ACUTE MESENTERIC ISCHEMIA: A CHALLENGE FOR

THE ACUTE CARE SURGEON

dr. Ade Tan Reza, Sp.B, dr. Andriana Purnama, MM, Sp.B, KBD

DIGESTIVE SURGICAL DIVISION DEPARTMENT OF FACULTY OF MEDICINE PADJAJARAN UNIVERSITY/

HASAN SADIKIN HOSPITAL BANDUNG, JAWA BARAT- INDONESIAN

INTRODUCTION

Acute mesenteric ischemia is considered uncommon, but it appears to be more frequent cause of acute abdomen than appendicitis or ruptured
abdominal aortic aneurysm in elderly patients. Surgical treatment without revascularization is associated with high overall mortality, up to 80%.
The modern treatment of acute mesenteric ischemia requires collaboration of gastrointestinal surgeons, vascular surgeons, and interventional
radiologists. Early revascularization may reduce the overall mortality associated with acute mesenteric ischemia by up to 50%. Clinical suspicion
and contrast-enhanced computed tomography performed at early stage are keys to improve outcomes of acute mesenteric ischemia treatment.

CASE

The patient on behalf of Mr. B/ 56 years old complains of heartburn and upper right. Pain has been felt since 4 days
of SMRS. The pain comes and goes and gets worse. The pain started from the pit of the heart since 3 months ago
which radiated to the lower right abdomen. Complaints accompanied by nausea (+), vomiting (-). Complaints are not
accompanied by fever. Complaints of difficult bowel movements and flatus were denied. BAK no complaints. The
patient has a history of high blood pressure (+) in the past 5 years and used to take aspirin but not routinely. The
patient has a known history of DM since 3 months ago with the highest blood sugar 340 mg/dl and routinely uses
novorapid 3x10 units and lantus 1x18 night unit.and. History of taking anti-pain medication (-), history of taking
herbal medicine. The patient denied previous complaints of weight loss. Currently the patient weighs 90kg with a
height of 160cm.

DISCUSSION

Acute mesenteric ischemia (AMI) may be defined as a sudden interruption of the blood supply to a segment of the small intestine, leading to
ischemia, cellular damage, intestinal necrosis, and eventually patient death if untreated. In this case, a 56-year-old man
came with complaints of pain in the pit of the stomach and right upper abdomen since 4 days ago. The patient has a
history of high blood pressure and diabetes mellitus. In cases of extensive infarction of most of the small bowel with
or without a portion of the colon, the surgeon could face with a philosophical decision whether to do anything.
Resection of the entire involved bowel will result in short bowel syndrome with its serious associated consequences.
This may not be a preferable state, particularly in elderly infirm patients, who may not tolerate long-term parenteral
nutrition. A preoperative discussion with the patient and the patient’s family concerning these issues is warranted and
often necessary peri-operatively as well so that an agreeable plan can be reached.

CONCLUSION

AMI is a true surgical emergency. First and foremost, important evidence is a high index of suspicion based on the
combination of history of abrupt onset of abdominal pain, acidosis, and organ failure. This clinical scenario should prompt imaging (CTA) in
order to establish the diagnosis. In parallel with rapid resuscitation and after careful assessment of the CTA, the patient should be explored to
assess bowel viability, re-establish vascular flow, and resect non-viable bowel. Subsequently, the employment of damage control techniques and
continued critical care resuscitation is essential. Planned re-assessment of the bowel with further resection or anastomosis and stoma as needed is
integral. Close cooperation between acute care surgeons, radiologists, anesthetists, and the vascular surgeons is essential

REFERENCES

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