Mesenteric thrombosis

Mesenteric

Thrombosis

A DIAGNOSTIC

CHALLENGE

GEORGE J. FARHA, M.D. AND FRED W. ROBINSON, M.D., Wichita, Kansas

From Veterans Administration

Center, Wichita, Kansas.

operation with a successfu1 outcome, aIong with a brief mention of other cases in which the diagnosis was entertained. Certain diagnostic cIues we have observed wil1 be discussed. This case represents the onIy patient to have survived this disease at this hospita1 in the Iast ten years. That mesenteric thrombosis is a rare condition is evidenced by the fact that it has been Iisted as “unspecified obstruction” when coded with other causes of intestinal obstruction. (TabIe I.) It is interesting to note that the InternationaI List of Causes of Death does not cIassify mesenteric thrombosis with intestina1 obstruction. An inquiry was made from the MetropoIitan Life Insurance Company, Statistica1 Bureau, and we have been informed that the death rates per IOO,OOOfrom mesenteric infarction in the United States, were as foIIows :*

ESENTERIC THROMBOSIS is an

acute abdominaI catastrophe, usuaIIy manifested by sudden mid-abdomina1 pain, nausea, vomiting, hematemesis and paraIytic iIeus, with a shock-like state. Distention due to infarction of the smaI1 intestine occurs often and is foIIowed by rapid coIIapse and death. When portal vein thrombosis is the cause, it deveIops more sIowIy; or when smaI1 branches are invoIved, these signs may be inconspicuous or some may be absent. Other causes are obstruction of the superior mesenteric artery, either by an emboIus, cIot or gradua1 obstruction. Buerger’s disease has been observed as an etioIogic factor. The mortaIity rate has been variousIy stated from 23 to go per cent [I] and these patients aIways present a diagnostic and therapeutic chaIIenge. The purpose of this paper is to present a case of mesenteric thrombosis diagnosed prior to

M

TABLE CAUSES

OF

INTESTINAL

I

Deatbs

I959 1958

1,895 1,694.

I .o

I957

1,183

0.7

OBSTRUCTION

Coded Diagnoses

Hernia of abdomina1 cavity with obstruction Inguinal hernia causing obstruction. Femoral hernia causing obstruction., UmbiIicaI hernia causing obstruction., Ventral hernia causing obstruction.. . Other specified site causing obstruction. IntestinaI obstruction without hernia. Intussusception......... .._..__.......,. v01vu1us.. Impaction of intestines with obstruction. IntestinaI adhesions with obstruction. Other unspecified obstruction..

Deatb Rate

Year

CASE

I.1

REPORT

J. D., No. AbgTo, a thirty-seven year old white veteran was admitted to the Wichita V. A. Hospital on April g, 1962 with a chief compIaint of abdomina1 pain for approximately four hours. The patient stated that he had been a heavy drinker for fifteen years. Two to three days prior to his admission he had been drinking constantly. This history was incomplete and the patient was unabIe to give a cIear-cut description of his symptoms. He complained onIy of diffuse, generalized, severe abdominal pain. He was unabIe to IocaIize the pain or to give the character or time of the

No. of Cases

I 12 3

;( 5 a

* 6

* Data from Vita1 Statistics-Special Reports, VoIume 54, No. I, of the NationaI Vita1 Statistics Division of the U. S. Department of HeaIth, Education and WeIfare.

