What's Your Diagnosis? Acute Mesenteric Ischemia in the Emergency Department

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Emergency Department Management of Patients With Low Back Pain: A Review of Current Evidence correct.

Case Presentation: Diagnosis and Management of Acute Mesenteric Ischemia in the Emergency Department

A 55-year-old woman presents via EMS with vomiting and diarrhea in the setting of new, severe abdominal pain for the past 30 minutes…

The patient states that she was previously diagnosed with atrial fibrillation, but she never established care due to concerns about the cost of anticoagulation medication.
Her temperature is 37˚C; blood pressure, 156/90 mm Hg; heart rate, 110 beats/min; respiratory rate, 20 breaths/min; and oxygen saturation, 96% on room air.
On physical examination, you note that despite the patient reporting severe abdominal pain, she does not seem to have any significant tenderness or guarding. Her laboratory test results are notable for mild acute kidney injury but no leukocytosis or lactic acidosis.
You wonder whether these laboratory tests have sufficiently ruled out acute mesenteric ischemia. If not, is it still reasonable to move forward with CT imaging?

Case Conclusion

Based on the patient’s history of untreated atrial fibrillation and her physical examination, you believed that she was having an episode of acute embolic mesenteric ischemia. You recognized that you could not exclude the diagnosis based on WBC count or serum lactate, and the benefits of timely diagnosis of this condition outweighed the potential risks of administering IV contrast, so you ordered a CTA. Once obtained, it showed an acute clot without evidence of irreversible ischemia—yet. You resuscitated and anticoagulated the patient in the ED before sending her for emergent endovascular embolectomy.