This is a classic picture and the author of the question has taken care to give us enough clues so that we do not miss it. When reading this statement, multiple alarms go off: - Atrial Fibrillation: at the mir and at the ED door, any elderly person with AF and abdominal pain is emboligenic mesenteric ischemia until proven otherwise. - Acute abdominal pain, SIRS, renal failure, metabolic acidosis (ischemia!), probably an elevated lactic... - CT: The finding of portal gas is also highly indicative of mesenteric ischemia, we could also have been told of intestinal pneumatosis. Why are not the other pictures? - Perforated ulcus: We would have been told of a history of NSAID use, or a history of pain that improves with ingestion, of pneumoperitoneum on chest X-ray. - Biliary ileus: There would be a history of biliary colic or pain in the right hypochondrium, they would also speak of aerobilia in the imaging test and dilatation of the small loops with image (or not) of biliary lithiasis in the terminal ileum. - Neo sigmoidoscopy: In the myocardial imaging they would speak of weight loss, change of stool habit, pneumoperitoneum in Rx or CT and peritonitic abdominal exploration and may even be able to palpate the mass.

A 78-year-old woman with dementia and institutionalized is brought in by her caregivers for significant abdominal pain with deterioration of general condition and abdominal distension. CBC shows leukocytosis, elevated hematocrit, renal failure and metabolic acidosis. ECG shows atrial fibrillation. Abdominal tomography shows edematous small bowel loops, with intestinal and portal accumulation. The most probable diagnosis is:

Perforation of gastric or duodenal ulcus.

Obstructive neoplasm of the sigma with perforation.

Synchronous celiac axis and superior mesenteric artery embolism.

We present a case of combined celiac axis and superior mesenteric artery embolism in a 70-year-old patient that was examined in emergency department for atrial fibrillation and diffuse abdominal pain. Standard abdominal x-ray showed air in the portal vein. CT scan with contrast showed air in the lumen of the stomach and small intestine, bowel distension with wall thickening, and a free gallstone in the abdominal cavity. Massive embolism of both celiac axis and superior mesenteric artery was seen after contrast administration. On laparotomy, complete necrosis of the liver, spleen, stomach and small intestine was found. Gallbladder was gangrenous and perforated, and the gallstone had migrated into the abdominal cavity. We found free air that crackled on palpation of the veins of the gastric surface. The patient,s condition was incurable and she died of multiple organ failure a few hours after surgery. Acute visceral thromboembolism should always be excluded first if a combination of atrial fibrillation and abdominal pain exists. Determining the serum levels of d-dimers and lactate, combined with CT scan with contrast administration can, in most cases, confirm the diagnosis and lead to faster surgical intervention. It is crucial to act early on clinical suspicion and not to wait for the development of hard evidence.

A Case of Strangulation Ileus Due to a Low-Grade Appendiceal Mucinous Neoplasm.

BACKGROUND Strangulation ileus is caused by external obstruction to the small bowel, which results in ischemia and loss of bowel peristalsis. Low-grade appendiceal mucinous neoplasm (LAMN) is a low-grade adenocarcinoma that arises in the appendix. LAMN is usually asymptomatic but can present with appendiceal rupture and pseudomyxoma peritonei (PMP). This report is of a rare presentation of LAMN with strangulation ileus in a 92-year-old man. CASE REPORT A 92-year-old man was admitted to the emergency room with sudden onset of lower abdominal pain and abdominal distension. Laboratory investigations showed a leukocytosis with a white blood cell (WBC) count of 14.6×10³/μL with 85.5% neutrophils, blood urea nitrogen (BUN) of 26.6 mg/dL, and serum creatinine of 2.6 mg/dL, consistent with acute renal failure. Arterial blood gas analysis showed lactic acidosis (pH of 7.11) with a base excess of -20.8 mmol/L and lactate of 13.7 mmol/L. Abdominal computed tomography (CT) showed ascites and a dilated obstructed closed loop of the distal ileum associated with an external mass (3.9×2.8 cm). An initial diagnosis was of strangulation ileus due to Meckel's diverticulum. Emergency ileocecal resection was performed. Histopathology showed a low-grade mucinous tumor arising from the mucosa of the appendix, consistent with LAMN. At a 13-month follow-up, the patient was well with no tumor recurrence. CONCLUSIONS This report is of a rare case of LAMN that presented as a surgical emergency with strangulation ileus.

Portal pneumatosis in a patient with severe Salmonella colitis.

A 65-year-old patient with a history of ischemic stroke, residual ophthalmoparesis, positive fecal occult blood screening and pending colonoscopy attended the Emergency Room due to three days with pain, abdominal distension and diarrhea. In the Emergency Room, he presented diffuse abdominal pain, hemodynamic instability with acute renal failure and metabolic acidosis, with severe elevation of acute phase reactants. Abdominal fluid resuscitation and computed tomography (CT) were performed, which reported a dilatation of the loops of the small intestine to the distal ileum with thickening of the wall of the right colon and gas, dissecting intrahepatic portal branches and splanchnic veins.