32 3

47

American

Journal

of Surgery,

Volume

108, July

1964

Farha and Robinson onset of his pain. He said that the pain gradually increased in severity; that he had frequent vomiting; that he had had no recent or remote hematemesis or melena. He stated that he had had no previous pain of this character. Past history revealed that the patient was hospitaIized at another hospital one and a half years ago for a right sympathectomy because of a “blood clot” in his right leg. He compIained of cIaudication on occasions. His Ieft leg was free of symptoms. Physical examination on admission revealed a temperature of 98%., pulse 100, respiration 20, blood pressure 126/80 mm. Hg. The patient was a we11 developed, we11 nourished, intoxicated young man in acute distress with abdomina1 pain. He was very apprehensive and agitated. It was very difficult to examine this patient accurateIy because he constantly compIained of his pain and demanded immediate reIief. This behavior of the patient produced a marked disturbance on the ward, the nurses were unabIe to confine him to bed, and he wandered around the ward and frequentIy entered the isoIated areas. He was described as a “wild man.” Examination of the head, ear, eye, nose and throat reveaIed no abnorma1 findings. Examination of the abdomen reveaIed a flat, soft abdomen with generaIized tenderness but without specific point tenderness. The patient was unabIe to point to any specific area producing the pain. BoweI sounds were hyperactive. The Iiver, kidneys and spIeen were not paIpabIe and no masses were feIt. There was a well heaIed scar in the right midabdomen from previous sympathectomy. There were no hernias. External genitalia were normaI. Recta1 examination reveaIed good sphincter tone with a mildly enIarged prostate gIand. There was no bIood on the examining glove and there was no tenderness to paIpation. Examination of the lower extremities revealed the right to be sIightIy warmer than the left. There was no atrophy. The right femoral puIse was present and of good tone. PuIsations of the posterior tibiaI, dorsalis pedis and popIitea1 arteries were absent in the right Ieg. FemoraI puIsation on the left side was good. PuIsations of the Ieft popIitea1, Ieft dorsaIis pedis and left posterior tibia1 were present but diminished. NeuroIogic survey was grossIy normaI. He was not cooperative enough for a complete neuroIogic examination. Admission Iaboratory examinations revealed the foIIowing: UrinaIysis showed neutral reaction with specific gravity 1,020; albumin 2 PIUS; sugar trace; biIe negative; serum amyIase 74 units (norma 40 to I 10 units); caIcium 10.5 mg. per cent; phosphorus 2.5 mg. per cent. Admission hemogram reveaIed a white bIood count of 10,850 with 84 neutrophils, 14 Iymphocytes, I monocyte, I eosinophiI, hematocrit 4g per cent and hemogIobin 17.8

w.

IOO m1. Urine porphyrins were negative. Results of serologic tests were negative. Admission flat plate and upright films of the abdomen revealed a moderate amount of Iarge bowel gas with a minimum amount in the small bowel. There was no definite evidence of intestinal obstruction. During the first ten hours of his admission the patient continued to complain of abdominal pain which he claimed was getting worse. However, the abdomina1 findings were essentially negative with the exception of some diffuse tenderness on paIpation. Bowel sounds remained active. At 8 P.M. the patient was re-examined and at this time he was able to IocaIize the pain and pointed to the right lower quadrant. His temperature had increased to 103.6’~. with a p&e of 140 per minute. PaIpation revealed mild voluntary guarding of the right side of the abdomen. A repeat Ieukocyte count reveaIed 8,300 white bIood ceIIs with 54 neutrophils, 24 bands, 20 Iymphocytes and 2 monocytes. A repeat of the ffat and upright fiIms of the abdomen reveaIed much air in the smaI1 bowe1 with numerous fluid IeveIs. There was no Iarge bowel distention. At this time the diagnosis of bowe1 obstruction secondary to mesenteric thrombosis was made, and at g:oo P.M. the patient was taken to the operating room. An expIoratory Iaparotomy was performed and 360 cm. of bIack, gangrenous smaI1 bowel were removed in two segments, leaving the patient with 60 cm. of iIeum and jejunum, incIuding 30 cm. of dista1 ileum. The resected bowe1 contained much dark bIood. The pathoIogic diagnosis was gangrene of the smaI1 bowe1. The day of the operation the patient was given 30 mg. of papaverine every two hours for forty-six hours. He aIso received heparin and Coumadin.@ AnticoaguIation was continued unti1 ApriI 26, 1962. PostoperativeIy, the patient had two to three loose bowel movements a day. However, at the time of his discharge he was having onIy one or two well formed stools dairy. He had no diffIcuIty in maintaining eIectroIyte baIance. On ApriI IO, 1962, sodium was 130 mEq./L.; potassium 4.1 mEq./L.; chIoride 102 mEq./L. and carbon dioxide 27.5 mEq. A right femoraI arteriogram was performed. The femora1 artery and the profunda femoris demonstrated no atheromatous pIaques or narrowing. However, the smaI1 vesseIs below the knee were markedIy decreased in size. The patient was discharged on ApriI 27, 1962 after 17 pounds Ioss of weight. AIcohoI and smoking were forbidden and he was to be foIIowed periodicaIIy for nutritiona d&uIties. COMMENTS Mesenteric thrombosis is not a common entity. It represents about 2 per cent of a11 intestina1 obstruction [2]. In&ding the re-

