, especially after cardiac surgery. The aim of the present series was to propose a simple scoring system based on biological data for the diagnosis of bowel ischemia. Methods In a retrospective monocentric study, patients admitted in cardiac ICU, after cardiovascular surgery, were screened for inclusion. According to a 1:2 ratio (case–control), matching between two groups was based on sex, type of cardiovascular surgery, and the operative period (per month). Patients were divided into two groups: “ischemic group” which corresponds to patients with confirmed bowel ischemia and “non-ischemic group” which corresponds to patients without bowel ischemia. Primary objective was the conception of a scoring system for the diagnosis of bowel ischemia. Secondary objectives were to detail the postoperative morbidity and the diagnostic features for the distinction between acute mesenteric ischemia and ischemic colitis. Results Forty-eight patients (1.3%) had confirmed bowel ischemia (“ischemic group”). According to the 2:1 matching, 96 patients were included in the “non-ischemic group.” Aspartate aminotransferase > 449 UI/L, lactate > 4 mmol/L, procalcitonin > 4.7 μg/L, and myoglobin > 1882 μg/L were found to be independently associated with bowel ischemia. Based on their respective odds ratios, points were assigned to each item ranging from 4 to 8. AUROCC [95% confidence interval] of the scoring system to diagnose bowel ischemia was 0.93 [0.91–0.95], p < 0.001. The optimal threshold after bootstrapping was ≥ 14 points; this yielded a sensitivity of 85.4%, a specificity of 94.8%, a positive likelihood ratio of 16.42, a negative likelihood ratio of 0.15, a Youden’s index of 0.802, and a diagnostic odds ratio of 106.62. Conclusions A biological scoring system based on PCT, ASAT, lactate, and myoglobin measurement allows the diagnosis of bowel ischemia after cardiac surgery with high accuracy. This score could help clinician to propose an early diagnosis and an early treatment in this high mortality disease. Electronic supplementary material The online version of this article (10.1186/s13613-018-0395-5) contains supplementary material, which is available to authorized users.
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Kim JS, Kim HJ, Hong SM, Park SH, Lee JS, Kim AY, Ha HK. Post-Ischemic Bowel Stricture: CT Features in Eight Cases. Korean J Radiol 2017; 18:936-945. [PMID: 29089826 PMCID: PMC5639159 DOI: 10.3348/kjr.2017.18.6.936] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/04/2017] [Indexed: 01/28/2023] Open
Abstract
Objective To investigate the characteristic radiologic features of post-ischemic stricture, which can then be implemented to differentiate that specific disease from other similar bowel diseases, with an emphasis on computed tomography (CT) features. Materials and Methods Eight patients with a diagnosis of ischemic bowel disease, who were also diagnosed with post-ischemic stricture on the basis of clinical or pathologic findings, were included. Detailed clinical data was collected from the available electronic medical records. Two radiologists retrospectively reviewed all CT images. Pathologic findings were also analyzed. Results The mean interval between the diagnosis of ischemic bowel disease and stricture formation was 57 days. The severity of ischemic bowel disease was variable. Most post-ischemic strictures developed in the ileum (n = 5), followed by the colon (n = 2) and then the jejunum (n = 1). All colonic strictures developed in the “watershed zone.” The pathologic features of post-ischemic stricture were deep ulceration, submucosal/subserosal fibrosis and chronic transmural inflammation. The mean length of the post-ischemic stricture was 7.4 cm. All patients in this study possessed one single stricture. On contrast-enhanced CT, most strictures possessed concentric wall thickening (87.5%), with moderate enhancement (87.5%), mucosal enhancement (50%), or higher enhancement in portal phase than arterial phase (66.7%). Conclusion Post-ischemic strictures develop in the ileum, jejunum and colon after an interval of several weeks. In the colonic segment, strictures mainly occur in the “watershed zone.” Typical CT findings include a single area of concentric wall thickening of medium length (mean, 7.4 cm), with moderate and higher enhancement in portal phase and vasa recta prominence.
