VCOM Research Day Program Book 2023
Medical Resident Research Case Reports
12 Chronic Mesenteric Ischemia
Rebekah Kim, DO; Tara Mancl, MD Corresponding author: Rebekah.Kim@LPNT.NET
SOVAH Health Internal Medicine Residency Program
CBC unremarkable, Magnesium 1.0, Albumin 2.6, Lipase 225, Bilirubin 0.5, TSH 6.23. Hemoccult positive. Urinalysis was positive for infection. Clinical course: The patient was admitted and started on supportive measures, including intravenous fluids, bowel rest, pain management, and nasogastric tube to suction for gastric decompression. Despite these measures, the patient’s symptoms did not improve, and a small bowel series showed persistent SBO. The patient was eventually taken into the operating room for laparotomy. In the OR, the patient was found to have contrast that leaked around the bowels. The small intestine appeared dusky, with numerous ulcers throughout, some of which were perforated. No arterial blood flow was identified on the omentum using a handheld doppler. The patient’s operative findings were consistent with Chronic Mesenteric Ischemia (CMI). The patient and family were informed of the diagnosis, prognosis, and treatment, including revascularization at a tertiary center. After multiple goals of care conversations, they opted to go home with home hospice.
Context: Chronic mesenteric ischemia (CMI) is an uncommon yet important diagnosis that needs timely treatment. Case report: 78-year-old Caucasian female presented to the ED with intractable nausea, vomiting, abdominal pain, and diarrhea. CT scan showed small bowel obstruction. Medical history: Systemic lupus erythematosus, hypertension, hyperlipidemia, hypothyroidism, and atrial fibrillation on chronic anticoagulation therapy. Family history: Diabetes. Social history: Lives at home with a daughter, a former smoker of 20 pack years, and denies alcohol or illicit drug use. Pertinent ROS: Unintentional weight loss of 50 pounds and dark liquid stools. Pertinent physical exam: Abdomen – soft, mild tenderness with palpation in all four quadrants, diminished bowel sounds. Pertinent labs:
Comment: CMI is caused by atherosclerotic narrowing of the origins of the celiac or superior mesenteric artery. Risk factors include atrial fibrillation, atherosclerotic occlusive disease, and vasculitis from conditions such as SLE. The patient presents with recurrent abdominal pain after eating, a disorder called “intestinal angina,” which leads to food aversion and weight loss. CT angiography is the preferred diagnostic test. Revascularization via open surgical reconstruction or percutaneous transluminal angioplasty is possible, which comes with its risks. Conclusion: CMI is challenging to diagnose, given its overlap of presentations with other abdominal conditions. However, early recognition and treatment are vital in restoring blood flow to ischemic bowels.
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