[Twenty-six consecutive patients with acute superior mesenteric infarction. Comparison of conventional radiology, ultrasonography, and computerized tomography].

Ischemic bowel disease is a rare disorder whose incidence is increasing as the mean age of the population increases. Diagnosis by clinical, laboratory and radiologic means is often difficult, and delay in definitive therapy results in substantial morbidity and mortality. A series of 26 consecutive patients, with proved acute superior mesenteric ischemia, was retrospectively reviewed: the authors report the diagnostic methods performed preoperatively, the site and the cause of infarction and the time passed between the first radiograph ans surgery. Plain abdominal radiographs were performed in 25 of 26 patients, screening abdominal US in 23 cases and CT in 19 cases. All radiological examinations were retrospectively reviewed by three authors, independently, to recognize the different signs of infarction. On plain abdominal films, the findings warranting a presumptive diagnosis of bowel infarction were air-fluid levels (84% of cases), dilated bowel loops (48%), thickened and unchanging loops (20%), gastric distension and gasless abdomen (12%), small bowel pseudo-obstruction (8%). Screening abdominal US demonstrated intraperitoneal free fluid (26%) and dilated bowel loops (22%). Abdominal CT showed air-fluid levels (79%), dilated loops and free intraperitoneal fluid (47%), intramural gas and thickened bowel loops (36.8%), engorgement of the mesenteric vessels (31%), mesenteric-portal gas, mesenteric thrombus and marked reduction in the volume of gas in the small bowel (10.5%) and paper-thin bowel loops (5%). The authors conclude that air-fluid levels, dilated loops and intraperitoneal free fluid are the most frequent findings, even though they are not specific. While abdominal plain film and screening ultrasonography can be negative, CT detects at least one abnormal finding and at least three abnormal findings in 73% of cases.

InternalMed_Harrison

Nonocclusive or vasospastic mesenteric ischemia presents with generalized abdominal pain, anorexia, bloody stools, and abdominal distention. Often these patients are obtunded, and physical findings may not assist in the diagnosis. The presence of a leukocytosis, metabolic acidosis, elevated amylase or creatinine phosphokinase levels, and/or lactic acidosis is useful in support of the diagnosis of advanced intestinal ischemia; however, these markers may not be indicative of either reversible ischemia or frank necrosis. Investigational markers for intestinal ischemia include D-dimer, glutathione S-transferase, platelet-activating factor (PAF), and mucosal pH monitoring. Regardless of the need for urgent surgery, emergent admission to a monitored bed or intensive care unit is recommended for resuscitation and further evaluation. Early manifestations of intestinal ischemia include fluid sequestration within the bowel wall leading to a loss of interstitial volume. Aggressive fluid

A rare case of digestive hemorrhage in an elderly patient: diagnosis and treatment difficulties.

Abdominal pain represents one of the most common clinical conditions. However, there are some challenging cases in which an extensive work-up is mandatory for the diagnosis. We present the case report of a 65-year-old man admitted to our department for diffuse abdominal pain, nausea, vomiting, diarrhea, painful joints and rectal tenesmus. He initially had an urticarial rash, followed by palpable purpura involving the lower extremities. The diarrheic stools evolved towards melena. Endoscopic examination of the upper gastrointestinal tract showed hiatal hernia, superficial erosions in the stomach and multiple areas of deep and superficial ulcerations disseminated from the second to the third portion of the duodenum. Terminal ileum intubation at colonoscopy showed redness, edema, swelling, petechiae and ecchymosis, irregular erosions and ulcers. Endoscopic biopsy specimens showed non-specific inflammation. Computed tomography showed moderate ascites, small pleural effusion, mesenteric lymphadenopathy and small bowel wall thickening at the level of the second duodenum, proximal jejunum and segments of ileum. The urine analysis revealed microscopic hematuria with nephrotic range proteinuria, red cells and cellular casts. Therapy with corticosteroids and pulses of cyclophosphamide was started with significant clinical improvement. Three weeks after the first admission, the patient developed an acute peritonitis due to an intestinal perforation and acute mesenteric ischemia of the small bowel. We concluded that the patient had a Henoch-Schönlein type vasculitis with acute mesenteric ischemia and perforation of the small bowel.

