S

Guess Again. When the actual diagnosis is the last thing on your differential.

History of Present Illness

S 35yoF PMH morbid obesity & asthma w/ epigastric abd pain x5 days

S Gradual onset

S Aching, bloating

S Unsure about radiation

S “More than her usual helping of spicy food a few days before symptoms began”

S Has tried 2 aspirin this AM, without relief

S 2 prior C-sections, denies EtOH, sick contacts, travel hx, chronic NSAID use

S LMP 17 days prior. Uses OCP.

Review of Systems

S Constitutional: Negative for fever and fatigue.

S HEENT: Negative for visual disturbance, rhinorrhea.

S Respiratory: Negative for SOB.

S Cardiovascular: Negative for CP.

S Gastrointestinal: Negative for vomiting, positive for nausea (initially a few days prior, resolved), abdominal pain, diarrhea (2 loose BM this AM)

S Endocrine: Negative.

S Genitourinary: Negative for dysuria, hematuria.

S Musculoskeletal: Negative for back pain.

S Skin: Negative for rash.

S Neurological: Negative for HA.

S Hematological: Does not bruise/bleed easily.

Physical Examination

S Vitals: 36.9C, BP 161/89, HR 92, RR 16, SpO2 97%, BMI 40.23

S Constitutional: No distress. Morbidly obese.

S Neuro:Alert and oriented to person, place, time.

S HEENT:Normocephalic, atraumatic. No eye discharge. Normal neck ROM.

S Cardiovascular: Tachycardic.

S Lungs/Chest: Effort normal, no wheezes.

S Abdomen: Soft, BS (+), no palpable masses, no rebound, no bruit, no CVA tenderness. Epigastric tenderness. Rectal?

S MSK: Normal ROM.

S Skin: No rash

Differential Diagnosis

S GI Causes:

S Biliary Disease

S Pancreatitis

S PUD

S GERD

S Gastritis

S Small bowel obstruction

S IBD

S Abd CA

S Non GI causes:

S DKA

S Pregnancy/ectopic

S Pneumonia

35yoF w/ epigastric abd pain x5d

Investigative Studies

S DD: gastritis vs. GERD vs. pancreatitis vs. UTI

S U/A (-)

S U Preg (-)

ED Course

S Pt given Maalox, reports “patient feels better”.

S Nursing note: “Pt reports no improvement with Maalox.”

S D/Ced home with limited PPI & told to lose weight

Return to the ED

S Pt returns 12 days later, f/u with PCP in interim, abd pain unresolved, ROS same with vomiting now.

S Vitals: 36.6C, BP 165/102, HR 105, RR 20, SpO2 100%, BMI 45.71

S Physical Exam (same except):

S Abd: Soft with diffuse tenderness worst in epigastric and LUQ.

S DD: Pancreatitis, gallstones

S Tx: IVF, analgesics, anti-emetics

Return to the ED

S Upreg (-)

S U/A: Large bld, Protein 100, Ketones 80, Leuk Est trace, RBC 802, otherwise normal. Patient on menstrual period.

S Lactate 2.0

S Lytes: Na 139, K 3.5, Cl 102, Bicarb 23, AG 14, Crt 0.74, Glc 132, Ca 8.9

S Coags initially deranged, repeat WNL

S LFTs: Mildly inc ALT 63; Dec alb 2.9 (3.7-4.8); AST, TBili, DBili, Alk Phos WNL

CT Abd w/ contrast

CT Abd w/ contrast

S 1. Portal vein thrombosis. Distal superior mesenteric vein thrombosis.

S 2. Significant wall thickening and mucosal enhancement of the mid to distal small bowel suggests ischemia in the setting of portal vein and superior mesentery vein thrombosis. Inflammatory or infectious etiology is considered less likely.

S 3. Mild degree of ascites throughout the abdomen.

Management

S Acute Care Surgery consult

S Start heparin drip, dilaudid for pain control

S Admit to SICU

Hospital Course

S Started on high-intensity heparin, pain control, IVF, admit to SICU

S (Day 4) Worsening WBC, repeat CT Abd showed worsening bowel ischemia, IR thrombolysis unsuccessful

S (Day 6) IR refused 2nd attempt 2 days later because procedure would require t-PA and patient had multiple a-line attempts

S US Abd reveal IVC, hepatic, portal vein patency (no comment about SMV)

S (Day 10) AKI, fluid overload, respiratory failure

S (Day 17) Intra-abdominal E. faecalis abscess, IR drainage, ABs started.

S (Day 27) Febrile again, 2nd abdominal abscess seen on CT Abd, IR unable to aspirate

S (Day 40) Discharge after bridging to coumadin subQ hep

Hospital Course

S Discharged after 40-day hospital stay on Dec 16th

S From Dec 16th to Feb 16th, patient has 4 separate admissions for abd pain, not tolerating po, nausea, spends 41/59 total days in hospital

S 2 additional microperforations of small bowel managed with antibiotics, eventually complicated by stricture of small bowel s/p lysis of adhesions and 20cm resection of jejunum on Jan 6th.

S Other complications:

S “Failure to thrive”, requiring TPN (BMI dropped from 44 to 36 with substantial deconditioning)

S C Diff, completed Ab course.

Hospital Course

S Hematology hypercoaguability workup:

S Only factor IDed was OCP use.

S Extensive workup was negative, including:

S Factor V Leiden, Heparin-induced plt antibody, anti-nuclear

Ab, anti-cardiolipin antibodies, beta-2 microglobulin, activated

protein C resistance, normalized activated protein C resistance

ratio, dilute Russell’s viper venom time, JAK-2 mutation.

S Hematology will re-evaluate duration of anticoagulation in

3 months.

