Case presentation including intraoperative photos and management review of a 38 year old male presenting with the potentially serious acute mesenteric ischaemia syndrome. Dr. Mohamad Al-Gailani FRCS Consultant Surgeon Al Hammadi Hospital, Nuzha Riyadh KSA 2018

1. ACUTE ABDOMEN
IN DISGUISE!
CASE PRESENTATION
DR. MOHAMAD AL-GAILANI FRCS
‫الكيالني‬ ‫محمد‬ ‫الدكتور‬
CONSULTANT SURGEON SURGEON
KSA

2. THE CASE:
38 Year old Male
with
Acute Abdominal Pain
DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 2

3. E.R
JANUARY 2018, 11:53 AM
38 Year Old Male
•5 days non specific central abdominal pain increasing with
time
•No vomiting, no diarrhoea, no urinary symptoms
•No past such history
•No Allergies
•No Family History of IBD
•Fit otherwise
DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 3

4. On Exam
TEMP 36.4 C
PULSE 68/MINUTE
BP 140/88 MM HG
RESPIRATORY RATE 18/MINUTE
SPO2 98%
•In pain, but moving freely
•Abdomen soft, Non specific
deep tenderness, No guarding
•Bowel sounds normal
•PR Empty Rectum, No Blood
DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 4

5. INVESTIGATIONS
•HB 15.8 G/DL
•WCC 10.9 PCMM
•PLATLETS 197 PCMM
•PROTH TIME 13.9 SEC
oAPTT 34 SEC
oINR 1.2
CREATININE 0.73 MG/DL
Na 138 MMOL/L
K 4 MMOL/L
AST 34 U/L
ALK PHOS 98 U/L
LIPASE 26 U/L
LDH 215 U/L
LACTIC ACID 1.5 MMOL/L
C-REACTIVE PROTEIN 117.8
DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 5

6. ABDOMINAL ULTRASOUND
•Mild amount of intraperitoneal pelvi-abdominal free
fluid at the Hepato-Renal Pouch & Right Iliac Fossa
•Minimal right pleural effusion
•Otherwise normal
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7. DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 7
• CHEST XRAY: NORMAL
NO AIR UNDER DIAPHGRAM

8. DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 8
AXR ERECTAXR SUPINE

9. MANAGEMENT
•Admit for inpatient observations
•Fluids only per oral
•Analgesic
•CT Abdomen
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10. INPATIENT OBSERVATIONS
•All observations remained stable
•Apyrexial, normal pulse, BP, Respiratory Rate & SpO2
•Increasing analgesic requirements
•Slightly increased non specific abdominal tenderness
DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 10

11. ABDOMINAL CT
Findings:
•Short thickened segment
of upper jejunum
•No free gas
•No fluid collection
•No intestinal obstruction
Differential Diagnosis:
oMesenteric Ischaemic
oCohn’s Disease
oIntestinal lymphoma
DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 11

12. MANAGEMENT DECISION
•In view of:
oCT findings
oCRP 117.8
oContinuing abdominal pain despite few physical signs
•Mesenteric Ischaemia can’t be ruled out!
Proceed with Emergency Exploratory Laparotomy
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13. EMERGENCY EXPLORATORY
LAPAROTOMY
February 2018

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28 CM JEJUNAL SEGMENT
DR. GAILANI
OPERATIVE FINDINGS
• Ischaemic Bowel
• 28 cm Jejunal Segment
• 28 cm from DJ Flexure
• No Intestinal Obstruction
• Rest of Bowel All Normal

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ISCHAEMIC JEJUNUM
OPERATIVE FINDINGS

16. DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 16
MOBILIZATION OF ISCHAEMIC SEGMENT
OPERATIVE
PROCEDURE
1

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SIDE-TO-SIDE
JEJUNO-JEJUNOSTOMY
2-LAYER CONTINUOUS
ANASTOMOSIS
OPERATIVE
PROCEDURE
2

18. POSTOPERATIVE
•ITU recovery:
•2 days
•Surgical Ward:
•1 night
•Discharged
•3rd Postoperative Day
•All Bloods and
Observations Stable
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19. HISTOPATHOLOGY:
Mesenteric Ischaemia
•Thickened oedematous wall affecting all layers with
mucosal ulcerations
•Foci of muscle necrosis & intra vascular thrombi
•No Neoplasia, No Inflammatory Bowel Disease
•Resection margins healthy
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20. THROMBOPHELIA INVESTIGATIONS
FACTOR V LEIDIN: Absence of Mutation
PROTEIN C ASSAY: 98% (70-140%)
PROTEIN S ASSAY: 99% (65-140%)
LUPUS ANTICOAGULANT: 1.2 (1.2-1.5 WEAKLY PRESENT)
*((LA1 45 SEC, LA2 37.3 SEC, LA1/LA2 RATION 1.2))
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21. DISCHARGE & FOLLOW-UP
Discharged on:
•Aspirin 100 mg/ day
Follow Up at:
•2 weeks
•5 weeks
•Well
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22. THE ACUTE MESENTERIC ISCHAEMIA
SYNDROME
DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 22