Abdominal pain

By location The location of abdominal pain can provide information about what may be causing the pain. The abdomen can be divided into four regions called quadrants. Locations and associated conditions include: Diffuse Peritonitis Vascular: mesenteric ischemia, ischemic colitis, Henoch-Schonlein purpura, sickle cell disease, systemic lupus erythematosus, polyarteritis nodosa Small bowel obstruction Irritable bowel syndrome Metabolic disorders: ketoacidosis, porphyria, familial Mediterranean fever, adrenal crisis Epigastric Heart: myocardial infarction, pericarditis Stomach: gastritis, stomach ulcer, stomach cancer Pancreas: pancreatitis, pancreatic cancer Intestinal: duodenal ulcer, diverticulitis, appendicitis Right upper quadrant Liver: hepatomegaly, fatty liver, hepatitis, liver cancer, abscess Gallbladder and biliary tract: inflammation, gallstones, worm infection, cholangitis

Necrotizing enterocolitis

Diagnosis is usually suspected clinically, but often requires the aid of diagnostic imaging, most commonly radiography, which can show the intestines and may show areas with death tissue or a bowel perforation. Specific radiographic signs of NEC are associated with specific Bell's stages of the disease: Bell's stage 1 (suspected disease): Mild systemic disease (apnea, lethargy, slowed heart rate, temperature instability) Mild intestinal signs (abdominal distention, increased gastric residuals, bloody stools) Nonspecific or normal radiological signs Bell's stage 2 (definite disease): Mild to moderate systemic signs Additional intestinal signs (absent bowel sounds, abdominal tenderness) Specific radiologic signs (pneumatosis intestinalis or portal venous gas) Laboratory changes (metabolic acidosis, too few platelets in the bloodstream) Bell's stage 3 (advanced disease): Severe systemic illness (low blood pressure)

Pylephlebitis

Pylephlebitis is an uncommon thrombophlebitis of the portal vein or any of its branches (i.e. a portal vein thrombosis) that is caused by infection. It is usually a complication of intra-abdominal sepsis, most often following diverticulitis, perforated appendicitis, or peritonitis. Considered uniformly lethal in the pre-antibiotic era, it still carries a mortality of 10-30%. Presentation It typically presents with fever, rigors, and right upper quadrant abdominal pain, but sometimes abdominal pain may be absent. Liver function test abnormalities are usually present but frank jaundice is uncommon. Cause It is a cause of portal hypertension and can cause bowel ischemia sometimes leading to bowel infarction. Diagnosis In the modern era, it is usually diagnosed by CT scans of the abdomen and pelvis. Bacteriology is often polymicrobial and blood cultures are positive in some cases. A significant fraction of people presenting with this condition have an underlying hypercoagulable state.

Surgery_Schwartz

localized in the upper abdomen, which may be precipitated by meals.Diagnostic EvaluationThe differential diagnosis of acute mesenteric ischemia includes other causes of severe abdominal pain of acute onset, such as perforated viscus, intestinal obstruction, pancreatitis, cholecys-titis, and nephrolithiasis. Laboratory evaluation is neither sensitive nor specific in distinguishing these various diagnoses. Figure 23-39. A lateral projection of the magnetic resonance angi-ography of the aorta showing a chronic compression of the celiac artery by the median arcuate ligament (arrow).Brunicardi_Ch23_p0897-p0980.indd 93027/02/19 4:14 PM 931ARTERIAL DISEASECHAPTER 23In the setting of mesenteric ischemia, complete blood count may reveal hemoconcentration and leukocytosis. Metabolic acidosis develops as a result of anaerobic metabolism. Elevated serum amylase may indicate a diagnosis of pancreatitis but is also com-mon in the setting of intestinal infarction. Finally, increased lac-tate

Surgery_Schwartz

ensues. The classical symptoms include postprandial abdominal pain, food fear, and weight loss. Persistent nausea and occasionally diarrhea may coexist. Diagnosis remains challenging, and most of the patients will undergo an extensive and expensive gastro-intestinal tract workup for the above symptoms prior to referral to a vascular service.The typical patient who develops nonocclusive mesenteric ischemia is an elderly patient who has multiple comorbidities, such as congestive heart failure, acute myocardial infarction with cardiogenic shock, hypovolemic or hemorrhagic shock, sepsis, pancreatitis, and administration of digitalis or vasocon-strictor agents such as epinephrine. Abdominal pain is only present in approximately 70% of these patients. When present, the pain is usually severe but may vary in location, character, and intensity. In the absence of abdominal pain, progressive abdominal distention with acidosis may be an early sign of isch-emia and impending bowel

Intestinal ischemia

Diagnostic heuristics In the absence of adequate quantitative studies to guide diagnosis, various heuristics help guide diagnosis: Intestinal ischemia" should be suspected when individuals, especially those at high risk for acute intestinal ischemia, develop severe and persisting abdominal pain that is disproportionate to their abdominal findings"., or simply, pain out of proportion to exam. Regarding intestinal arterial thrombosis or embolism: "early symptoms are present and are relative mild in 50% of cases for three to four days before medical attention is sought". Regarding intestinal arterial thrombosis or embolism: "Any patient with an arrhythmia such as atrial fibrillation who complains of abdominal pain is highly suspected of having embolization to the superior mesenteric artery until proved otherwise."

