LAUSR

A 64-year-old female presented to the emergency department (ED) of a metropolitan hospital with a 12-h duration of acute onset severe abdominal pain and distension. Her past history was significant for scleroderma complicated by interstitial lung disease and gastrointestinal (GI) involvement with known small bowel dysmotility on domperidone, gastro-oesophageal reflux and Barrett’s oesophagus. Due to small bowel dysmotility, the patient had recurrent presentations of severe abdominal pain, distention and vomiting, which has previously self-resolved with conservative management. A magnetic resonance enterography performed over a year prior demonstrated a dilated bowel from the duodenum to distal small bowel, suggestive of chronic pseudo-obstruction consistent with GI scleroderma (Fig. 1). On arrival to ED, the patient was haemodynamically unstable with a heart rate of 112 beats/min and blood pressure of 79/39 mmHg. Her abdomen was grossly distended and tense, a venous blood gas suggested a metabolic acidosis with a pH of 7.19 and lactate of 5.9 mmol/L. Intravenous fluid resuscitation and vasopressor support were rapidly initiated. Computed tomography (CT) scan of her abdomen/pelvis demonstrated markedly dilated, hypo-enhancing small bowel loops with pneumatosis intestinalis and extensive free intraperitoneal fluid suggestive of severe, extensive bowel ischaemia in the superior mesenteric artery (SMA) territory. Proximal SMA stenosis was noted on CT but with preserved distal arterial supply contradicting complete ischaemia (Fig. 2). No evidence of atrial fibrillation was identified on the electrocardiogram and the patient had no other risk factors for a thromboembolic event. Urgent exploratory laparotomy revealed aperistaltic, severely dilated small bowel with a dusky appearance throughout its whole length consistent with mesenteric ischaemia. SMA pulse was absent Fig. 1. Magnetic resonance enterography: Coronal slice demonstrating marked small bowel dilation.