Acute Mesenteric Ischemia

(AMI)

S Cokkinis, 1926: “Occlusion of mesenteric vessels…diagnosis is impossible, prognosis is hopeless, treatment almost useless.”

S Mortality remains 60-80%

S Acute vs. Chronic (eg. intestinal angina)

S Categories: Arterial embolus (50%), arterial thrombosis, non-occlusive ischemia, venous thrombosis (5-15%)

S Absolute ischemia: histo changes in 15 min., mucosal sloughing in 3 hrs, transmural necrosis in 6 hrs

Mesenteric Venous Thrombosis

S Most frequently involves the SMV and branches

S Causes:

S Virchow’s Triad:

S Hypercoagulability

S >75% have underlying thrombotic disorder (eg. Factor V Leiden, AT-III deficiency, Protein C deficiency)

S 9-18% w/ OCP use in young women

S Endothelial injury

S Intra-abd inflammation (pancreatitis, malignancy, IBD, trauma)

S s/p splenectomy

S Stasis

S Portal HTN

S Abdominal mass causing venous compression

AMI: History & Physical

S Arterial embolus/thrombus: Sudden onset (hours) of poorly localized abdominal pain w/ N/V

S Venous thrombus: Recent onset (few days) of poorly localized abdominal pain

S 1/3 of arterial embolic and ½ of mesenteric venous thrombosis have hx PE, DVT, ischemic stroke

S Pain out of proportion to physical exam

S Initially, visceral pain soft abd, vague; then parietal peritoneum = somatic pain sharp, guarding

S Heme-positive stool

S Commonly, soft abd; however, peritoneal signs = Ex-lap

AMI: Diagnostic Studies

S Positive lab studies nonspecific, non-sensitive – inc WBC, inc hct because of hemoconcentration, metabolic acidosis

S Did someone say Biomarkers?

S D-dimer, IL-6, serum ischemia-modified albumin, lactate have all been studied

S One small study showed lactate was 100% sensitive, poorly specific; unclear of true sensitivity

S I guess we need to get imaging…

S AGA guidelines indicate angiography as gold standard, however this was before multiple studies demonstrated multidetector CT scanners 96% sensitive and 94% specific.

S Watch out for pneumatosis intestinalis and portal venous gas bowel infarction

S Mesenteric angiography, if available, allows for both diagnosis and treatment

S Duplex sonography is a useful adjunct imaging modality, however it has limited sensitivity beyond the proximal main vessel (70-89% sensitive).

AMI: Management

S Initial goals aggressive fluid resuscitation and hemodynamic

stabilization, if necessary.

S Arterial

S Vasopressors? Dobutamine, dopamine and milrinone have

been shown to cause less mesenteric vasoconstriction.

S Ex lap for peritoneal signs indicating infarction or perforation

S Can use thrombolytics, angioplasty, embolectomy, vascular

stenting.

AMI: Management

S Venous

S Mainstay of treatment is anti-coagulation, though they can receive same interventions as arterial.

S Not if portal HTN.

S Watch out for varices and bleeding – contraindication to anti-coagulation.

S F/U CT in 24-48 hrs to make sure small bowels are not progressing to transmural necrosis.

S Traditionally, OR determined by peritoneal signs, but they may underestimate the severity of ischemia

S Bowel-wall thickness and enhancement has been suggested as a surrogate

S May progress to SBO.

Mesenteric Venous Thrombosis:

Novel Interventions

S Catheter-based thrombolysis techniques have little to no evidence, considered if poor response to systemic anti-coagulation

S More studies needed to assess safety and efficacy

S Transvenous thrombolysis/thrombectomy performed by transhepatic, transfemoral, transjugular approaches

S Success rates?

S In a case series of 28 patients, 82% had partial or complete lysis, 87% had improvement of symptoms. None required resection, several had serious bleeding, two died of refractory thrombosis in setting of sepsis.

S In a retrospective review of 25 patients, catheter-directed thrombolysis had similar mortality to surgically treated group, but had shorter hospital stays, earlier resumption of po nutrition, lower treatment costs.

Our Patient

S Poor thrombolysis in response to heparin, required catheter-

directed approach which failed.

S Would detecting the SMV clot during first stay with earlier

treatment have led to better response to systemic heparin?

S Thoughts, questions, or comments?

References

S Rosen's emergency medicine : concepts and clinical practice / editor-in-chief, John A. Marx; senior editors, Robert S. Hockberger, Ron M. Walls ; editors, Michelle H. Biros … [et al.].—8th ed. Disorders of the Small Intestine, Acute Mesenteric Ischemia.

S Harnik IG, Brandt LJ. Mesenteric venous thrombosis. Vasc Med 2010; 15:407.

S Rhee RY, Gloviczki P, Mendonca CT, et al. Mesenteric venous thrombosis: still a lethal disease in the 1990s. J Vasc Surg 1994; 20:688.

S McKinsey JF, Gewertz BL. Acute mesenteric ischemia. Surg Clin North Am 1997; 77:307.

S Boley SJ, Kaleya RN, Brandt LJ. Mesenteric venous thrombosis. Surg Clin North Am 1992; 72:183.

S Acosta S, Alhadad A, Svensson P, Ekberg O. Epidemiology, risk and prognostic factors in mesenteric venous thrombosis. Br J Surg 2008; 95:1245.

S Brunaud L, Antunes L, Collinet-Adler S, et al. Acute mesenteric venous thrombosis: case for nonoperative management. J Vasc Surg 2001; 34:673.

S Yang SF, Liu BC, Ding WW, et al. Initial transcatheter thrombolysis for acute superior mesenteric venous thrombosis. World J Gastroenterol 2014; 20:5483.