First_Aid_Step2

Patients present with sudden onset of severe abdominal pain out of proportion to the exam. A history of prior episodes of similar abdominal pain after eating (“intestinal angina”) may be present. Other symptoms may include nausea, vomiting, diarrhea, and bloody stools. Early abdominal exam is often unremarkable; later findings may include peritoneal signs (suggest bowel infarction). Lab tests may show leukocytosis, metabolic acidosis with ↑ lactate, ↑ amylase, ↑ LDH, and ↑ CK. AXR and CT may reveal bowel wall edema (“thumbprinting”) and air within the bowel wall (pneumatosis intestinalis). Mesenteric angiography is the gold standard for arterial occlusive disease. Volume resuscitation, broad-spectrum antibiotics, optimization of hemodynamics, and avoidance of vasoconstrictors. Anticoagulation for arterial or venous thrombosis or embolism. The mortality rate for acute mesenteric ischemia is > 50%.

Abdominal pain

Given that a variety of diseases can cause some form of abdominal pain, a systematic approach to the examination of a person and the formulation of a differential diagnosis remains important. Differential diagnosis The most frequent reasons for abdominal pain are gastroenteritis (13%), irritable bowel syndrome (8%), urinary tract problems (5%), inflammation of the stomach (5%) and constipation (5%). In about 30% of cases, the cause is not determined. About 10% of cases have a more serious cause including gallbladder (gallstones or biliary dyskinesia) or pancreas problems (4%), diverticulitis (3%), appendicitis (2%) and cancer (1%). More common in those who are older, ischemic colitis, mesenteric ischemia, and abdominal aortic aneurysms are other serious causes.

Renal Infarction -- Differential Diagnosis

Aortic dissection and renal cell carcinoma are other differentials for patients presenting with flank pain. Other causes of abdominal pain, like mesenteric ischemia, should also be ruled out because systemic embolization in a patient with atrial fibrillation could potentially occlude the blood vessels supplying the intestine leading to acute bowel infarction. Aortic aneurysm Aortic dissection Appendicitis Biliary colic Diverticulitis Gastroenteritis Gynecologic and ovarian disorders Mesenteric ischemia Nephrolithiasis "Passed" urinary stone Pancreatitis Pyelonephritis Renal cell carcinoma

InternalMed_Harrison

Any severe acute pain in the abdomen or back should suggest the possibility of acute pancreatitis. The diagnosis is established by two of the following three criteria: (1) typical abdominal pain in the epigastrium that may radiate to the back, (2) threefold or greater elevation in serum lipase and/or amylase, and (3) confirmatory findings of acute pancreatitis on cross-sectional abdominal imaging. Patients also have associated nausea, emesis, fever, tachycardia, and abnormal findings on abdominal examination. Laboratory studies may reveal leukocytosis, hypocalcemia, and hyperglycemia. Although not required for diagnosis, markers of severity may include hemoconcentration (hematocrit >44%), admission azotemia (BUN >22 mg/dL), SIRS, and signs of organ failure (Table 371-3).

Acute abdomen

An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate surgical treatment. Differential diagnosis The differential diagnosis of acute abdomen includes: Acute appendicitis Acute peptic ulcer and its complications Acute cholecystitis Acute pancreatitis Acute intestinal ischemia (see section below) Acute diverticulitis Ectopic pregnancy with tubal rupture Ovarian torsion Acute peritonitis (including hollow viscus perforation) Acute ureteric colic Bowel volvulus Bowel obstruction Acute pyelonephritis Adrenal crisis Biliary colic Abdominal aortic aneurysm Familial Mediterranean fever Hemoperitoneum Ruptured spleen Kidney stone Sickle cell anaemia Carcinoid

