LOW THRESHOLD FOR LAPAROSCOPIC EXPLORATION IN DEMENTIA PATIENTS WITH UNEXPLAINED ABDOMINAL PAIN AND RISK FACTORS FOR ACUTE MESENTERIC ISCHEMIA

Objectives: Introduction
Acute mesenteric ischemia (AMI) is a surgical emergency with 60-80% mortality. Studies are limited on the presentation and diagnosis of AMI in dementia patients.

Case Presentation
An 88-year-old woman with dementia, hypertension, hyperlipidemia, type 2 diabetes mellitus, and hypothyroidism presented with acute onset severe abdominal pain and emesis. Her mental status was altered from baseline with fluctuating agitation and lethargy. Following admission, she developed new-onset atrial fibrillation with otherwise stable vitals. She had mild but diffuse tenderness on abdominal exam. Labs were significant for leukocytosis. CT chest, abdomen, and pelvis without contrast demonstrated right lower lobe pneumonia and a sliding hiatal hernia, but no intraabdominal pathology to explain her symptoms. Treatment for pneumonia and atrial fibrillation ensued and she was NPO for serial exams. She had persistent leukocytosis, developed lactic acidosis, kidney function worsened, and became distended with increasing tenderness, guarding, and pain out of proportion to exam on hospital day (HD) 3. A CT chest, abdomen, and pelvis with contrast on HD4 demonstrated new circumferential distal jejunal thickening with diffuse small bowel dilatation. Patient was taken to the OR for a diagnostic laparoscopy, with extensive bowel ischemia noted upon abdominal entry prompting conversion to exploratory laparotomy. Approximately 220 centimeters of small bowel and the proximal ascending colon were nonviable and resected with 40 centimeters of small bowel remaining. Upon ligation of the right colic artery, an organized clot was identified (Figure). She was left in discontinuity with a temporary closure and transferred to the ICU sedated, intubated, and requiring vasopressors. On HD6 she was taken back to the OR for re-exploration, jejuno-colostomy, gastrojejunostomy tube placement, and definitive closure. She gradually improved with nutritional support via TPN and tube feeds and was ultimately discharged on HD 39.

Discussion
AMI is a potentially life-threatening condition which can be difficult to diagnose early in the course of disease. This patient’s presentation was further complicated by dementia with superimposed AMS. However, her pain out of proportion to exam in combination with multiple risk factors prompted surgical exploration. After a prolonged hospitalization, she was able to return home with family but continues to require supplemental nutrition.

In an aging population with a rising prevalence of dementia, a high index of suspicion for AMI in patients with abdominal symptoms and risk factors is crucial to avoiding delay in care. Timely exploration is essential to minimize the significant morbidity and mortality associated with AMI.

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