Patchy small bowel ischaemia secondary to sepsis.

Editor,

Insufficient blood perfusion to the small bowel may result from arterial occlusion by embolus or thrombosis, thrombosis of the venous system, or non-occlusive processes such as vasospasm or low cardiac output. Patterns of segmental, skipped, or patchy small bowel ischaemia have been reported post abdominal aortic aneurysm repair and is thought to imply that microembolisation has played an important role1. Microvascular thrombi in various organs can result from disseminated intravascular coagulation2. We present a case of patchy small bowel ischaemia in a septic patient who had developed evidence of disseminated intravascular coagulation.

Case presentation

A 50-year-old man prescribed four weeks of diclofenac for a muscular strain presented with frank haematemesis secondary to an eroding gastric ulcer measuring 7 cm in diameter. A partial gastrectomy and Rouxen-Y reconstruction was performed and a massive blood transfusion of 25 units was required peri-operatively. The patient was referred to a tertiary care centre for intensive care where on day six post operatively, he developed peritonitis as a result of a biliary leak from his duodenal stump. His blood tests at that time were suggestive of non-overt disseminated intravascular coagulation secondary to sepsis with an elevated D-dimer of 7.36 μg/ml (0.01–0.5 μg/ml). An emergency exploratory laparotomy was performed. This revealed a duodenal stump blowout and a 2 inch segment of proximal jejunum containing multiple less than 1 cm blisters in a triangular arrangement (figure 1). These were found to be necrotic areas and were resected. Histology of the specimen confirmed areas of transmural haemorrhagic ischaemic necrosis associated with a marked serosal exudate and incipient perforation. Thrombi were histologically identified within the omentum. Later in the post-operative period he developed bleeding from his duodenal stump for which he had successful radio-embolisation of the gastroduodenal artery. After a complicated postoperative period, he was discharged home. Although, patchy bowel ischaemia has been reported in past, this pattern in a mid jejunal small bowel segment containing multiple less than 1 cm areas of necrosis in a septic patient has not been reported to our knowledge.

Fig 1

Proximal jejunum with multiple necrotic areas

Discussion

Patchy small bowel ischaemia has been noted in patients following abdominal aortic aneurysm repair1. Some of these patients have been found to have widespread microembolisation or to have pathological evidence of microemboli. As a result it has been postulated that this pattern of ischaemia is a direct consequence of microembolisation3. Sepsis almost invariably leads to haemostatic abnormalities. These range from the insignificant to severe disseminated intravascular coagulation. Compelling evidence from clinical and experimental studies suggests that disseminated intravascular coagulation is involved in the pathogenesis of microvascular dysfunction and that deposition of microvascular thrombi can occur3,4. Given the above patient had an elevated D-dimer and evidence of thrombi on histology it is our feeling that the likely mechanism behind this unusual intra-operative finding was microembolisation. With sepsis related disseminated intravascular coagulation being the most likely cause.

Conclusions

We conclude that in septic patients, the bowel should be carefully examined as missing such pathology will have serious implications for critically ill surgical patients.