Gastro Case Challenge: After Routine Procedure, 52-Year-Old Has Black Vomit, Diarrhea

Sarah El-Nakeep, MD


February 27, 2023


The patient in this case had arterial thrombosis and bowel ischemia. Acute mesenteric ischemia resulted from ligation of the celiac artery, with complete thrombosis of the mesenteric vessels.

Intestinal ultrasonography showed signs of acute bowel ischemia (Figures 2, 3, and 4), in the form of mural hyperechogenicity, and increased bowel thickening with hypoechogenicity of the submucosal layers and loss of stratification of the bowel layers. The absence of a Doppler sign indicated ischemia rather than inflammation.[1] Colonoscopy showed ulceration and hyperemia with areas of patchy ischemia.

Figure 2.

Figure 3.

Figure 4.

Mesenteric ischemia is either acute or chronic and is classified etiologically as nonocclusive, venous occlusion, or arterial occlusion. Because this condition is difficult to identify, an accurate diagnosis is made in only one third of patients preoperatively. The typical triad of symptoms in bowel ischemia, which consists of fever, hematochezia, and abdominal pain, occurs in only one third of patients. Chronic bowel ischemia may present with weight loss in the absence of abdominal pain.[2] The thrombus may appear in the early stages of the obstruction.[1]

The patient smokes regularly and has a history of hyperlipidemia, which suggests atherosclerotic disease. Various case reports have shown mesenteric ischemia after laparoscopic procedures, in which most patients have a history of atherosclerosis. The elevation of the intraabdominal pressure during the procedure is linked to abdominal hypertension and splanchnic ischemia, especially in atherosclerotic vessels.[3] Thus, using intermittent decompression gas in patients who are at higher risk for the induction of pneumoperitoneum should be avoided.[5] Moreover, the elevation of the intraabdominal pressure in pneumoperitoneum creation during the laparoscopic procedure can cause a decreased arterial perfusion and ischemia of the mesenteric organs, even in the absence of atherosclerosis.[6]

This patient's kidney function tests indicated prerenal dehydration; thus, CT with contrast was postponed until she was resuscitated with fluids. Antibiotics were given because of suspected acute ascending cholangitis; however, the condition did not resolve because this was a case of bowel ischemia. Magnetic resonance cholangiopancreatography (MRCP) showed no biliary dilation, and the results of laboratory investigations (total and direct bilirubin, GGT, and ALP levels) were normal. However, the bacteremia was secondary to the bowel ischemia, which could proceed to full-blown septic shock.[3]


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