gastrointestinal disorders/mesenteric ischemia

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Question 1 / 3

683d163ec1b3f4bd827dacf7

Surgery

gastrointestinal disorders

mesenteric ischemia

Case History

A 68-year-old female presents to the gastroenterology clinic with a 4-month history of debilitating postprandial abdominal pain. The pain, described as severe, cramping, and periumbilical to epigastric, typically commences 20-40 minutes after consuming food, lasting for up to 2 hours, and is significantly alleviated by cessation of eating. She reports a profound fear of eating (sitophobia) due to the pain, leading to an unintentional weight loss of 8 kg (17.6 lb) over this period. Her medical history is significant for diffuse atherosclerotic disease, including severe coronary artery disease status post multiple percutaneous coronary interventions, peripheral artery disease with intermittent claudication, well-controlled hypertension, and dyslipidemia. Current medications include aspirin, clopidogrel, rosuvastatin, ramipril, and metoprolol. On examination, she appears frail with temporal wasting and pale conjunctiva. Vital signs are stable. Abdominal examination reveals mild epigastric tenderness to deep palpation, and a distinct, harsh systolic bruit is auscultated superior to the umbilicus. Pedal pulses are diminished bilaterally. Previous workup, including an esophagogastroduodenoscopy (EGD), colonoscopy, and abdominal ultrasound, yielded normal findings, ruling out peptic ulcer disease, inflammatory bowel disease, and biliary pathology. Given her presentation and extensive vascular history, what is the most appropriate next diagnostic step and initial management strategy?

Lab Parameter	Value	Reference Range
Hemoglobin	11.2 g/dL	12-15 g/dL
White Blood Cell Count	8.5 x 10^9/L	4.5-11.0 x 10^9/L
Albumin	3.0 g/dL	3.5-5.0 g/dL

A ) Capsule endoscopy for small bowel bleeding and iron supplementation

B ) Gastric emptying study for gastroparesis and metoclopramide prescription

C ) CT mesenteric angiography to assess for vascular stenosis and consultation for endovascular or surgical revascularization

D ) Abdominal Doppler ultrasonography of mesenteric vessels and a trial of empiric acid suppression therapy

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Question 2 / 3

683d163ec1b3f4bd827dacbd

Surgery

gastrointestinal disorders

mesenteric ischemia

Case History

A 72-year-old woman is admitted to the general medical ward from the emergency department, complaining of progressively worsening diffuse abdominal pain over the past 12 hours, initially periumbilical but now generalized. Her medical history includes paroxysmal atrial fibrillation, hypertension, and peripheral vascular disease. She describes the pain as severe, constant, and disproportionate to the mild tenderness elicited on physical examination. She has had several episodes of loose, dark stools and persistent nausea. On examination, her temperature is 37.2 C (99.0 F), blood pressure is 128/76 mmHg, heart rate is 98/min and irregularly irregular, and respiratory rate is 18/min. Abdominal examination reveals diffuse tenderness, particularly periumbilical, with subtle involuntary guarding. Bowel sounds are diminished. Rectal examination is positive for guaiac. Laboratory results are pending but some initial findings are available.

Lab Parameter	Value	Reference Range
White Blood Cell Count	18.5 x 10^9/L	4.5-11.0 x 10^9/L
Lactate	4.8 mmol/L	0.5-2.2 mmol/L
Hemoglobin	13.2 g/dL	12.0-15.5 g/dL
Bicarbonate (HCO3)	20 mmol/L	22-28 mmol/L
Creatinine	1.1 mg/dL	0.6-1.2 mg/dL

A ) Mesenteric Angiography to confirm vascular occlusion, followed by urgent surgical embolectomy or revascularization.

B ) Emergent CT Angiography of the abdomen to identify source of ischemia, with preparation for potential laparotomy if findings are consistent.

C ) Abdominal ultrasound with Doppler studies and initiation of empirical broad-spectrum antibiotics.

D ) Diagnostic laparoscopy to assess bowel viability and administer intravenous fluid resuscitation.

E ) Barium enema to rule out colonic obstruction and administration of opioid analgesia.

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Question 3 / 3

683d163ec1b3f4bd827dacbe

Surgery

gastrointestinal disorders

mesenteric ischemia

Case History

A 68-year-old female with a history of atrial fibrillation and recent myocardial infarction presents to the emergency department complaining of sudden onset, severe, diffuse abdominal pain, disproportionate to physical examination findings. She also reports several episodes of bloody diarrhea and nausea. Her vital signs upon arrival are: BP 88/50 mmHg, HR 118 bpm, RR 24 bpm, Temp 37.8°C. On physical examination, her abdomen is mildly distended with diffuse tenderness, but without overt rebound or guarding, although bowel sounds are diminished. Laboratory studies show: Given these findings and the laboratory results, what is the most likely diagnosis and the immediate critical management step?

Lab Parameter	Value	Reference Range
Leukocyte count	22.0 x 10^9/L	3.5–10.5 x 10^9/L
Hemoglobin	112 g/L	125–170 g/L
Platelet count	159 x 10^9/L	130–380 x 10^9/L
Sodium	142 mmol/L	135–145 mmol/L
Potassium	4.1 mmol/L	3.5–5.0 mmol/L
Chloride	100 mmol/L	98–106 mmol/L
Bicarbonate	14 mmol/L	24–30 mmol/L
PO2 (on 3L O2)	150 mm Hg	83–116 mm Hg
PCO2 (on 3L O2)	30 mm Hg	32–45 mm Hg
pH (on 3L O2)	7.18	7.38–7.46
Lactate	7.8 mmol/L	< 2.0 mmol/L
Creatinine	1.5 mg/dL	0.6–1.2 mg/dL

A ) Acute diverticulitis and broad-spectrum antibiotics

B ) Ischemic colitis and emergent colonoscopy

C ) Acute mesenteric ischemia and emergent exploratory laparotomy

D ) Small bowel obstruction and conservative management with NG decompression

E ) Acute pancreatitis and aggressive intravenous fluid resuscitation

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