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Affiliation(s)
- Jin Sil Kim
- Department of Radiology, College of Medicine, Ewha Womans University, Mokdong Hospital, Seoul 07985, Korea
| | - Hyun Jin Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seung-Mo Hong
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seong Ho Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Jong Seok Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Ah Young Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Hyun Kwon Ha
- Department of Radiology, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung 25440, Korea
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Sekino M, Funaoka H, Sato S, Okada K, Inoue H, Yano R, Matsumoto S, Ichinomiya T, Higashijima U, Matsumoto S, Hara T. Intestinal fatty acid-binding protein level as a predictor of 28-day mortality and bowel ischemia in patients with septic shock: A preliminary study. J Crit Care 2017; 42:92-100. [PMID: 28710988 DOI: 10.1016/j.jcrc.2017.07.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 06/30/2017] [Accepted: 07/06/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE We sought to evaluate the levels of intestinal fatty acid-binding protein (I-FABP), a biomarker of enterocyte injury, as a predictor of 28-day mortality and bowel ischemia in septic shock patients. MATERIAL AND METHODS In this preliminary prospective observational study, 57 adult septic shock patients under mechanical ventilation were enrolled. Serum I-FABP levels and prognostic biomarkers were recorded upon intensive care unit (ICU) admission. RESULTS The overall 28-day mortality rate of participants was 23% (13/57). Non-survivors displayed significantly higher lactate (p=0.009), I-FABP (p=0.012), and N-terminal pro-B-type natriuretic peptide (p=0.039) levels compared to survivors. Only I-FABP was associated with 28-day mortality (odds ratio, 1.036; 95% confidence interval, 1.003-1.069; p=0.031) in a multiple logistic regression analysis adjusted for the Acute Physiology and Chronic Health Evaluation II score. When divided into low and high I-FABP groups based on the optimum cut-off value of 19.0ng/mL for predicting 28-day mortality, high-I-FABP patients had a significantly higher incidence of non-occlusive mesenteric ischemia (NOMI) (2% [1/43] vs 29% [4/14]; p=0.011). CONCLUSIONS I-FABP level at ICU admission can serve as a predictor of 28-day mortality in septic shock patients and is associated with the incidence of NOMI.
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Affiliation(s)
- Motohiro Sekino
- Division of Intensive Care, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Hiroyuki Funaoka
- DS Pharma Biomedical Co., Ltd., 33-94 Enoki-cho, Suita, Osaka 564-0053, Japan.
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Kyoko Okada
- Department of Anesthesiology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Haruka Inoue
- Division of Intensive Care, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Rintaro Yano
- Division of Intensive Care, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Sojiro Matsumoto
- Division of Intensive Care, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Taiga Ichinomiya
- Department of Anesthesiology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Ushio Higashijima
- Division of Intensive Care, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Shuhei Matsumoto
- Division of Intensive Care, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Tetsuya Hara
- Department of Anesthesiology, Nagasaki University Graduate School of Biomedical Science, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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Brillantino A, Iacobellis F, Renzi A, Nasti R, Saldamarco L, Grillo M, Romano L, Castriconi M, Cittadini A, De Palma M, Scaglione M, Di Martino N, Grassi R, Paladino F. Diagnostic value of arterial blood gas lactate concentration in the different forms of mesenteric ischemia. Eur J Trauma Emerg Surg. 2018;44:265-272. [PMID: 28612169 DOI: 10.1007/s00068-017-0805-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 05/29/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE The role of serum lactate measurement in patients with intestinal ischemia still remains unclear. The aim of this study was to prospectively evaluate the diagnostic performance of arterial blood gas lactate concentrations in the patients with acute mesenteric ischemia and its different forms. METHODS All the patients reporting abdominal pain associated with risk factors for mesenteric ischemia underwent arterial blood gas and contrast enhanced abdominal computer tomography (CT). RESULTS At CT, 201 patients (70.7%) showed a nonischemic disease (group 1) and 83 patients (29.2%) showed findings of mesenteric ischemia. Out of these, 35 patients (42.1%) showed bowel ischemia secondary to non vascular causes (group 2) and 48 (57.8%) had a vascular intestinal ischemia (group 3). Out of these, 20 showed small bowel arterial occlusion (group 3a), 13 a small bowel nonocclusive ischemia (group 3b), 7 a venous small bowel occlusion (group 3c) and 8 showed isolated colonic ischemia (group 3d). The median lactate serum level was significantly higher in patients with vascular ischemia if compared with patients with nonischemic disease and secondary mesenteric ischemia (p < 0.0001; Kruskal-Wallis test). The areas under ROC curves for the lactate serum levels in the groups 2, 3, 3a, 3b, 3c and 3d were, respectively, 0.61, 0.85, 0.93, 0.93, 0.68 and 0.67. CONCLUSIONS Arterial blood gas lactate levels seem to show good diagnostic accuracy in diagnosing small bowel arterial and nonocclusive ischemia and poor accuracy in diagnosing secondary mesenteric ischemia, small bowel venous ischemia and ischemic colitis.