Bowel Ischemia -- History and Physical

A careful review of the patient's medical conditions and family history is essential for the evaluation of intestinal ischemia. The history of cardiac disease [34] , aortic surgery, peripheral artery disease, hemodialysis, vasoconstrictive medications, acquired or hereditary thrombotic conditions, hypovolemia, and inflammation or infections should increase suspicion of intestinal ischemia in a patient with abdominal pain. [35] Abdominal pain is the most common symptom in patients with intestinal ischemia. Some features of a patient can help to distinguish between the acute small bowel and colonic ischemia. Patient's characteristics, such as age over 60 years, not appearing severe ill, mild abdominal pain, tenderness, rectal bleeding, or bloody diarrhea, are the features that are more common in acute colonic ischemia. [9] The features of the pain, physical exam, and accompanying symptoms can help to distinguish the etiology of intestinal ischemia. In mesenteric artery embolism, usually, the pain is sudden onset, severe, periumbilical, and often accompanied by nausea and vomiting. [36] The pain in thrombotic mesentery ischemia commonly presented postprandial. [37] In mesenteric veins thrombosis, the pain usually described as wax and wane before the definite diagnosis. [38] The patients with nonocclusive mesenteric ischemia do not have classic severe pain and typically present in patients with a history of hypotension, hypovolemia, cardiac arrhythmia, and heart failure. [39] Patients with chronic mesenteric ischemia usually present with recurrent abdominal pain after eating and subsequently can cause patients losing weight. [26] Patients with acute colonic ischemia commonly are presented with sudden onset cramping abdominal pain, which usually involves the left side. The pain can be accompanied by an urgent desire for a bowel movement. Instead of periumbilical pain in small intestine ischemia, patients with colonic ischemia usually feel the pain laterally. [40] [41] Physical examination in patients with intestinal ischemia can vary from normal to peritoneal sign (rebound tenderness and guarding) based on the time course of the onset. [42]

Bowel Ischemia -- Evaluation

Laboratory tests in intestinal ischemia are nonspecific. In the early stage of the disease, complete blood cell count can be normal, but with the progression of the ischemia, leukocytosis with the leftward shift, elevated amylase, and lactate dehydrogenase levels may be observed. [43] Based on underlying risk factors, laboratory studies can be abnormal. In MVT, patients need to evaluate for hypercoagulopathy states such as examined for protein C and S and antithrombin III deficiency, lupus anticoagulant, and platelet aggregation. [15] [44] In CMI, abnormal laboratory tests, including leukopenia, hypoalbuminemia, and electrolyte abnormalities, may be observed secondary to malnourishment. [45] The diagnostic approach in patients with intestinal ischemia depends on the severity of symptoms. In patients with peritonitis signs, the diagnosis will be made by abdominal exploration. Plain radiographs, computed tomography angiography (CTA) or magnetic resonance angiography (MRA), invasive angiography, and duplex ultrasound are common radiology studies in patients with suspicion of intestinal ischemia. [42] Plain abdominal radiography is nonspecific; however, the presence of ileus with bowel loops distention, bowel wall thickening, and pneumatosis intestinalis can be suggestive for mesenteric ischemia. Plain abdominal radiography commonly used in patients with signs of sepsis and unstable hemodynamics. [46] Generally, abdominal CT is used in hemodynamically stable patients who present with acute abdominal pain. In addition to, rule out other causes of abdominal pain, some findings including pneumatosis intestinalis, portal vein gas, mesenteric edema, streaking of the mesentery, focal edematous bowel wall, abdominal gas pattern, and solid organ infarction can be suggestive for acute mesenteric ischemia in abdominal CT scan. [10] [11] In patients with high suspicious for intestinal ischemia, CT angiography, and MR angiography are the initial tests. However, the CTA is preferred over MRA due to lower cost, white availability, and speed. [12] The CT scans should be done without oral contrast due to oral contrast that can obscure the bowel wall enhancement and the mesenteric vessels, which both lead to a delay of definitive diagnosis. [47] [48] [49] [50] Angiography usually reserved in patients with high suspicious of AMI with negative CTA or patients with NOMI. Diffuse stenosis in mesenteric vessels with the absence of occlusive lesions is the finding in NOMI patients by angiography. [51] The role of duplex ultrasound is just limited to the detection of clots in the proximal of the main vessels. In addition to that, peritoneal gas, previous abdominal surgical intervention, obesity can decrease the sensitivity of duplex ultrasound. [42] In hemodynamically stable patients with clinical features of acute colonic ischemia, including abdominal pain, urgent desire to defecation, diarrhea, and lower gastrointestinal bleeding in addition to common imaging studies (plain radiography, CTA) may require sigmoidoscopy or colonoscopy and biopsy for definitive diagnosis. [52] If colonic ischemia is suspected, colonoscopy preferred to be performed within 48 hours of initial symptoms rather than later. [53] [54]

[Mesenteric ischemia in hemodialysis patients].

