acute mesenteric ischemia ( ami ) is an emergency situation that is caused by circulatory disturbances of mesenteric vessels and is frequently associated with atherosclerosis and cardiovascular disorders .
ami is a complex disease entity including acute mesenteric arterial embolism and thrombosis , mesenteric venous thrombosis , and non - occlusive mesenteric ischemia ( nomi ) .
nomi results from low - velocity blood flow states or from mesenteric vasoconstrictions caused by some drugs .
the abdominal pain caused by intestinal ischemia is not proportional to the physical examination findings , especially in elderly persons .
although computed tomography ( ct ) , magnetic resonance imaging and angiography are valuable diagnostic steps , definite diagnosis of intestinal ischemia frequently depends upon the clinical history because the representation would be subtle and obscure . the majority of patients with ischemic colitis can be treated medically , but approximately 20% of the patients clinically deteriorate to develop peritonitis and sepsis , necessitating surgical intervention with an associated 60% mortality rate [ 1 , 2 ] .
a laparotomy is helpful for rapid confirmation of the diagnosis and for optimal treatment , which often consists of revascularization and resection of the affected bowel .
alcohol is well recognized as a systemic toxin that causes serious health problems , including psychosocial problems , myocardial infarction , stroke and atherosclerosis .
we reported a case of sub - acute ileal and colonic ischemia in an elderly patient , not having a history of cardiovascular disorders , after heavy alcohol intake , and we present a review of the literature .
an 80-year - old male patient was admitted due to uncontrolled diarrhea and abdominal pain accompanied by fever . he became unconscious after drinking 1,800 ml of soju ( korean traditional drink
, 25% distilled alcohol ) in one sitting and was then admitted to a local clinic . after conservative management
, he woke up coherent , but he was referred to ewha womans university mokdong hospital because his diarrhea , fever and abdominal pain had not subsided after 10 days .
he had no history of chronic diseases such as diabetes , cardiovascular disease , hypertension , hepatitis or smoking .
he had had a drinking habit of half a bottle of soju ( 90 ml ) daily for forty years .
on admission , his blood pressure was 110/60 mmhg , his pulse rate was 84 beats / min , his respiratory rate was 24 breaths / min , his body temperature was 36 , and his mental status was clear . he had continuously suffered from diarrhea from the onset of the illness , 6 to 7 times daily , including night - time defecation . upon physical examination , there was mild generalized tenderness with abdominal distension on the whole abdomen and hyperactive bowel sound .
laboratory data included the following : leukocyte count , 14,100/l with no leftward shift ( neutrophil count , 61.8% ) ; hemoglobin level , 12.1 g / dl ; platelet count , 263,000/dl ; total protein , 4.8 g / dl ; albumin , 2.2 g / dl ; aspartate transaminase , 78 iu / l ; alanine transaminase , 103 iu / l ; blood urea nitrogen 8 mg / dl ; serum creatinine , 0.7 mg / dl ; amylase , 82 u / l ; creatine kinase , 48
upright and supine roentgenograms of the abdomen showed the paralytic ileus with bowel distension ( fig .
abdominal ct scan showed circumferential wall thickening of the bowel from the distal ileum to the ascending colon ( fig .
frequently the clinician finds no evidence of alcohol - induced hepatitis or pancreatitis that could be the cause of abdominal pain in patients suffering from alcohol abuse . upon the suspicion of ischemic colitis ,
the patient was treated with intravenous hydration , bowel rest , and broad - spectrum antibiotics .
after 5 days of treatment , he still had intermittent fever above 39 and severe cramping abdominal pain . on day 7
diffuse wall thickening of the terminal ileum to the transverse colon and a large amount of ascites in the pelvic cavity were noted in the ct scan ( fig .
mucosal edema and multiple phlegmons were found on the ascending colon with colonoscopy ( fig .
, symptoms such as diffuse abdominal distension , abdominal tenderness and rebound tenderness were aggravated ; hence , a laparotomy was performed .
when the abdomen was opened , a small amount serous colored ascites was noted in the pelvic cavity .
the outer surface of the ileum ( from the ileocecal valve to the proximal 30 cm ) looked dark brown to blackish with severe edema and a weakening of the tissues of the bowel wall was observed .
also , the findings of the cecum and the ascending colon appeared to be similar to those of the affected ileum .
the gross appearances of the transverse and the descending colon and the sigmoid colon were almost normal .
pathologically , a diffuse acute infarction was present in the ileum and cecum , with acute vasoconstrictions of the mesenteric vessels .
a polyp of 0.4 cm was found on the ascending colon , 13 cm distal to the ileocecal valve , and was revealed to be a mucosal adenocarcinoma .
the postoperative course was uncomplicated , and the patient was discharge in good condition on the 15th postoperative day .
nomi , the dominant non - thrombotic cause of acute mesenteric ischemia , results from low - flow states ( cardiogenic shock , sepsis , and hypovolemia ) , vasoconstriction , or occasionally drugs .
nomi is defined as " intestinal infarction without mesenteric vascular occlusion , " and is the most lethal form of ami , with mortality rates of up to 70% [ 3 , 4 ] .