23. ACUTE MESENTERIC ISCHAEMIA
•Inadequate blood flow through the mesenteric vessels resulting in
ischemia and eventual gangrene of the bowel wall.
•Potentially life-threatening condition.
•Symptoms are nonspecific initially, before evidence of peritonitis
presents.
•Thus, diagnosis and treatment are often delayed until the disease is
advanced.
DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 23

24. TYPES
OCCLUSIVE 80%
ARTERIAL
Embolic Occlusion 50%
Thrombotic Occlusion 25%
VENOUS
Thrombotic Venous Occlusion 5%
NON-OCCLUSIVE 20%
Vasospasm
Low Cardiac Output
DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 24
Acute mesenteric
ischaemia

25. Occlusive Mesenteric Ischemia (80%)
ARTERIAL EMBOLIC:
oCardiac Emboli
oAortic Emboli
oArterial Emboli
ARTERIAL THROMBOTIC:
Atherosclerotic vascular disease
(most common)
Aortic aneurysm, Aortic dissection
Arteritis
Decreased cardiac output from MI or
CHF
Dehydration from any cause
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26. MESENTERIC VENOUS THROMBOSIS (5%)
*Hypercoagulability
•Polycythaemia Vera (Most
Common)
•Thrombophilia:
1. Protein C & S Deficiency
2. Antithrombin III Deficiency
3. Factor V Leiden Mutation
4. Dysfibrinogenemia
5. Abnormal Plasminogen
•Thrombocytosis
•Sickle Cell Disease
•Pregnancy
•Oral Contraceptive
DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 26

27. MESENTERIC VENOUS THROMBOSIS (5%)
**Other causes
Paraneoplastic syndrome:
tumour causing venous
compression or
hypercoagulability
Intra-abdominal sepsis
Portal hypertension
Venous trauma from
accidents or surgery E.G.
Laparoscopic colonic surgery
Increased intra-abdominal
pressure from
pneumoperitoneum
Pancreatitis
Decompression sickness
DR. MOHAMAD AL-GAILANI FRCS ACUTE ABDOMEN IN DISGUISE! APRIL 2018 27

28. Non-Occlusive Mesenteric Ischaemia (20%)
Hypotension
Vasopressors
Ergotamines
Cocaine
Digitalis
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29. PRESENTATION
•Pain that is disproportionate to physical examination
findings.
•Typically pain is moderate to severe, diffuse,
nonlocalized, constant, and sometimes colicky.
• In the presence of risk factors especially age older
than 60 years
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30. EXAMINATION
•Normal abdominal examination in the face of severe
abdominal pain.
•Physical signs are few and nonspecific, tenderness is
minimal to nonexistent.
•Peritoneal signs develop late, when infarction with
necrosis or perforation occurs.
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31. DIAGNOSTIC WORKUP
•Bloods, AXR, US are Non Specific
•*ESR, *CRP
•*CT
•MRI
•High index of suspicion especially in elderly with
disproportionate pain to physical findings!
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32. TREATMENT:
TIMELY SURGERY!
•Exploratory laparotomy
•Assessment of extent
•Resection
•Primary Anastomosis?
•Double Barrel Stoma?
•Second look in 48 hours with closure of stoma?
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33. MEDICAL MANAGEMENT
Thrombophilia screen
VTE prophylaxis:
1. Papaverine
2. Heparin
3. Low-Molecular-Weight Heparin (LMWH)
4. Warfarin
5. Rivaroxaban
6. Aspirin
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34. COMPLICATIONS
•Gangrene of bowel
•Sepsis and Septic Shock
•Multi Organ Dysfunction Syndrome
•Death (up to 93%)
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35. •Mortality average 71% (range, 59-93%)
•Even with good treatment, as many as 50-80% of
patients die
•Risk of re-thrombosis is high
•Short-Gut Syndrome Total Parenteral Nutrition (TPN)
for life
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36. “Occlusion of the mesenteric vessels is apt to be regarded
as one of those conditions of which the diagnosis is
impossible, the prognosis hopeless, and the treatment
almost useless”
A J Cokkinis FRCS 1930
Not much has changed since!
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37. ACUTE MESENTERIC ISCHAEMIA
Morbid Condition
High Mortality Rate
Pain Out of Proportion to Signs
High Index of Suspicion Essential
Early Diagnosis and Treatment is Crucial
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