EARLY DIAGNOSIS OF MESENTERIC THROMBOSIS IN NONAGENARIAN PATIENTS

Abstract

Case presentation: Patient NRP, a 93-year-old male, was admitted to the hospital through the emergency room on March 10, 2024, with sudden abdominal pain localized to the epigastrium, which progressed to diffuse abdominal pain associated with nausea. Physical examination revealed a globular, normotensive abdomen, with diffuse tenderness on superficial and deep palpation, a positive abrupt decompression sign, and an irreducible umbilical hernia. Other system findings were unchanged. His general condition was fair and pale. Urgent tests were requested, including a contrast-enhanced computed tomography scan of the abdomen and pelvis, which revealed thrombosis of the portal vein and branches of the superior mesenteric vein, with signs of small bowel edema, but no signs of intestinal distress. The patient was admitted to the intensive care unit under the care of the general surgery team, with strict monitoring and initiation of full anticoagulation. During hospitalization, he developed constipation. New imaging studies, performed using non-contrast CT, identified air-fluid levels and a "stack of coins" (stacking of bowel loops), without obstructive factors, indicating a subocclusive acute abdomen. Total parenteral nutrition (TPN) and enteroclysis were initiated to treat constipation. The condition progressed favorably, with return of bowel movements, good oral intake, and no new abdominal pain. The patient was discharged from the ICU to his room and subsequently discharged on March 20, 2024. Discussion: Acute abdomen is characterized by sudden and progressive abdominal pain, which may require hospitalization and, in urgent cases, surgical intervention within the first 24 hours. Mesenteric ischemia is a relevant cause of vascular acute abdomen, more common in the elderly, and results from the interruption of intestinal blood flow, usually due to thrombosis or embolus. Severe pain disproportionate to the physical examination is a significant warning sign. Diagnosis requires clinical evaluation, laboratory tests, and imaging, with CT angiography being the most sensitive method. Treatment may be clinical with monitoring, hemodynamic support, anticoagulation, and antibiotics; or surgical, indicated when there are signs of peritonitis or intestinal necrosis. Prognosis is directly linked to the speed of diagnosis and initiation of treatment. Despite the importance of early detection, clear guidelines regarding the ideal time for intervention are lacking, reinforcing the need for high clinical suspicion and early use of sensitive tests. Although in most cases, a laparotomy with removal of part of the intestine is necessary, for example, in this case, the patient was found to be quite stable, with no signs of bowel distress. Considering his age, conservative treatment with anticoagulants was chosen, and the patient responded well. Final comments: Vascular acute abdomen, although rare, is highly serious and requires rapid diagnosis to avoid necrosis and sepsis. CT angiography is the examination of choice, confirming mesenteric venous ischemia and guiding management. The case presented demonstrated that, in stable patients without signs of peritonitis, conservative treatment with early anticoagulation can result in a good outcome, even in elderly patients, reinforcing the importance of clinical suspicion and immediate intervention.