Mesenteric Ischemia in a Young Man With the First Presentation of Diabetic Ketoacidosis

Abstract

Background: Diabetic Ketoacidosis is known as an inflammatory state. Review of literature shows a number of cases of mesenteric ischemia described in the adolescent and adult population with long term IDDM. There have also been publications and reports of pediatric patients developing strokes.(1) However there are no reports of adults presenting with the first episode of DKA associated with acute mesenteric ischemia. The hypercoagulable state of DKA has been attributed to decreased activity of protein C and S. VWF activity and factor have also been shown to be increased prior to initiation of treatment and activity was shown to be continuously increased even at 120 hours after treatment. The prothrombotic state and activation of the vascular endothelium is thought be secondary to increased vWF and the decreased levels of protein C activity and of free protein S.(2) Clinical case: 37 year old man with no known past medical history presented with a few day history of abdominal pain, nausea and vomiting. He was found to be significantly hyperglycemic at 635mg/dL, acidotic with bicarb level of 6mEq/L and ABG Ph of 6.9. He was also found to have elevated B hydroxybutyrate >5.5mmol/L and ketones in urine. CT scan of the abdomen was nonspecific and he was started on an insulin drip and the treatment protocol for DKA. His lactic acidosis resolved from 3.9mmol/L to 0.8mmol/L. He clinically improved and started tolerating liquids and oral diet within a few hours. 36 hours after presentation, the patient reported recurrence of abdominal pain and nausea. Lab work up showed recurrence of lactic acidosis. His pain intensified and a repeat ct scan of the abdomen showed multiple dilated fluid filled loops with a transition point in the mid abdomen. Mesenteric vein gas was also noted which was concerning for SMA thrombosis and gut ischemia. Emergent surgical consultation was requested and the patient underwent exploratory laparoscopy and laparotomy which showed extensive small bowel ischemia with 135cm of unaffected small bowel. Patient underwent bowel resection and SMA arteriogram. He then required repeat surgery for inspection of bowels and closure of abdomen. Patient was liberated from the ventilator, and as his bowel function recovered, he was restarted on a clear liquid diet and advanced to a regular diabetic diet prior to discharge. Conclusion: This is a rare case of mesenteric ischemic in the setting of the first episode of DKA in an adult man. Both DKA and mesenteric ischemia are potentially fatal. Prognosis depends on detection and early treatment of both conditions. Persistent or recurrent abdominal pain, nausea and vomiting should raise concern for thrombotic and inflammatory complications of DKA. 1. Ho J, Pacaud D, Hill MD, Ross C, Harniwka L, Mah JK. Diabetic ketoacidosis and pediatric stroke. CMAJ 2005;172(3):327–8. [PMC free article] [PubMed] 2.Carl GF, Hoffman WH, Passmore GG, Truemper EJ, Lightsey AL, Cornwell PE, Jonah MH. Diabetic ketoacidosis promotes a prothrombotic state. Endocr Res. 2003 Feb;29(1):73–82. doi: 10.1081/erc-120018678. PMID: 12665320.

Rare Emergency Case of Bowel Ischaemia as a Result of Diabetic Ketoacidosis Complication: A Case Report and Literature Review of an Unusual Entity

“…Patients with diabetes are at risk of developing DKA as a feature of poor-controlling DM. DKA is an inflammatory process that is associated with a reduction in proteins C and S and enhancement of von willebrand factor activities, initiating a pro-thrombotic situation [1,3]. Further studies demonstrated that diabetic patients had elevated levels of clotting factors and aggregated platelets [1].…”

“…Ischaemic bowel and DKA relation is a life-threatening situation that is related to high morbidity and mortality rates [1]. This relationship can irreversibly damage the bowel through hypoperfusion, leading to infarcted and/or gangrenous bowel loops [3].…”

“…The resultant bowel ischaemia can be due to primary vascular factors. These include mesenteric ischaemia and bowel obstruction causes [2,3]. Multiple etiologies are related to disturbed perfusion of the small bowel wall, which can be classified into acute, including occlusive and nonocclusive mesenteric ischaemia, and chronic causes [2].…”

“…The non-occlusive mesenteric ischaemia (NOMI) can be manifested in traumatic abdominal injuries, systemic hypotension, and vasoconstriction induced by medication [2,3]. Small bowel obstruction is additionally involved in the NOMI component [2].…”

“…DKA occurs more frequently in the pediatric population with diabetes type 1 but is less likely in type 2 DM, accounting for 34% [2]. Contrary to the pediatrics, the literature reported few cases of bowel ischaemia related to DKA in type 1 DM in the adult population, and limited similar cases were documented in the adults with type 2 DM [3]. Non-occlusive mesenteric ischaemia (NOMI), which is a type of bowel ischaemia, is a rare complication of DKA associated with abdominal conditions, bowel necrosis, and sudden hypovolemia, leading to significant morbidity and mortality rates [1,4].…”