Odysseys of George

From : A Lethal Rare Event

This is a rare event. It is usually due to sudden reduction of blood flow to the intestine. The reason for it could either be from a blood clot that has shifted away(emboli) and impacted an artery that carries blood to the intestine or a blood clot forming at the site of the artery(thrombosis).An emboli’s source are usually from the heart or a abnormal dilatation of the aorta, e.g. irregular pulses (arryhtmias), a disease involving the valves of the heart, a dilated and failing heart, or an aneurysm. A thrombus however usually occurs when there is stasis of the blood flow, some blood disorders which causes the blood to clot or a damage to the internal lining of the vessel.This damage is usually due to changes which we call artherosclerotic changes which is secondary to diabetes mellitus, hypertension or high cholesterol levels(hyperlipidaemia), smoking and aging. Mesenteric artery stenosis is found in 17.5% of independent elderly adults.

So, upon seeing this, I recalled the history. His complaints and of his wife fits correctly. He had all the risk factors. The problem is that it has been a few days now and he is very ill and also very septic. The figures were running in my mind. Because of the delay in diagnosis, mortality rate is of 45-65%. When more than half the bowel is removed, mortality rates of up to 80% have been reported The studies have shown that mortality rates are highest for patients with arterial thrombosis (70-87%), followed by nonocclusive mesenteric ischemia (70-80%), arterial embolism (66-71%), and venous thrombosis (44%).

I rechecked his bowels again making sure that it is no more viable and assessed the length involved - which was approximately half the length of his small bowel.

Now came the next dilemma — to call it the quits and close the abdomen or remove the dead intestine? To close, he will surely die. To resect, well he will have that 20% chance but it will take a little longer. This would increase his risk of developing other complications, the commonest with a background of diabetes and hypertension ( artherosclerosis), would be a heart attack (myocardial infarction, MI) and the other is renal failure. Other possible complications include bleeding, infection,further bowel infarction and prolonged ileus.

So with a decision made, I informed my anaesthetist and proceeded to resect the involved segment. As he was ill, the bowel perfusion is in question and time is of the essence, so I brought out the ends as a stoma rather than to sew (anastomose) the ends together.

He was placed in ICU after surgery. However, he did not look any better. The ileus set in and his kidneys started to shut down. Sadly on the night, three days after surgery he developed the most feared about complication - heart attack - and expired.

Over the past 20 years, diagnosis and treatment of mesenteric ischemia has advanced only minimally. In a review of 57 cases, only 18% of patients were properly diagnosed with mesenteric ischemia before operation or death. Of the 57 patients in this review, 46 died.

This entry was posted on Sunday, October 29th, 2006 at 6:38 pm and is filed under Medical, Health. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.