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A Memon W, Siddiqui S, Hamza A. Autoimmune Disease Presenting As Acute Abdomen. J Ayub Med Coll Abbottabad 2017; 29:139-141. [PMID: 28712193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Mesenteric vasculitis and resultant bowel ischemia is rare but serious complication of autoimmune disorders. Early detection and treatment is the key to avoid potentially fatal outcomes of bowel perforation and peritonitis. In this series, we present patients presenting with acute abdominal pain and having CT imaging features of bowel ischemia who responded well to immunosuppressive therapy. The aim of this work is to familiarize health professionals with possibility and imaging features of mesenteric vasculitis.
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Affiliation(s)
- Wasim A Memon
- Department of Radiology, Aga Khan University Karachi, Pakistan
| | - Saad Siddiqui
- Department of Radiology, Aga Khan University Karachi, Pakistan
| | - Ameer Hamza
- Department of Radiology, Aga Khan University Karachi, Pakistan
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Lerkvaleekul B, Treepongkaruna S, Saisawat P, Thanachatchairattana P, Angkathunyakul N, Ruangwattanapaisarn N, Vilaiyuk S. Henoch-Schönlein purpura from vasculitis to intestinal perforation: A case report and literature review. World J Gastroenterol 2016; 22:6089-6094. [PMID: 27468201 PMCID: PMC4948269 DOI: 10.3748/wjg.v22.i26.6089] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/07/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023] Open
Abstract
Henoch-Schönlein purpura (HSP) is generally a self-limited vasculitis disease and has a good prognosis. We report a 4-year-old Thai boy who presented with palpable purpura, abdominal colicky pain, seizure, and eventually developed intestinal ischemia and perforation despite adequate treatment, including corticosteroid and intravenous immunoglobulin therapy. Imaging modalities, including ultrasonography and contrast-enhanced computed tomography, could not detect intestinal ischemia prior to perforation. In this patient, we also postulated that vasculitis-induced mucosal ischemia was a cause of the ulcer, leading to intestinal perforation, and high-dose corticosteroid could have been a contributing factor since the histopathology revealed depletion of lymphoid follicles. Intestinal perforation in HSP is rare, but life-threatening. Close monitoring and thorough clinical evaluation are essential to detect bowel ischemia before perforation, particularly in HSP patients who have hematochezia, persistent localized abdominal tenderness and guarding. In highly suspicious cases, exploratory laparotomy may be needed for the definite diagnosis and prevention of further complications.
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Duinhouwer LE, Deerenberg E, Rociu E, Kortekaas RTJ. Herniation of the colon through the foramen of Winslow-A case report. Int J Surg Case Rep 2016; 24:14-7. [PMID: 27176504 PMCID: PMC4874454 DOI: 10.1016/j.ijscr.2016.04.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/27/2016] [Accepted: 04/27/2016] [Indexed: 12/26/2022] Open
Abstract
Herniation is rare and diagnostic delay increases mortality and morbidity. Patients present with nonspecific acute abdominal pain. Computed tomography helps early diagnosis and could thereby prevent bowel ischemia. Herniation can be reversed laparoscopically without bowel resection in case of early diagnosis.
Introduction Herniation of the bowel through the foramen of Winslow is a rare condition presenting with acute abdominal pain. Diagnostic delay often results in high morbidity and mortality. Case presentation A patient presented with right sided acute abdominal pain. Computed tomography showed herniation of the ascending colon through the foramen of Winslow which could be reversed laparoscopically without the need for bowel resection. There were no postoperative complications and no recurrences have occurred to date. Discussion Bowel herniation through the foramen of Winslow is very rare, comprising only 8% of all internal herniations. Historically, the majority of cases was diagnosed intra-operatively and bowel resection was necessary because of ischemia. With the introduction of computed tomography, the diagnosis can be made earlier, possibly resulting in a lower morbidity and mortality rate. Conclusion Herniation through the foramen of Winslow is a rare condition. Patients will present with sudden onset abdominal pain. Early imaging helps to recognize the diagnosis and could prevent bowel ischemia.
