Acute Occlusive Mesenteric Ischemia in Taif Province, Saudi Arabia

Mesenteric ischemia is relatively a rare disorder seen in the emergency department (ED). Due to the effect of hypobaric hypoxia and higher liability for thrombosis encountered in high altitude areas, acute occlusive mesenteric ischemia (AOMI) would represent an actual challenge in Taif and related districts. Another risk factor is that about twenty-five percent of Saudis are victims of diabetes due to the changes in lifestyle and diet leading to increasing levels of obesity. Vague nonspecific clinical findings and limitations of diagnostic studies in addition to cultural and social factors, may lead to late presentation making the diagnosis a significant challenge and in turn higher morbidity and mortality are expected.
 
Objectives:
 In this study, we review type of AOMI, pattern of presentation, laboratory, radiological, Intraoperative findings and results of treatment in 36 patients who were admitted to King Abdul Aziz Specialist Hospital and King Faisal Hospital, Al Taif, Saudi Arabia from January 2009 to January 2012.
 
Methods:
 36 patients with final diagnosis of AOMI were included in this retrospective study by means of review of their files and medical records.
 
Results:
 The disease was more common in men than women (23 male and 13 females). The mean age of patients was 54 years. The mean time of presentation was 2.4 days after occurrence of symptoms. Abdominal pain was the most common symptom of patients followed by nausea, vomiting, constipation and bloody diarrhea.  On physical examination; tachycardia was prevalent, Oliguria was seen in approximately 69.4% of patients, 11.1% of patients were in shock status. All patients had abdominal tenderness and 61.1% of patients had marked peritoneal signs (rebound tenderness with guarding or/and rigidity). Twenty one/36 (58.3%) patients were diabetics, 17/36 patients (47.2%) were hypertensive and 8/36 patients (22.2%) with associated cardiac disorders. In laboratory tests, Leukocytosis was present in all patients. Secondary polycythemia was seen in 38.9% of patients. D-Dimer level was high in all patients. In 61.1% of patients, exploratory laparotomies were done based on clinical, laboratory, abdominal ultrasound and plain x-ray findings without performing CT angiography due to presentation with marked peritoneal signs. In all patients gangrenous lesions were detected during surgery and resection of these parts was done. Gangrene and in turn resection, was extensive in 14/36 patients (38.9%) and they developed short bowel syndrome. There were 22/36 patients (61.1%) with superior or/and inferior mesenteric vein thrombosis, 10/36 patients (27.8%) with superior mesenteric artery thrombosis, in one of them there is associated focal thrombosis of aorta and renal arteries and 4/36 patients (11.1%) with superior mesenteric artery embolism. All patients received postoperative anticoagulant therapy. Patients with short bowel syndrome were prepared to receive total parental nutrition (TPN) for life. Intra-operative deaths were 3/36
 
 (8.3%).There were 5/36 deaths (13.9%) accruing within one month after surgery and all died secondary to sepsis and its sequalae with total deaths of 8/36 patients (22.2%).
 
Conclusion:  
Acute occlusive mesenteric ischemia (AOMI) especially of venous type will represent a challenging problem in Taif and related districts. The surgeon must pay intensive attention to patients presented by unexplained central abdominal pain and he has to be with high index of suspicion especially if it meets with the classic teaching of "pain out of proportion to physical findings ". Early diagnosis, aggressive approach to early resuscitation of the patients, correction of metabolic and hemodynamic derangements, and performing laparotomy as soon as these derangements were corrected would decrease morbidity and mortality. In some patients it is necessary to perform second look operation for re-evaluation of the viability of the intestine.