Acute mesenteric ischemia as cause of acute abdomen

Acute mesenteric ischemia is caused by the occlusion of the mesenteric vessels, which leads to bowel necrosis. Mortality of the acute mesenteric ischemia is high. 75% of the cases is due to embolism and thrombosis of the superior mesenteric artery (AMS), 20% is non-occlusive mesenteric ischemia and 5% is mesenterial vein thrombosis. Signs and symptoms-like meteorism, nausea, vomiting, bowel paralysis, with or without bloody stools-are not specific. Laboratory results such as elevated wbc, CRP, D-dimer are non-specific either. Diffuse intermittent abdominal pain and muscle tenderness show the development of peritonitis. The real diagnosis is revealed during laparotomy. Arterial and venous occlusion could be diagnosed by CT/MRI angiography. The basis of the treatment is the prompt diagnosis, aggressive intervention (rehydratation, antibiotic profilaxis, anticoagulant therapy, vasodilatators, radiology intevention). If peritonitis occurs laparotomy should be performed, in order to restore the blood flow and resect the unviable bowel. The second look operation should be considered.

The first case was an 82-year-old woman with hypertension.2 days before her admission she suffered from meteorism, bloody stools and vomiting. ECG showed atrial fibrillation, which was unknown earlier. Physical examination showed diffuse abdominal pain, no bowel movements, rectal bleeding. Laboratory tests revealed elevated CRP, wbc and low K-level. X-ray showed the signs of ileus. Laparotomy was performed which proved the AMS embolism and total small bowel necrosis. After the operation the patient died. The second patient was a 33-year-old male, who earlier suffered from several deep vein thrombosis, treated with warfarin but decided to leave it. Before his admission he had upper abdominal pain, meteorism, vomiting. Physical findings were right abdominal pain, with tenderness. X-ray showed the signs of small bowel ileus. During the operation we found mesenteric vein thrombosis and extended small bowel necrosis. 120cm of the jejunum was resected. 2 weeks later the patient was discharged from the hospital with life long anticoagulant therapy.