Intestinal necrosis due to trauma!
Acute mesenteric ischemia is interruption of intestinal blood flow by embolism, thrombosis, or a low-flow state (e.g. aortic dissection). It leads to mediator release, inflammation, and ultimately infarction. It can occur as a result of arterial embolism, arterial thrombosis, mesenteric venous thrombosis and non-occlusive causes such as thoracic aortic dissection that can occlude any vessel orifice in the aorta, leading to decreased mesenteric perfusion and ischemia. Bowel damage is in proportion to the mesenteric blood flow decrease and may vary from minimum lesions, due to reversible ischemia, to transmural injury, with subsequent necrosis and perforation. The resultant intestinal infarction classically presents as relatively normal abdominal examination despite excruciating pain. Later, as necrosis develops, signs of peritonitis appear, with marked abdominal tenderness, guarding, rigidity, and no bowel sounds. Selective mesenteric angiography is the diagnostic procedure of choice in arterial occlusive disease. CT with angiography can directly visualize vascular occlusion, more accurately on the venous side, and reveal bowel wall edema or air within the bowel wall. X-ray is mainly used to rule out other causes. Necrotic bowel isn’t salvageable, so resection of the necrotic bowel back to healthy edge is necessary, with reanastomosis and restoration of blood flow performed afterwards. If ischemia presents due to acute occlusion of a mesenteric artery without necrosis of the intestine, it is desirable to revascularize the bowel. The involved mesenteric artery should be exposed and the occlusion either removed by embolectomy or bypassed, with postoperative mesenteric angiography to inspect and ensure optimal results.
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