Clinical Case Summary

Male, 57 years old, heavy smoker, with a history of hypertension and ischemic stroke. Since the last 6 months, the patient reported non-bloody diarrhea, anorexia, involuntary weight loss of 25kg (34.5% of standard weight) and self-limited postprandial epigastric pain, with increasing need of opioid therapy in the last month. Physical examination revealed marked cachexia. Blood samples displayed Hemoglobin: 11.1g/dL and C-reactive protein: 123.7mg/L. An extensive analytical workup for chronic diarrhea, including celiac disease, Clostridioides difficile and Giardia, fecal calprotectin, thyroid function, and syphilis was unremarkable. Upper endoscopy and ileocolonoscopy revealed multiple clean-based ulcers in the antrum and nonspecific superficial aphthous ulcers in the colon. Computed tomography enterography revealed no valuable parietal thickening of the small bowel. Due to aggravating diarrhea and postprandial abdominal pain, the patient underwent an abdominopelvic angiotomography, which revealed extensive aortoiliac atheromatosis, occlusion at the origin of the celiac trunk (CT), segmental occlusion of the superior mesenteric artery (SMA) with an extent of 4cm, and stenosis at the emergence of the inferior mesenteric artery. The patient underwent mesenteric revascularization surgery with bypass from the supra-celiac aorta to the SMA, with extension to the CT. Resolution of abdominal pain and diarrhea were achieved within 24 hours postoperatively, and the patient remains asymptomatic to date.
Chronic mesenteric ischemia is a rare clinical condition, underdiagnosed due to its low level of suspicion. This clinical case highlights the importance of equating the diagnosis of ‘acute-on-chronic’ mesenteric ischemia in a patient with risk factors for atherosclerosis and typical symptoms. Timely diagnosis and treatment are paramount in preventing complications such as fulminant intestinal necrosis, a condition with high morbimortality.

References

1. Terlouw LG, Moelker A, Abrahamsen J, et al. European guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United European Gastroenterol J. 2020;8(4):371-395.
2. Huber TS, Björck M, Chandra A, et al. Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery. J Vasc Surg. 2021;73(1S):87S-115S.
3. van Dijk LJ, van Noord D, de Vries AC, et al. Clinical management of chronic mesenteric ischemia. United European Gastroenterol J. 2019;7(2):179-188.

Introduction

This study investigates the potential link between elevated D-dimer levels and the development of mesenteric ischemia, a severe vascular condition. D-dimer, a fibrin degradation product, is typically elevated in the presence of clot formation and breakdown. Mesenteric ischemia, a life-threatening condition, occurs due to reduced blood flow to the intestines. This study explores how elevated D-dimer levels could indicate mesenteric ischemia, potentially serving as a valuable diagnostic tool. Through statistical analyses of clinical data, we seek to understand the relationship's nature and its implications for early detection and improved patient outcomes in mesenteric ischemia cases.

Aims & Methods

Our retrospective study, spanning 2009-2023, included all Mesenteric ischemic patients from the Nationwide Inpatient Sample (NIS) database. We collected data on comorbidities, Mesenteric ischemia, D dimer levels, Gender, race insurance, and socioeconomic factors using CPT and ICD codes. The first step involved descriptive analysis, examining the distribution of D-dimer levels and the prevalence of mesenteric ischemia cases. We conducted a Mann-Whitney U test, a non-parametric statistical test suitable for comparing medians between two independent groups. Spearman's rank correlation coefficient was used to assess the strength and direction of the association between D-dimer levels and mesenteric ischemia. This test provided a measure of correlation, which was moderate and statistically significant in our dataset.

Results

A total of 7854 patients diagnosed with Mesenteric ischemia were included in the study. 4398 (54%) were female. The average age in the study is 58±7 years. The average BMI in the study group was 31± 10. Among the races, The Mann-Whitney U test (10.5 p<0.01) showed a higher D dimer level was associated with Mesenteric ischemia Similarly, the Spearman correlation coefficient of approximately 0.260 (p<0.05) demonstrates a moderate positive correlation between D-dimer levels and mesenteric ischemia, further supporting this association.

Conclusion

The results of our study reveal a noteworthy association between elevated D-dimer levels and mesenteric ischemia. The Mann-Whitney U test indicated significantly higher D-dimer levels in patients with mesenteric ischemia, reinforcing the potential of D-dimer as a marker for this condition. Furthermore, the Spearman correlation's moderate positive coefficient strengthens the evidence for this link. These findings suggest that monitoring D-dimer levels could aid in the early identification of mesenteric ischemia, potentially improving patient outcomes through timely intervention. However, the study highlights the need for cautious interpretation and consideration of other influencing factors in clinical settings

References

1. Zhang Z, Li GX, Wang XM, Wang D, Han KY, Xu D, Jiang T. [Early diagnosis and treatment of acute mesentric ischemia for 42 cases in single center]. Zhonghua Wai Ke Za Zhi. 2012 Dec;50(12):1068-71. Chinese. PMID: 23336481.