Mesenteric

Thrombosis diagnosis of this acute condition but, s&ice it to say, that a few hours spent in getting certain laboratory procedures to ruIe out acute pancreatitis, acute coronary occIusion, acute cholecystitis, appendicitis, and other conditions, are we11 spent. The rarity of this condition shouId not decrease the physician’s suspicion of its presence, for diagnoses should not be made on a statistica basis onIv. 3. Fiat and upright “scout films” of the abdomen, aIthough negative at the onset of the disease, may demonstrate paraIytic iIeus or a picture of smaI1 bowe1 obstruction a few hours pattern of gas-diIated Iater. The “cIassic” smaI1 and Iarge bowe1 to the region of the splenic fIexure in acute superior mesenteric artery 0ccIusion is rare [3,4]. 4. AI1 etiologic factors shouId be evaIuated. This, of course, depends upon the art of history taking which is mandatory for making a correct diagnosis and upon a knowledge of the pathophysioIogy of the entity. 5. The presence of bIood in the gastrointestina tract shouId increase one’s index of suspicion in cases Iike these. Each of our patients had some form of bIood in the gastrointestina1 tract. Some of them denied meIena but, when further questioned, answered that they did not “Iook at their stooIs.” Recta1 examination in these patients shouId be done not onIy on admission but aIso several times during the earIy hours of hospitaIization to detect the presence of bIoody stooIs. By the same token, their vomitus or the fluid that is sucked out through the nasogastric tube shouId be investigated for the presence or absence of bIood. 6. Aortography to evaIuate the patency of the mesenteric arteries, though not practiced here, may prove heIpfu1. If mesenteric occIusion is demonstrated, corrective surgery is indicated [J]. 7. Aspiration of peritonea1 fluid may be heIpfu1 in differentiating acute pancreatitis from mesenteric thrombosis. BIoody ascitic fluid is present in both situations but when infarcted bowe1 is present, the fluid obtained has a fou1 odor and shows the presence of Escherichia coIi on the smear [6]. EarIy operative intervention in these patients is the key to success. A preoperative diagnosis cannot be absoIute but if the previousIy mentioned diagnostic cIues are kept in mind, earIy expIoratory Iaparotomy might save more patients.