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Affiliation(s)
- Lucia E Duinhouwer
- Department of Surgery, Franciscus Gasthuis & Vlietland, The Netherlands Kleiweg 500, 3045 PM Rotterdam, The Netherlands.
| | - Eva Deerenberg
- Department of Surgery, Franciscus Gasthuis & Vlietland, The Netherlands Kleiweg 500, 3045 PM Rotterdam, The Netherlands.
| | - Elena Rociu
- Department of Radiology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.
| | - R T J Kortekaas
- Department of Surgery, Franciscus Gasthuis & Vlietland, The Netherlands Kleiweg 500, 3045 PM Rotterdam, The Netherlands.
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43
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Abstract
Intestinal ischemia, which refers to insufficient blood flow to the bowel, is a potentially catastrophic entity that may require emergent intervention or surgery in the acute setting. Although the clinical signs and symptoms of intestinal ischemia are nonspecific, computed tomography (CT) findings can be highly suggestive in the correct clinical setting. In our article, we review the CT diagnosis of arterial, venous, and nonocclusive intestinal ischemia. We discuss the vascular anatomy, pathophysiology of intestinal ischemia, CT techniques for optimal imaging, key and ancillary radiological findings, and differential diagnosis.
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Affiliation(s)
- Harpreet S Dhatt
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA
| | - Spencer C Behr
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA
| | - Aaron Miracle
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA
| | - Zhen Jane Wang
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA
| | - Benjamin M Yeh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA.
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Abstract
Small bowel obstruction and large bowel obstruction account for approximately 20% of cases of acute abdominal surgical conditions. The role of the radiologist is to answer several key questions: Is obstruction present? What is the level of the obstruction? What is the cause of the obstruction? What is the severity of the obstruction? Is the obstruction simple or closed loop? Is strangulation, ischemia, or perforation present? In this presentation, the radiologic approach to and imaging findings of patients with known or suspected bowel obstruction are presented.
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Affiliation(s)
- Richard M Gore
- Department of Radiology, Evanston Hospital, North Shore University Health System, 2650 Ridge Avenue, Evanston, IL 60201, USA.
| | - Robert I Silvers
- Department of Radiology, Evanston Hospital, North Shore University Health System, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Kiran H Thakrar
- Department of Radiology, Evanston Hospital, North Shore University Health System, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Daniel R Wenzke
- Department of Radiology, Evanston Hospital, North Shore University Health System, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Uday K Mehta
- Department of Radiology, Evanston Hospital, North Shore University Health System, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Geraldine M Newmark
- Department of Radiology, Evanston Hospital, North Shore University Health System, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Jonathan W Berlin
- Department of Radiology, Evanston Hospital, North Shore University Health System, 2650 Ridge Avenue, Evanston, IL 60201, USA
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Lehtimäki TT, Kärkkäinen JM, Saari P, Manninen H, Paajanen H, Vanninen R. Detecting acute mesenteric ischemia in CT of the acute abdomen is dependent on clinical suspicion: Review of 95 consecutive patients. Eur J Radiol 2015; 84:2444-53. [PMID: 26413771 DOI: 10.1016/j.ejrad.2015.09.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 08/24/2015] [Accepted: 09/08/2015] [Indexed: 01/26/2023]
Abstract
OBJECTIVES (1) To evaluate the ability of emergency room radiologists to detect acute mesenteric ischemia (AMI) from computed tomography (CT) images in patients with acute abdominal pain. (2) To identify factors affecting radiologists' performance in the CT interpretation and patient outcome. MATERIALS AND METHODS A retrospective study of 95 consecutive patients treated for 97 AMI events between 2009 and 2013 was carried out. The etiology of AMI was embolism in 24 (25%), atherosclerotic vascular disease (ASVD) in 39 (40%), non-obstructive mesenteric ischemia (NOMI) in 25 (26%), and mesenteric venous thrombosis (MVT) in nine (9%) cases. The protocols, referrals and initial radiology reports of the abdominal CTs were analyzed. The CT studies were further scrutinized for vascular and intestinal findings. RESULTS The referring clinician had suspected AMI in 30 (31%) cases prior to imaging. The crucial findings of AMI had been stated in 97% of the radiology reports if the clinician had mentioned AMI suspicion in the referral; if not, the corresponding rate was 81% (p=0.04). Patients without suspicion of AMI prior to CT were more prone to undergo bowel resection. CT protocol was optimal for AMI (with contrast enhancement in arterial and venous phases) in only 34 (35%) cases. Intestinal findings were more difficult to detect than vascular findings. Vascular findings were retrospectively detectable in 92% of cases with embolism and 100% in ASVD and MVT. Some evidence of intestinal abnormality was retrospectively found in the CT findings in 92%, 100%, 100% and 67% of cases with embolism, ASVD, NOMI and MVT, respectively. CONCLUSIONS AMI is underdiagnosed in the CT of the acute abdomen if there is no clinical suspicion.