the condition commonly occurs in elderly patients , but a subset of young patients with mesenteric ischemia has been reported in the literature . in this young population , etiologies were reported as hypovolemic shock , vasculitis , and drug use .
medication and addictive drugs , such as digitalis , oral contraceptives , phenobarbital , ergotamine , furosemide and cocaine , have been implicated in the development of ischemic intestinal disease .
for a long time , alcohol has been known to be a precipitating factor of vasodilatation ; thus , after alcohol intake , the face becomes red , the blood pressure falls and the blood flow increases in the splanchnic vasculature . unlike such physiologic changes
, pathological binge drinking is known to act as a vasocontricting situation and to be the cause of cardiovascular events . during the past ten years
, alcohol consumption has come to be known as a risk factor for developing cerebral vascular diseases , such as stroke .
several studies suggest that ethanol produces prolonged constrictions in cerebral blood vessels , and the vasoconstrictive actions of ethanol are involved in the hypoxic , ischemic and hemorrhagic actions on the brain [ 5 , 6 ] .
although several studies have investigated alcohol 's effect on the vascular system , there are no reports that alcohol - caused mesenteric vasoconstriction directly causes intestinal ischemia .
the mechanism of alcohol - induced splanchnic vasoconstriction is unclear and is thought to be multifactorial .
several mechanisms want for consideration to explain how alcohol causes bowel ischemia in spite of the difficulty in proving a direct causal relationship between the abuse of alcohol and intestinal ischemia . at first
, alcohol may have a direct toxic effect on the gut mucosa and increase bacterial overgrowth in the small intestine [ 7 , 8 ] .
this persistent mucosal irritation is also likely to impair the susceptibility to abundant normal bacterial floras inside the bowel .
another indirect effect of alcohol on the mucosal microcirculation is an enhanced trans - capillary fluid filtration , increasing the permeability of the mucosa to macromolecules , such as endotoxin and/or other bacterial toxin that cause sepsis .
in such a state , the intestinal infection has already started and may result in an irreversible clinical course .
alcohol intake induces abnormalities in the plasma proteins that are required for blood clotting , leading to the formation of blood clots and the thrombotic occlusion of arterioles .
alcohol may induce mesenteric vasoconstriction directly by suppressing the endothelium - dependent vasorelaxation , leading to reduced blood flow and ischemia . in our case ,
the patient had no history of any specific infection , had no predisposing factors for systemic vascular problems , and was healthy for his age .
we tried conservative treatment under the clinical diagnosis of acute gastroenteritis because there was no evidence of thrombus or constricted vessels in the first series of ct scans , but , in spite of bowel rest and conservative management , the symptoms continued for 15 days ( including the treatment period at another hospital ) without improvement
. there were some differences between the operation findings and the ct findings . during surgery ,
however , the distal ileum to the mid - transverse colon showed diffuse ischemic change , and there were much ascites .
pathological examination of the mesenteric vessels harvested revealed neither thrombosis or embolus within arteries or veins nor evidence of inflammatory bowel disease , such as systemic vasculitis and chronic granulomatous inflammation .
extensive mucosal necrosis , which was associated with inflammation of the mucosa and vascular congestion , was consistent with nomi .
it is doubtful that the clinical course of this patient would have been positive if prompt surgery had not been performed . recently , with increasing average life span , the elderly population has been increasing rapidly .
many studies on systemic vascular disorders in the elderly have been reported . in the case of emergency situations such as cerebrovascular disease or cardiovascular disease ,
the best procedure has been established relatively well . however , there are frequent occasions where even doctors can not diagnose an intestinal infarction when a patient presents with an acute abdomen .
fortunately , with the improvement of high resolution ct , the accuracy of the diagnosis of an acute abdomen in the elderly is much improved .
ct may be helpful in determining the primary cause of bowel ischemia and in allowing direct evaluation of the bowel wall , the adjacent mesentery , and vascular structures .
ct is fundamental for early diagnosis and management when evaluating elderly patients with an acute abdomen , and we should have intestinal infarction in mind when evaluating patients with a history of binge drinking .
drug abuse , including excessive alcohol consumption in particular , has become a major health problem in korea .
this report established that , for successful treatment , mesenteric ischemia should be considered in the differential diagnosis of an acute abdomen in patients with a history of alcohol abuse .
 alcohol is well - recognized systemic toxin that causes numerous adverse effects , including psychosocial problems , fatal myocardial infarction , stroke and atherosclerosis . 
 the intra - abdominal complications caused by acute alcohol consumption have not been defined . 
 we report an 80-year - old man with sub - acute small bowel and colonic ischemia after heavy alcohol intake in one sitting . 
 we performed a resection of gangrenous bowel segments . 
 microscopically , there were diffuse infarction , with vasoconstriction of the mesenteric vessels in the ileum and colon without any thrombotic occlusion of the intestinal vessels . 
 the clinicians should always be assured by confirmation of a history of recent substance abuse in patients with unexplained abdominal pain , and mesenteric ischemia should be considered in the differential diagnosis of acute or chronic abdominal pain in consumers of alcohol . 