Presentation
Acute abdominal pain associated with vomiting 1 day. No fever. Known case of atrial fibrillation, hypertension, diabetes mellitus, and dyslipidemia.
Patient Data
No abnormal bowel dilatation, air-fluid levels, or pneumoperitoneum is seen. Multiple calcifications are seen in the subcutaneous soft tissues of the abdomen which are compatible with guinea worm disease.
Findings: Total occlusion of the superior mesenteric artery (sparing its proximal 6 cm) and its distal branches is seen. This is associated with hypoenhancement of the mid/distal jejunum, whole ileum, and the ascending colon. Mild mural thickening of the jejunal loops measuring up to 8 mm is also seen. No pneumatosis intestinalis, abnormal bowel dilatation, or pneumoperitoneum is seen. Right renal parapelvic cyst and wedge compression fracture of the L1 vertebra. Multiple calcifications are seen between the muscles of the abdominal wall and gluteal regions.
Impression: Thrombosis of the superior mesenteric artery (sparing its proximal 6 cm) and its distal branches, associated with arterial bowel ischemia of the mid/ distal jejunum, ileum, and the ascending colon.
Ischemic, non-viable jejunum 20 cm from the duodenojejunal junction, whole ileum and proximal colon (cecum and ascending colon till hepatic flexure). The affected bowel was resected.
Case Discussion
The patient was poorly compliant with the management of his medical diseases. There was a past history of multiple cerebral infarctions. There was also a history of traumatic L1 vertebral fracture.
Laboratory investigations showed elevated WBC=31 x 109/L (4.00-11.00), Lactic acid=4.2 mmol/L (0.50-2.20), CRP=89 mg/L (≤1.20), and random blood glucose=23 mmol/L (2.9-7.8).
Intra-operative findings of the laparotomy: Ischemic small bowel 20 cm from the duodenojejunal junction, and non-viable cecum & ascending colon till hepatic flexure. Resection of the small bowel and ascending colon was done with jejunotransverse colon anastomosis.
Pathological analysis of the resected bowel showed diffuse ischemic necrosis of the bowel mucosa with edema and vascular congestion of the submucosa.
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