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Affiliation(s)
- Tiina T Lehtimäki
- Department of Clinical Radiology, Kuopio University Hospital, Puijonlaaksontie 2, P.O. Box 100, FI-70029 Kuopio, Finland.
| | - Jussi M Kärkkäinen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Puijonlaaksontie 2, P.O. Box 100, FI-70029 Kuopio, Finland; Heart Center, Kuopio University Hospital, Puijonlaaksontie 2, P.O. Box 100, FI-70029 Kuopio, Finland.
| | - Petri Saari
- Department of Clinical Radiology, Kuopio University Hospital, Puijonlaaksontie 2, P.O. Box 100, FI-70029 Kuopio, Finland.
| | - Hannu Manninen
- Department of Clinical Radiology, Kuopio University Hospital, Puijonlaaksontie 2, P.O. Box 100, FI-70029 Kuopio, Finland; Unit of Radiology, Department of Clinical Medicine, University of Eastern Finland, Yliopistonranta 1, P.O. Box 1627, FI-70211 Kuopio, Finland.
| | - Hannu Paajanen
- Department of Gastrointestinal Surgery, Kuopio University Hospital, Puijonlaaksontie 2, P.O. Box 100, FI-70029 Kuopio, Finland; Unit of Surgery, Department of Clinical Medicine, University of Eastern Finland, Yliopistonranta 1, P.O. Box 1627, FI-70211 Kuopio, Finland.
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Puijonlaaksontie 2, P.O. Box 100, FI-70029 Kuopio, Finland; Unit of Radiology, Department of Clinical Medicine, University of Eastern Finland, Yliopistonranta 1, P.O. Box 1627, FI-70211 Kuopio, Finland.
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Abstract
Although an ascending aortic thrombus is a rare condition, it can cause serious complications of thromboembolism. Here we present a rare case of a patient who was hospitalized due to ileal arteries embolization caused by emboli from a giant thrombus in the ascending aorta. After 10 days anti-coagulation therapy, we performed a surgery to replace the ascending aorta containing the strip organized thrombus with a synthetic graft. During two years of postoperative follow-up, no recurrence of aortic thrombosis was found. Although the exact cause of this thrombus remains unclear, we believe that it is important to perform a surgery as soon as the presence of an ascending aortic thrombus is confirmed, which could help preventing the major recurrent embolic events.
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Affiliation(s)
- Hua-Dong Li
- Department of Cardiovascular Surgery, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tu-Cheng Sun
- Department of Cardiovascular Surgery, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Moschetta M, Telegrafo M, Rella L, Stabile Ianora AA, Angelelli G. Multi-detector CT features of acute intestinal ischemia and their prognostic correlations. World J Radiol 2014; 6:130-138. [PMID: 24876917 PMCID: PMC4037539 DOI: 10.4329/wjr.v6.i5.130] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 02/08/2014] [Accepted: 03/17/2014] [Indexed: 02/06/2023] Open
Abstract
Acute intestinal ischemia is an abdominal emergency occurring in nearly 1% of patients presenting with acute abdomen. The causes can be occlusive or non occlusive. Early diagnosis is important to improve survival rates. In most cases of late or missed diagnosis, the mortality rate from intestinal infarction is very high, with a reported value ranging from 60% to 90%. Multi-detector computed tomography (MDCT) is a fundamental imaging technique that must be promptly performed in all patients with suspected bowel ischemia. Thanks to the new dedicated reconstruction program, its diagnostic potential is much improved compared to the past and currently it is superior to that of any other noninvasive technique. The increased spatial and temporal resolution, high-quality multi-planar reconstructions, maximum intensity projections, vessel probe, surface-shaded volume rending and tissue transition projections make MDCT the gold standard for the diagnosis of intestinal ischemia, with reported sensitivity, specificity, positive and negative predictive values of 64%-93%, 92%-100%, 90%-100% and 94%-98%, respectively. MDCT contributes to appropriate treatment planning and provides important prognostic information thanks to its ability to define the nature and extent of the disease. The purpose of this review is to examine the diagnostic and prognostic role of MDCT in bowel ischemia with special regard to the state of art new reconstruction software.