Mesenteric ischaemia is an abdominal pathology with a high mortality rate. Among the population under dialysis treatment it presents some different traits such as non-occlusive mesenteric attacks in most of the cases. Its diagnosis is difficult and it is usually the result of an interdisciplinary collaboration. It is necessary to know better the symptoms of this illness among dialytic patients in order to improve its prognosis. Eleven haemodialytic patients in our hospital (0.87% per patient-year) have diagnosed with mesenteric ischaemia confirmed by a laparothomy. We will list the main risk factors of this pathology, its symptoms, its evolution, some radiological and laboratory data more pointed out, the surgical findings anf its treatment. Ten patients (91%) had suffer from cardiovascular pathologies, five of them (45%) had suffer an ischaemia cardiopathy. Seven patients (64%) had a spell of arterial hypotension during their haemodialysis session, which preceded mesenteric ischaemia. The reason for consulting a physician was abdominal pain, specially on the right hemiabdomen (64%). The analytical date most frequently observed was leucocytosis (54%). The usual radiological tests such as abdominal plain radiography and ecography didn't give any detailed formation. Ten out of eleven patients (91%) had necrosis on the intestinal wall. The ileum was the most affected intestinal section. Five of the patients presented only a limited damage of the ileum (45%). Two patients (18%) presented an extensive damage in the whole small intestine and part of the right colon. Intestinal resection was the most chosen way of treatment, which was practiced on eight patients (73%). Only three of them (27%) survived the mesenteric ischaemia and were sent to their homes. The key factor of their survival was that they were operated on in less than 8 hours from their arrival at emergency room. Mesenteric ischaemia must be expected among patients under haemodialysis who suffer from abdominal pain, especially if they have had some arterial hypotensive spells during their previous dialytic session. It s a matter of urgent surgery where not only its diagnosis but also its early surgical treatment can lessen its high morbi-mortality risk.

Clinical factors and outcomes in patients with acute mesenteric ischemia in the emergency department.

The purpose of this study was to determine the initial clinical characteristics of acute mesenteric ischemia and identify variables associated with adverse outcomes in the emergency department (ED). The charts of 124 consecutive patients with surgically and pathologically identified acute mesenteric ischemia from September 1990 to September 2000 were reviewed retrospectively to obtain data about demographics, initial clinical presentations, predisposing diseases, previous medications, laboratory tests, and common findings on computed tomography scans with contrast. Only patients admitted through the ED and treated on medical or surgical wards were enrolled. Mean patient age was 71.1 years (range, 25-100 years). The overall mortality rate was 50%. There were no significant differences in gender, underlying disease, previous medication, initial signs and symptoms, and causes of mesenteric infarction, between survivors and non-survivors. Univariate analysis demonstrated that older age, bandemia, hepatic and renal impairment, hyperamylasemia, metabolic acidosis, hypoxia, intramural pneumatosis, and septic syndrome, were more frequent in patients who died than in those who survived (p < 0.05). Logistic regression identified the following variables as independent predictors of death: old age (odds ratio, OR, 1.077; 95% confidence interval, Cl, 1.013, 1.146; p = 0.02); bandemia (OR, 3.894; 95% Cl, 1.160, 13.074; p = 0.03); elevated serum aspartate aminotransferase (AST; OR, 4.532; 95% Cl, 1.274, 16.122; p = 0.02); increased blood urea nitrogen (BUN; OR, 7.219; 95% Cl, 1.166, 44.696; p = 0.03); and metabolic acidosis (OR, 6.604; 95% Cl, 1.804, 24.171; p < 0.01). A high index of suspicion and aggressive diagnostic imaging can facilitate early diagnosis and improve outcomes for patients with acute mesenteric ischemia. Risk stratification showed that elderly patients with metabolic acidosis, bandemia, or elevated AST and BUN had a poor prognosis. Greater therapeutic intervention is advocated to reduce mortality in high-risk patients with acute mesenteric ischemia.

Abdominal x-ray

An abdominal x-ray is an x-ray of the abdomen. It is sometimes abbreviated to AXR, or KUB (for kidneys, ureters, and urinary bladder). Indications In children, abdominal x-ray is indicated in the acute setting: Suspected bowel obstruction or gastrointestinal perforation; Abdominal x-ray will demonstrate most cases of bowel obstruction, by showing dilated bowel loops. Foreign body in the alimentary tract; can be identified if it is radiodense. Suspected abdominal mass In suspected intussusception, an abdominal x-ray does not exclude intussusception but is useful in the differential diagnosis to exclude perforation or obstruction. Yet, CT scan is the best alternative for diagnosing intra-abdominal injury. Computed tomography provides an overall better surgical strategy planning, and possibly less unnecessary laparotomies. Abdominal x-ray is therefore not recommended for adults with acute abdominal pain presenting in the emergency department. Projections

[Diagnosis and prognosis of mesenterial infarct].