of three patients with ported case, a tota mesenteric thrombosis have been encountered at the Wichita V. A. HospitaI in the past ten years. This is an incidence of about 3 per cent of a11 intestinal obstructions. In one case the diagnosis was not suspected prior to death and thrombosis may have been secondary to severe cardiac disease shown at autopsy. A verv recent patient with the “wiId man” behaGor was operated on with a preoperative diagnosis of mesenteric thrombosis. ExpIoration reveaIed gangrenous smaI1 and Iarge bowe1. No resection was possibIe and the patient died within twenty-four hours of surgery. Autopsy substantiated the diagnosis of massive intestina infarction. Two additiona earIier patients were thought cIinicaIIy to have the disease but autopsy faiIed to confirm it. Each had peritonitis due to other causes. Despite numerous advances in surgica1 technics and diagnostic tooIs the mortality rate remains up to 90 per cent. The reasons for this striking mortality are twofoId, nameIy, the very nature of the pathoIogic process invoIved, and the diffIcuIties in diagnosis which create detrimenta procrastination in treatment. This catastrophe has been appropriateIy caIIed the masquerader of the abdomen for it is most diffrcuIt to recognize. There are no pathognomanic findings to heIp the physician arrive at an accurate preoperative diagnosis. However, after thoroughly reviewing the case reports of the patients encountered at this hospita1 over a ten year period, and after going over other accounts, the foIIowing suggestions are thought to be of great heIp in arriving at a diagnosis : I. The disparity between the intense symptoms on the one hand and the miId physica signs on the other, constitutes a most important diagnostic cIue that cannot be overemphasized. This disparity was quite obvious in the case reported in this paper. This patient was examined by four different physicians, a11 of whom were startled by the intense pain the patient described and the paucity of objective physica findings. The patient was described as “wiId” by each of the examiners. 2. The entity of mesenteric thrombosis must be kept in mind whenever a physician encounters an acute condition of the abdomen. This is a prerequisite without which a correct preoperative diagnosis is impossibIe. It is not intended in this paper to give a differentia1 49

Farha

and Robinson

CONCLUSION

Of eighty cases of intestinal obstruction seen at Wichita V. A. HospitaI during the past ten years, three cases of mesenteric thrombosis were found. One case with a successfu1 outcome has been presented with a discussion of certain diagnostic cIues which may aid in arriving at a correct preoperative diagnosis. EarIy Iaparotomy may be Iife-saving.

3.

4. 5. 6.

ADDENDUM

Since submission of this report for pubIication, one additiona patient was successfuIIy treated on March 3, 1964, by emergency surgery after a correct preoperative diagnosis. AIthough the patient (G. T., a sixty-six year old man) had severe generaIized atheroscIerosis, his mesenteric obstruction was confined to a 20 cm. segment of smaI1 intestine.

superior mesenteric and inferior mesenteric artery. Surg. Clin. North America, 40: 1246, 1960. NELSON, S. W. and EGGLESTON. W. Findings on pIain roentgenograms of the abdomen associated with mesenteric vascuIar occIusion with a possibIe new sign of mesenteric venous thrombosis. Am. J. Roentgenol., 83: 886, 1960. WANG, C. C. and REEVES, J. D. Mesenteric vascuIar disease. Am. J. Roentgenol., 83: 895, 1960. GILLESPIE, G. Mesenteric thrombosis; diagnostic suggestions. Am. Surgeon, 27: 156, 1961. GRAY, E. B., JR. and AMADOR, E. Acute mesenteric venous thrombosis simuIating acute pancreatitis: the value of peritonea1 ffuid anaIysis. J. A. M. A., 167: 173, 1958.

Additional References Not Cited in Text ATWELL, R. B. Superior mesenteric artery emboIectomy. Surg. Gynec. cY Obst., 112: 257, 1961. CARUCCI, J. J. Mesenteric vascular occIusion. Am. J. Surg., 85: 47, 1953. DUMONT. A. E. et aI. ArterioscIerotic occIusion of the mesenteric artery: observations concerning surgica1 treatment. Ann. Surg., 154: 833, 1961. RABINOVITCH, J. et a1. Superior mesenteric artery syndrome. J. A. M. A., ;7g: 257, 1962. SHAW. R. S. and MAYNARD. E. P. Acute and chronic thrombosis of mesenteric arteries associated with maIabsorption, report of 2 cases successfuIIy treated with thromboendarterectomy. New England J. Med., 258: 874, 1958.

REFERENCES I. SHAKELFORD, R.

T. Surgery of the Alimentary Tract, vol. 11, p. I 140. PhiIadeIphia, 1955. W. B. Saunders. 2. NANSON, E. M. EmboIism and thrombosis of the

50