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Saba L, Berritto D, Iacobellis F, Scaglione M, Castaldo S, Cozzolino S, Mazzei MA, Mizio VD, Grassi R. Acute arterial mesenteric ischemia and reperfusion: Macroscopic and MRI findings, preliminary report. World J Gastroenterol 2013; 19:6825-6833. [PMID: 24187457 PMCID: PMC3812481 DOI: 10.3748/wjg.v19.i40.6825] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/17/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the physiopathology and magnetic resonance imaging (MRI) findings in an animal model of acute arterial mesenteric ischemia (AAMI) with and without reperfusion.
METHODS: In this study, 8 adult Sprague-Dawley rats underwent superior mesenteric artery (SMA) ligation and were then randomly divided in two groups of 4. In group I, the ischemia was maintained for 8 h. In group II, 1-h after SMA occlusion, the ligation was removed by cutting the thread fixed on the back of the animal, and reperfusion was monitored for 8 h. MRI was performed using a 7-T system.
RESULTS: We found that, in the case of AAMI without reperfusion, spastic reflex ileus, hypotonic reflex ileus, free abdominal fluid and bowel wall thinning are present from the second hour, and bowel wall hyperintensity in T2-W sequences are present from the fourth hour. The reperfusion model shows the presence of early bowel wall hyperintensity in T2-W sequences after 1 h and bowel wall thickening from the second hour.
CONCLUSION: Our study has shown that MRI can assess pathological changes that occur in the small bowel and distinguish between the presence and absence of reperfusion after induced acute arterial ischemia.
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Milone M, Minno MNDD, Musella M, Maietta P, Iaccarino V, Barone G, Milone F. Computed tomography findings of pneumatosis and portomesenteric venous gas in acute bowel ischemia. World J Gastroenterol 2013; 19:6579-6584. [PMID: 24151384 PMCID: PMC3801371 DOI: 10.3748/wjg.v19.i39.6579] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 04/02/2013] [Accepted: 05/19/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To use more representative sample size to evaluate whether computed tomography (CT) scan evidence of the concomitant presence of pneumatosis and portomesenteric venous gas is a predictor of transmural bowel necrosis.
METHODS: Data from 208 patients who were referred for a diagnosis of bowel ischemia were retrospectively reviewed. Only patients who underwent a surgical intervention following a diagnosis of bowel ischemia who also had a post-operative histological confirmation of such a diagnosis were included. Patients were split into two groups according to the presence of histological evidence of transmural bowel ischemia (case group) or partial bowel ischemia (control group). CT images were reviewed for findings of ischemia, including mural thickening, pneumatosis, bowel distension, portomesenteric venous gas and arterial or venous thrombi.
RESULTS: A total of 248 subjects who underwent surgery for bowel ischemia were identified. Among the 208 subjects enrolled in our study, transmural bowel necrosis was identified in 121 subjects (case group), and partial bowel necrosis was identified in 87 subjects (control group). Based on CT findings, including mural thickening, bowel distension, pneumatosis, pneumatosis plus portomesenteric venous gas and presence of thrombi or emboli, there were no significant differences between the case and control groups. The concomitant presence of pneumatosis and porto-mesenteric venous gas showed an odds ratio of 1.95 (95%CI: 0.491-7.775, P = 0.342) for the presence of transmural necrosis. The presence of pneumatosis plus porto-mesenteric venous gas exhibited good specificity (83%) but low sensitivity (17%) in the identification of transmural bowel infarction. Accordingly, the positive and negative predictive values were 60% and 17%, respectively.
CONCLUSION: Although pneumatosis plus porto-mesenteric venous gas is associated with bowel ischemia, we have demonstrated that their co-occurrence cannot be used as diagnostic signs of transmural necrosis.
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