Tait, Graeme W.

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THE UNIVERSITY of EDINBURGHTitle Unusual clinical presentation of ischaemic bowel diseaseAuthor Tait, Graeme W.Qualification Prize EssayYear 1981Thesis scanned from best copy available: maycontain faint or blurred text, and/or cropped ormissing pages.Digitisation Notes:Text very faint in originalScanned as part of the PhD Thesis Digitisation projecthttp://librarvbloRS.is.ed.ac.uk/phddigitisation ATIfT'AL I, ^R'IShDTT 'TIPN OF ISCHATSTC BOTTh DISEASEIntroductionThe late stage of massive intestinal infarction is usuallyeasily recognised, although initially the clinical presentation1may often be misleading. It usually occurs in elderly patients2 3with severe peripheral vascularity or cardiac disease.' Theatypical presentation of such an event in a woman of 54 yearswith no clinical evidence of cardiovascular disease illustratesthe difficulty there may be in making the diagnosis.Case HistoryA previously healthy 54-year-old woman had been sufferingfrom tirednes- , lassitude and epigastric pain for several we"ks.The pain was intermittent, sharp, and was relieved by eating.During the thro • weeks prior to admission, the pain became colickyin character and was located more towards the lower abdomen. Shebegan to vomit 3-4 times each day, the vomitus consisting of clear,white fluid. One week prior to admission, her general conditiondeteriorated further; she developed copious diarrhoea with 3 or 4fluid stools each day, and each bowel motion was accompanied by"stabbing" periumbilical pain.There was no previous medical history or significant familyhistory. She smoked ten cigarettes daily. Systemic enquiry wasuninformative. On examin tion. she was pale, thin (but shedenied weight loss), and looked very unwell. Her pulse was 90/min, and she was in sinus rhythm; BP 170/100. The cardiovascularsystem was normal, with no evidence of peripheral vascular disease.The respiratory system was normal. The liver was just palpable,but not abnormal in consistency. The spleen and kidneys wereimpalpable. Bowel sounds were present and high-pitched. Therectum felt empty and ballooned, but removing the finger re¬leased a stream of watery reddish-brown fluid.V/BC was 29 X 10^/l, with Qjfo neutrophils. BOO showed noabnormality. Plain films of the abdomen showed gaseous dis¬tension of th< colon end an increased volume of gas in the smallbowel. There --me " th :mb-printing" of the ascending colonbut the bowel wall did not appear thickened. The following day'.the abdomen wan slightly distended and a plain X-ray showedgaseous distension and multiple fluid levels in the smallbowel and colon. Bowel sounds were still present and increased.She remained apyrexial.Two days after admission, a barium en 'ma was performedimmediately prior to laparotomy. It demonstrated no abnormalityother than some deformity in the region of the recto-sigmoidjunction, presumed to be doe to a pelvic mass causing obstructionof the bowel. At laparotomy, the bowel was gangrenous from theregion of the duodeno-jejunai junction to the splenic flexureof the colon, with isolated patches of gangrene on the sigmoidcolon. There was a good aortic pulsation, but no superiormesenteric pulsation. There was no cause for bowel obstructionor strangulation. No operative treatment -was undertaken. Thepatient died the following day. Permission for a post-mortemexamination was refused.CommentDegenerative vascular disease is unusual at any site in aj-'oman of this age, but is particularly uncommon in the mesentericarteries. (See table).Mesenteric artery occlusion is often preceeded by a historyof post-prandial abdominal pain, evidence of peripheral vascular4disease of a source of arterial emboli. In one study, all but3 of 25 patients with ischaemic bowel disease had one or morepredisposing conditions'?The onset is usually heralded by severe generalizedabdominal pain and vomiting. Abdominal distension developsearly and is progressive. Bloody diarrhoea is a late feature.Peristalsis may be hyperactive initially, b t with the onset ofperitonitis and peripheral circulatory failure, peristalsis is5suppressed. Temperature rises dramatically.In this case the pathology, unexpected for the patient'sage and sex w s not suggested by the previous history or thefindings at the time of admission.Cause of deathNo of deaths in 1978All ages 50 - 55 yrsM F M FArteriosclerosis 334 621 1 0Arterial embolism and thrombosis 92 148 6 1Embolism and thrombosis ofmesenteric artery60 97 4 1From: Annual Report of Registrar General for Scotland, 1978., References1Ockner, R.K. : Vascular Diseases of the Intestine. In Beeson,P.B. McDermott, W. and Wyngarden, J.B. (eds) : Cecil Textbookof Medicine, 15th Ed. Philadelphia, W.B. Sa nders Company,1979. p. 1588.2Anon. : Gut ischaemia. Br. Med. J. (edit) 1 (6076) 1557-8,18th June, 1977.3Castelli M.F., Quizilbash A.H., Salem S., Pyshe T.G. IschaemicBowel Disease. Can. Med. Assoc-. J. 1974; 111 (9) : 935-6, 939-41 .^Ockner R.K. : Vascular Disease of the Bowel. In SleisengarM.H. and Pordtran J.S. (eds) : Gastrointestinal Disease. 2nded. Philadelphia. W.B. Saunders Comoany, 1978 p. 1899-1902.3Rhoads J.P. and Kbop C.E. : Diseases of the Mesentery. InBockun H.L. : Gastroenterology. 2nd ed. (Vol 2). Philadelphia.W.B. Saunders Company. 1964. p. 1171-2.I am grateful to Dr. W.H. Price for permission to report thiscase and to Dr. M. Pirie, Dr. M.A. Eastwood, Dr. G.M. Frasor.and Mr. M.C. Milson for their assistance.G.U. Tait - Medical StudentV/es tern General HosratalUniversity of EdinburghUeoartment of Medicine'est'rn General HospitalCreve Road SouthEdinburghEII4 2XUMr. G.W. Tait,24, lioodburn Terrace,Edinburgh,EH10 43S

Unusual clinical presentation of ischaemic bowel disease

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Unusual clinical presentation of ischaemic bowel disease

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