28 cases of arterial thrombosis, 18 arterial embolism, 16 venous thrombosis and twelve cases of nonocclusive intestinal ischemia were diagnosed. History of symptoms on admission was longer in venous thrombosis (80 hours) than in arterial vascular occlusion (40 hours). There was a leukocytosis of 19.7/nl and lactate in serum was elevated in 85.1% of patients. Sonographic abdominal examination without preparation of the gut was normal in 44.6% (33/74 patients), variable distended loops of small intestine in the other cases. Sonographic measurement of mesenteric vascular flow succeeded only in 10.9%. Abdominal X-ray photography showed no characteristic signs in 21.6%. Variable degree of gaseous distension and fluid levels was described in 73.7%. Angiography was only performed in patients which were not supposed to be operated because of clinical examination (e.g. peritonitis). Eleven of 19 cases were diagnosed correctly (specificity 73.7%). Mortality rate of all patients was 70.3% and showed in further analysis significant differences in age, etiology of mesenteric ischemia, the length of ischemic and operatively resected gut. If mesenteric vascular occlusion is suspected a quick diagnostic procedure and laparotomy for resection of gangrenous bowel is to be planned.

Abdominal guarding

Diagnosis Differential diagnosis Abdominal aortic aneurysm Appendicitis Blunt force trauma to the abdomen Bowel obstruction Diverticulitis Dyspepsia Ectopic pregnancy GERD Ileus Inflammatory bowel disease Intussusception Mesenteric ischemia Nephrolithiasis Ovarian cyst Pancreatitis Pelvic inflammatory disease Perforated peptic ulcer disease Pneumonia Spontaneous bacterial peritonitis (SBP) Urinary tract infection/pyelonephritis Volvulus Zoster Skin lesions may not be visible until another day or two Abdominal migraine Abdominal wall strain/injury Abscess (e.g. iliopsoas) Hepatic or splenic contusion/laceration Incarcerated hernia Insect toxins (e.g. black widow spider) Malingering Pneumoperitoneum secondary to abdominal trauma Septic miscarriage (See Miscarriage)

Abdominal pain

Right upper quadrant Liver: hepatomegaly, fatty liver, hepatitis, liver cancer, abscess Gallbladder and biliary tract: inflammation, gallstones, worm infection, cholangitis Colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer Other: pneumonia, Fitz-Hugh-Curtis syndrome Left upper quadrant Splenomegaly Colon: bowel obstruction, functional disorders, gas accumulation, spasm, inflammation, colon cancer Peri-umbilical (the area around the umbilicus, aka the belly button) Appendicitis Pancreatitis Inferior myocardial infarction Peptic ulcer Diabetic ketoacidosis Vascular: aortic dissection, aortic rupture Bowel: mesenteric ischemia, Celiac disease, inflammation, intestinal spasm, functional disorders, small bowel obstruction Lower abdominal pain Diarrhea Colitis Crohn's Dysentery Hernia Right lower quadrant Colon: intussusception, bowel obstruction, appendicitis (McBurney's point)

InternalMed_Harrison

Acute mesenteric ischemia resulting from arterial embolus or thrombosis presents with severe acute, nonremitting abdominal pain strikingly out of proportion to the physical findings. Associated symptoms may include nausea and vomiting, transient diarrhea, anorexia, and bloody stools. With the exception of minimal abdominal distention and hypoactive bowel sounds, early abdominal examination is unimpressive. Later findings will demonstrate peritonitis and cardiovascular collapse. In the evaluation of acute intestinal ischemia, routine laboratory tests should be obtained, including complete blood count, serum chemistry, coagulation profile, arterial blood gas, amylase, lipase, lactic acid, blood type and cross match, and cardiac enzymes. Regardless of the need for urgent surgery, emergent admission to a monitored bed or intensive care unit is recommended for resuscitation and further evaluation. If the diagnosis of intestinal ischemia is being considered, consultation with a surgical

Abdominal pain

Selected causes Traumatic: blunt or perforating trauma to the stomach, bowel, spleen, liver, or kidney Inflammatory: Infections such as appendicitis, cholecystitis, pancreatitis, pyelonephritis, Peritonitis, pelvic inflammatory disease, hepatitis, mesenteric adenitis, or a subdiaphragmatic abscess Perforation of a peptic ulcer, a diverticulum, or the caecum Complications of inflammatory bowel disease such as Crohn's disease or ulcerative colitis Mechanical: Small bowel obstruction secondary to adhesions caused by previous surgeries, intussusception, hernias, benign or malignant neoplasms Large bowel obstruction caused by colorectal cancer, inflammatory bowel disease, volvulus, fecal impaction or hernia Vascular: occlusive intestinal ischemia, usually caused by thromboembolism of the superior mesenteric artery

