Significance: Acute mesenteric ischemia is rare and accounts for 1:1,000 to 1: 10,000 acute hospital admissions in USA, Europe and Japan; and is associated with high morbidity and mortality if remain unrecognized. It can happen during colonoscopy, especially in patients with history of cardiac arrhythmia.
Clinical Presentation: This was a case of a 51-year-old female, known hypertensive with paroxysmal atrial fibrillation, who initially presented with constipation with bloatedness after a spine surgery. Chest findings were normal. Heart rate was normal and rhythm was regular. Abdominal examination revealed a globular abdomen with hypoactive bowel sounds, tympanitic on percussion, soft on palpation with tenderness in all quadrants. No peritoneal signs. On digital rectal examination, noted were tight sphinteric tone, no mass, no blood with fecal material present on examination finger. The constipation was unresponsive to laxatives, prokinetic and enemas.
Management: Initial impression was ileus probably secondary to cervical dysautonomia vs partial gut obstruction from colonic new growth. On CT scan, there was only noted dilatation of descending and transverse colon with fecal retention without evidence of bowel obstruction. Patient then underwent colonoscopy, and during colonoscopy, had episode of atrial fibrillation and desaturations and suddenly developed gangrenous bowels from previously normal-looking colonic mucosa and underwent emergency exploratory laparotomy.
Recommendation: Different therapeutic approaches are proposed for management of superior mesenteric artery embolus and these include surgical revascularization, intra-arterial perfusion with a thrombolytic agent, intra-arterial perfusion of vasodilators and simple systemic anticoagulation. But there is a uniform agreement that exploratory laparotomy is mandatory when signs of peritonitis are present.
Keywords: Case report, constipation, acute mesenteric ischemia, colonoscopy, cardiac arrhythmia