Ischemic Colitis after Hemorrhagic Shock Due to Obstetrical Reasons

Abstract

IntroductıonIschemic colitis is the most common form of ischemic injury of the gastrointestinal tract and arises from occlusion, vasospasm, and/or hypoperfusion of the mesenteric vessels [1]. In this case, a patient who suffered from ischemic colitis due to acute postpartum hemorrhage after cesarean section was presented. *Corresponding author: Case PresentationA 28-year-old, gravid-2 para-2 women was diagnosed with preeclampsia and abruption of placenta at 30 weeks of gestation had been operated in emergency conditions at another hospital. Developing postpartum hemorrhage, firstly she was treated by conservative methods then transferred to our clinic in five hours. On the first examination, the patient was pale and hypotensive. Her pulse was weak and tachycardic.Blood was oozing from the pfanenstiel's incision and there was 1500 ml of blood in the abdominal drain. Initial blood tests showed hemoglobin to be 6.1 g/dl, leukocytes 11.200/mm 3 , platelets 58.500/mm 3 , INR 1.23, D-dimer >4000 ng/mL, aspartate transaminase 62 U/mL, calcium 7.2 mg/dL, and fibrinogen 166.8 mg/dL. She had coagulation failure and shock.Emergent laparotomy was performed since the patient did not respond to bimanual uterine massage and uterotonic medication. At laparotomy we found of 2L hemoperitoneum. Uterine atony responded poorly to conventional uterotonics, bimanual uterine massage and also uterine artery ligation and internal iliac artery ligation. When the B-Lynch suture also failed to control bleeding, we proceeded to hysterectomy. On the postoperative first day, she developed hypertension and tachycardia (blood pressure was 230/135 mmHg; heart rate range 136 bpm and was treated with Esmolol Hydrochloride, Amlodipine, Furosemide and Sodium Nitroprusside. Ceftriaxon 2 g/day was administered. She had passage of flatus on postoperative day 2 and 3 then stabilized on postoperative day 4.On the fifth postoperative day, the patient complained of nausea, vomiting, abdominal pain and distension. Her bowel sounds were hypoactive and urine output was decreased. Her condition continued to deteriorate, and she developed acute renal failure, pyrexia (38.4°C) and increasing distension of the abdomen rapidly. Antibiotherapy was changed as Meropenem (1000 mg 3 x 1) and Teicoplanin (400 mg 1 x 1).Abdominal examination revealed mild to moderate tenderness. In the plain abdominal radiograph, the colon was filled with gas, and the ascending colon's diameter was increased to 96 mm (Figure 1). Air-fluid levels were present in the dilated bowel loops on upright radiographs. Computed Tomography (CT) imaging showed widespread colonic dilatation (Figure 2). Her laboratory values were as follows; white blood count, 30.600/μl; hemoglobin, 10.6 g/dl; platelets, 202.000/μl. As intestinal perforation could not be excluded, a laparotomy was performed.At laparotomy, the whole colon, especially the ascending colon was found to be greatly distended as well as pale and ischemic. There was no evidence of mechanical obstruction, perforation or peritonitis. A rectal tu...