Clinical Case Summary

We present the case of a 50-year-old man with six months of persistent, non-bloody watery diarrhea (8–10 episodes/day), unresponsive to antibiotics and probiotics. His past medical history was unremarkable, he took no home medications, and denied raw meat or fish consumption. Notably, he had recently started working in an animal feed production facility one month before symptom onset. Initial labs showed mild leukocytosis (10.04 x 10³/µL; ULN: 8.77) and mildly elevated CRP (7.5 mg/L; ULN: 3.4). Extensive infectious workup, including CMV serology, Quantiferon, stool cultures for Salmonella, and tests for fungi and parasites (e.g., Giardia), fecal elastase, rectal swabs for Klebsiella pneumoniae carbapenemase and Clostridium difficile returned negative. Colonoscopy and upper GI endoscopy were normal, and biopsies from all intestinal segments showed no pathological findings. He was discharged with partial improvement (3–4 bowel movements/day) and normalized CRP, but was readmitted a week later for worsening symptoms. Repeat blood work, thyroid function, serum calcitonin and inflammatory markers were within normal limits. Intestinal ultrasound showed a tubular descending colon suggestive of nonspecific left-sided colitis; other bowel segments were normal. Stool tests remained negative.Urine toxicology was positive for cannabinoids. Upon further questioning, the patient admitted to regular use over the past eight months, including during both hospitalisations (CUDIT-R score = 12). After cessation of cannabinoid use, diarrhea resolved completely. At 3-month follow-up, he was asymptomatic, with normal bowel habits and labs. He reported only sporadic cannabinoid use at present (CUDIT-R score 7). This case illustrates the potential for chronic cannabinoid use to induce persistent diarrhea mimicking infectious or inflammatory disease. Screening for substance use should be considered in chronic unexplained diarrhea.

Clinical Case Summary

We present a case of a 30-year-old female admitted to the emergency room with a 3-day history of constipation, acute abdominal pain, and rebound tenderness. Her vital signs and laboratory findings corresponded to a systemic inflammatory response (SIRS). The abdominal CT scan with intravenous contrast reported acute appendicitis associated with intraperitoneal fluid and abundant fecal matter throughout the colon. Appendectomy was performed. After surgery, the patient developed diarrhea. The patient was discharged asymptomatic. After two days she developed sepsis, hematochezia, anal pain. A colonic ischemia was suspected and rectosigmoidoscopy with biopsies was performed showing large hemorrhagic ulcerations, CT scan, and MRI showed proctitis. The patient was managed with intravenous broad-spectrum antibiotics, IV fluids, and NPO with rapid improvement. Five days later a colonoscopy was performed showing ischemic proctitis. The patient remained asymptomatic and SIRS resolved. She was discharged and remains asymptomatic. Ischemic colitis of the rectum secondary to stercoral colitis is a rare complication as a result of increased intraluminal pressure. Due to their narrower diameter sigmoid colon and rectosigmoid colon are the most common areas affected. It is an entity that must be diagnosed and managed urgently because of the reported mortality rates of up to 35%. Intestinal perforation and solitary stercolar ulcers are the most common complications. Ischemic colitis due to constipation is an extremely rare entity. Until now, only 6 cases have been reported. Due to the limited literature on this complication, management must be individualized. We used ischemic colitis guidelines to treat this case and obtained an excellent outcome.

References

1. Hung A, Calderbank T, Samaan MA, Plumb AA, Webster G. Ischaemic colitis: Practical challenges and evidence-based recommendations for management. Vol. 12, Frontline Gastroenterology. BMJ Publishing Group; 2021. p. 44–52.
2. Brandt LJ, Feuerstadt P, Longstreth GF, Boley SJ. ACG clinical guideline: Epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia (CI). Vol. 110, American Journal of Gastroenterology. Nature Publishing Group; 2015. p. 18–44.
3. Azimuddin K, Raphaeli T. Acute ischemic gangrene of the rectum: Report of 3 cases and review of literature. Int J Surg Case Rep. 2013;4(12):1120–3.
4. Uwagbale E, Bodiwala V, Agbroko S, Bigajer E. A Case of Stercoral Colitis Complicated by Ischemic Colitis in a Young Patient. Cureus. 2022 Jun 17;
5. Naseer M, Gandhi J, Chams N, Kulairi Z. Stercoral colitis complicated with ischemic colitis: A double-edge sword. BMC Gastroenterol. 2017 Nov 28;17(1).

Clinical Case Summary

We present the case of a 50-year-old man diagnosed with anti-EJ positive anti-synthetase syndrome in 2020. Two years after the diagnosis, he began experiencing subacute episodes of postprandial abdominal pain, distension, and vomiting. On physical examination, the abdomen was distended, non-tender, and tympanic. Abdominal CT revealed dilatation of small bowel loops without evidence of mechanical obstruction. Endoscopic studies ruled out endoluminal lesions. Given the suspicion of a severe gastrointestinal (GI) motility disorder, a comprehensive motility evaluation was performed. Esophageal manometry revealed absent contractility, gastric emptying scintigraphy was consistent with gastroparesis, and small bowel manometry demonstrated absence of normal migrating motor complexes during fasting and a weak postprandial motor response, findings compatible with a myopathic pattern. A diagnosis of chronic intestinal pseudo-obstruction (CIPO) secondary to autoimmune disease activity was established. The patient’s immunosuppressive therapy was escalated to tofacitinib and supportive treatment with prokinetics (prucalopride), non- absorbable antibiotics for small intestinal bacterial overgrowth and nutritional supplementation, was initiated. The patient showed symptomatic improvement during follow-up, although small bowel dilation persisted on imaging studies. CIPO is the most severe form of GI motility disorder, representing the end stage of various conditions affecting the neuromuscular system of the GI tract (1). Autoimmune diseases are recognized causes of CIPO, with connective tissue disorders being the most frequently documented. The treatment of CIPO involves two main approaches: addressing the underlying disease, in this particular case, through immunosuppression, and providing supportive care to maintain adequate nutrition. A high index of suspicion for severe GI motility disorders is essential to avoid delays in diagnosis and to initiate effective treatment promptly.

References

1. Malagelada C and Alcalá-González LG. Mistakes in chronic intestinal pseudoobstruction and how to avoid them. UEG Education 2024; 24: 12-17.
Pictures from abdominal distention crisis, radiological CT images and manometric tracings, including high-resolution jejunal manometry (small bowel) will be presented.