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01.12.2015 | Case report | Ausgabe 1/2015 Open Access

BMC Surgery 1/2015

Delayed intestinal stricture following non-resectional treatment for non-occlusive mesenteric ischemia associated with hepatic portal venous gas: a case report

Zeitschrift:
BMC Surgery > Ausgabe 1/2015
Autoren:
Shota Maezawa, Motoo Fujita, Takeaki Sato, Shigeki Kushimoto
Wichtige Hinweise

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

SM drafted the manuscript and assisted in all of the operative procedures described. MF and TS are members of the attending staff of the department who discussed and provided advice about the treatment and performed the initial operation. SK is the chief of the department and he supervised the management of the patient and contributed supportive information. MF, TS, and SK revised the manuscript for important intellectual content. All of the authors read and approved the final manuscript.

Abstract

Background

Hepatic portal venous gas associated with non-occlusive mesenteric ischemia is indicative of a serious pathology that leads to bowel necrosis and it has a high mortality rate. Although non-occlusive mesenteric ischemia is acknowledged as a condition that requires early surgical treatment, it has been reported that bowel necrosis and surgical resection of the gangrenous lesion may be avoided if the condition is identified quickly and the cause is detected at an early phase. However, no reports or guidelines have been published that describe the management of patients in whom bowel necrosis and surgical treatment were avoided. We report the case of a patient who presented with non-occlusive mesenteric ischemia who was managed with non-resectional treatment at an early phase and had a delayed small-bowel stricture.

Case presentation

A 24-year-old man presented to the hospital with fever, abdominal pain, and vomiting. Abdominal computed tomography confirmed a diffuse gaseous distention with small-bowel pneumatosis and hepatic portal venous gas. An urgent laparotomy was performed, because septic shock associated with diffuse peritonitis and bowel necrosis was strongly suspected. Although we found purulent ascites and a perforated appendix at the time of surgery, gangrenous and transmural ischemic changes were not evident in the small bowel and colon. We performed an appendectomy without a bowel resection, and the patient was discharged on an oral diet. However, he was re-admitted to hospital, because 4 days after discharge he developed postoperative paralytic ileus. Non-operative management was chosen, but his symptoms did not improve. We decided to perform a laparotomy 40 days after the initial operation, and a considerable adhesion was detected. Therefore, only a synechotomy was performed. On day 57, he experienced symptoms that were associated with bowel obstruction once again. On day 59, a partial resection of the jejunum was performed. Severe luminal strictures were apparent within the jejunum, and marked structural changes were evident.

Conclusion

While non-surgical management can be chosen for selected patients with non-occlusive mesenteric ischemia, continuous observation to evaluate the development of delayed strictures that lead to bowel obstructions is required in patients who undergo non-resectional treatment.
Literatur
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