Biloma

Biloma is collection of bile within the abdominal cavity. It happens when there is a bile leak, for example after surgery for removing the gallbladder (laparoscopic cholecystectomy), with an incidence of 0.3–2%. Other causes are biliary surgery, liver biopsy, abdominal trauma, and, rarely, spontaneous perforation. Symptoms are usually diffused or localized abdominal pain. Ascites and peritonitis are less common. Fever is often absent. Blood tests may show leukocytosis and nonspecific liver test abnormalities. Diagnosis is by abdominal ultrasound, MRCP, or HIDA scan. Treatment depends on the severity of the condition and ranges from ERCP with sphincterotomy or stent placement to surgical hepaticojejunostomy. See also Biliary injury References External links Bile Duct Leaks Biliary tract disorders

Defecation

Bowel obstruction Bowel obstruction is a bowel condition which is a blockage that can be found in both the small intestines and large intestines. Increase of contractions can relieve blockages, however, continuous contractions with decreasing functionality may lead to terminated mobility of the small intestines, which then forms the obstruction. At the same time, the lack of contractility encourages liquid and gas accumulation. and "electrolyte disturbances". Small bowel obstruction can result in severe renal damage and hypovolemia. while evolving into "mucosal ischemia and perforation". Patients with small bowel obstruction were found to experience constipation, strangulation and abdominal pain and vomiting. Surgical intervention is primarily used to cure severe small bowel obstruction condition. Nonoperative therapy included nasogastric tube decompression, water-soluble-contrast medium process or symptomatic management can be applied to treat less severe symptoms

[Abdominal complications of heart surgery].

Abdominal complications after cardiac surgery (excluding "medical" jaundice) are rare. Twenty six cases were observed out of a total of 7 847 operations (0.33%) performed between 1973 and 1980. The causes were very diverse; the most common being gastroduodenal ulceration, usually acute (9 cases). Other cases included intestinal (3 cases of postoperative ileus, 4 cases of mesenteric infarction, 2 cases of necrosing enterocolitis), biliary (2 cases of acute cholecystitis) and splenic pathology (2 cases of splenic infarction, one associated with necrosing enterocolitis). Anticoagulant therapy was implicated in 3 cases. Diagnosis is difficult in the immediate postoperative period, some complications only being recognised at autopsy. The clinical signs may be misleading and the interpretation of complementary investigations difficult. Therefore, the possibility of abdominal complications must be kept in mind, especially in patients with one or more predisposing factors. Excluding accidents due to anticoagulant therapy the following factors were associated with an increased risk of abdominal complications: previous history of gastro intestinal pathology (ulcer, gall stone, alcoholism) the nature of the underlying cardiac disease (coronary artery and aortic valve disease), cardiopulmonary bypass, and, above all, per- and postoperative incidents: hypovolaemia, low output syndrome (half the patients in this series) respiratory and infectious complications. The inappropriate use of vasoconstricting agents may also play a role. The majority of abdominal complications seemed to be related to ischaemia and anoxia in the splanchnic territory, which explains the important role of the preceding factors. The prognosis of abdominal complications after cardiac surgery was poor, mortality reaching 50 to 100% in some causes: in this series, 12 of the patients died. This justifies certain prophylactic measures: strict  selection of patients, diagnosis and treatment of associated abdominal pathology before operation, prevention of low output states, respiratory and infectious complications ... and careful examination of the abdomen after operation to ensure the early diagnosis and treatment of complications, should they develop.

[Color Doppler ultrasound in acute mesenteric ischemia: 2 case reports].

Acute mesenteric insufficiency is a surgical emergency with a difficult methodological approach. Its high mortality is mainly due to delay in the correct diagnosis. In turn this is due to the lack of specificity, especially in the early-middle phase of the clinical presentation, and of the laboratory data and abdominal radiographic findings. Echo-doppler ultrasound promises to be more accurate than conventional ultrasound in the diagnosis of visceral ischemia and may help to identify those patients who may require angiography. Two women presenting atrial fibrillation, abdominal pain, leukocytosis, hyperamylasemia were accepted in October 2000 ad March 2001. US colordoppler was performed 12 hours after admittance demonstrating a "stop" of enhancement of the superior mesenteric artery in one case and absence of enhancement in the other.

Polyarteritis nodosa

Renal system: Kidney involvement is common and often leads to death of parts of the kidney. Involvement of the renal artery, which supplies the kidneys with highly oxygenated blood, often leads to high blood pressure in about one-third of cases. deposition of protein or blood in the urine may also be seen. Almost all patients with PAN have renal insufficiency caused by renal artery narrowing, thrombosis, and infarctions. Cardiovascular system: Involvement of the arteries of the heart may cause a heart attack, heart failure, and inflammation of the sac around the heart (pericarditis). Gastrointestinal system: Damage to mesenteric arteries can cause abdominal pain, mesenteric ischemia, and bowel perforation. Abdominal pain may also be seen. Musculoskeletal system: Muscle and joint aches are common. Complications Stroke Heart failure resulting from cardiomyopathy and pericarditis Intestinal necrosis and perforation