Yale New Haven Hospital New Haven, CT, United States
Rabia Rizwan, MD1, Karthik Gnanapandithan, MD2, Umer Ejaz Malik, MD3, Abdelkader Chaar, MD4, Paul Feuerstadt, MD5 1Yale New Haven Hospital, New Haven, CT; 2Mayo Clinic, Jacksonville, FL; 3Albany Medical Center, Albany, NY; 4Yale-New Haven Hospital, New Haven, CT; 5Yale University School of Medicine and PACT-Gastroenterology Center, Hamden, CT
Introduction: About 10% of cases of acute mesenteric ischemia are classified as non-occlusive mesenteric ischemia (NOMI) with an associated mortality rate of ~70- 90%. Our case exemplifies the importance of early detection and management of NOMI.
Case Description/Methods: A 60-year-old man with history of cocaine use presented to the ED with diffuse abdominal pain for 2 days. His last cocaine use was 1 week prior. Exam revealed abdominal distension and generalized tenderness with mild guarding. Labs: WBC with 25% bands and lactate: 2.2 mmol/L. CT without contrast showed thick-walled and dilated small bowel in the right side of the abdomen with pneumatosis linearis. His CT-angiography (CTA) showed patent mesenteric vessels. He was initially treated with IVF, antibiotics and his lactate improved to 1.5 mmol/L. Subsequently, his symptoms and abdominal distension worsened and a mesenteric arteriogram showed diffusely narrowed superior mesenteric artery (SMA) and branches with no thrombus or focal stenosis consistent with NOMI (Figure 1a). A SMA catheter was placed, and prostaglandin E1 infusion was given for four 4 days with repeat angiogram demonstrating improvement in visibility of distal SMA with therapeutic benefit (Figure 1b). After initial improvement the patient’s hospital course was later complicated by small bowel obstruction, development of pelvis abscess due to ileal perforation requiring exploratory laparotomy, and small bowel resection. The patient improved clinically and was discharged feeling well.
Discussion: NOMI is intestinal gangrene with patent vasculature secondary to splanchnic vasoconstriction and occurs as a protective mechanism during low arterial blood flow to the intestine or vasospasm due to vasoactive substances (e.g., cocaine). Following an extended period of vasoconstration, this might become irreversible despite correction of the precipitating event. NOMI is challenging to diagnose due to significant variation in abdominal exam findings, and lactic acid levels do not rise until later stages necrosis. Importantly, there is no obstructing lesion on imaging, therefore the radiologist needs to proactively look for the characteristics of NOMI to identify this process. The diagnostic study of choice is a CTA or a biphasic multi-detector CT without oral contrast. Therapies include selective mesenteric angiography with intra-arterial administration of vasodilators and surgical intervention when necrosis/gangrene is suspected.
Figure: Figure 1 : superior mesenteric arteriogram; (a) diffusely decreased caliber of the SMA and its branches with no thrombus or focal occlusion; (b) Improved visibility of SMA small branches, indicating treatment efficacy; which persisted after a 30 minute hold of Prostaglandin E1 infusion
Disclosures: Rabia Rizwan indicated no relevant financial relationships. Karthik Gnanapandithan indicated no relevant financial relationships. Umer Ejaz Malik indicated no relevant financial relationships. Abdelkader Chaar indicated no relevant financial relationships. Paul Feuerstadt indicated no relevant financial relationships.
Rabia Rizwan, MD1, Karthik Gnanapandithan, MD2, Umer Ejaz Malik, MD3, Abdelkader Chaar, MD4, Paul Feuerstadt, MD5. P0951 - Cocaine-Induced Non-Occlusive Mesenteric Ischemia (NOMI) Managed With Intra-Arterial Prostaglandins, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.