Case #022

Severe abdominal pain with a soft, benign-feeling abdomen, pain out of proportion to examination findings, is the signature of acute mesenteric ischemia, and it is the reason the diagnosis is so often missed. The visceral peritoneum is not yet involved, so guarding and rebound appear only once the bowel has infarcted transmurally, by which point the operative mortality is dismal. An akinetic apical segment after a recent anterior infarct is a mural thrombus waiting to embolise, and aspirin alone provides no protection; the superior mesenteric artery is a favoured destination because it leaves the aorta at a shallow angle. Raised lactate with a metabolic acidosis and a leukocytosis reflect ischemic tissue, and a modestly raised amylase is a recognised non-specific finding that can misdirect towards pancreatitis. CT angiography is the investigation of choice and must be arterial phase: a routine portal venous study can miss the occlusion entirely. The scan also says how much time is left. The jejunal walls are thin and poorly enhancing, ischaemic but not yet dead, and no free gas means nothing has perforated, which still permits revascularization first: open embolectomy or endovascular retrieval of the clot, then resection of only what is frankly necrotic, with a second-look laparotomy at 24 to 48 hours because marginal bowel declares itself late. Antibiotics, fluid resuscitation and systemic heparin run alongside. Survival turns on time to reperfusion, mortality passing 70% once transmural infarction is established, which is why the decision to operate rests on this scan rather than on waiting for the guarding that would confirm the diagnosis too late to act on it. The other lesson sits in her discharge summary: an akinetic apex after anterior infarction warrants anticoagulation, not aspirin alone.