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Acute Mesenteric Ischemia Diagnosed after Emergent Single-Balloon Enteroscopy

A 57-year-old woman presented to the emergency department with a 2-day history of progressive abdominal pain with vomiting and hematochezia in the last 12 h. There was no relevant personal or familial history, besides major depression. On physical examination, the patient presented tachycardia (110/min), as well as abdominal tenderness and distension. Laboratory studies revealed leukocytosis (white-cell count of 21,000/mm3), metabolic acidosis (pH = 7.21), and elevated serum lactate (7.5 mmol/L). Since a dark hematic content was present in the nasogastric tube, an upper gastrointestinal endoscopy was deemed necessary. In the upper gastrointestinal endoscopy, dark blood was visualized in the esophagus and stomach, whereas fresh blood was present in the duodenum. After thorough washing and aspiration, no active bleeding nor lesions were found up to the 4th part of the duodenum, but fresh blood was noted refluxing from the jejunum. An emergent single-balloon enteroscopy was performed, which showed distal to the angle of Treitz, congestive mucosa with hemorrhagic suffusions, dark coloration, circumferential ulcers, and spontaneous bleeding (Fig. 1, 2a–d), consistent with acute mesenteric ischemia (AMI). Computed tomography (CT) revealed total portal vein thrombosis extending from the superior mesenteric vein (Fig. 3a, b). The patient underwent emergent laparotomy. All of the jejunum and ileum was found to be necrotic during surgery; hence, no bowel was resected. The patient eventually died after surgery. AMI is defined as a sudden arterial or venous occlusion or a drop in the circulating pressure resulting in inadequate blood flow within the mesenteric circulation to meet the metabolic demands [1]. AMI is classified into four groups according to its etiology: arterial embolism of