A 56 year old female presented with intractable pain and a cold right lower extremity. She had End Stage Renal Disease (ESRD) on hemodialysis, hypertension, and severe peripheral vasculature disease (PVD), with bilateral iliofemoral stents.
She had an angioplasty with stents but this was unsuccessful with continued compromised blood flow and progression of symptoms. She then had an above knee amputation and discharge to rehabilitation.
On day two in rehabilitation, 3 hours after hemodialysis, she became hypotensive, lethargic, and unresponsive. After fluid resuscitation, although her mental status improved, systolic blood pressure remained between 70-80’s and mean arterial pressure ≤ 65. At that time, she reported mild abdominal tenderness, but had no findings of an acute abdomen on physical exam. Her right stump was cold, tender and was mottled. Norepinephrine was started for perfusion. Over the next 4 hours, her mottled discoloration extended superiorly to the right lower abdomen and she now complained of severe pain of the right lower extremity. The abdominal pain did not progress. CT-Abdomen revealed an occluded right common iliac artery and calcifications of the superior mesenteric artery. Since there was no circulation in the right lower extremity, a hip disarticulation was performed and was immediately followed by an exploratory laparotomy. The findings of the exploratory laparotomy was severe ischemia throughout the entire small bowel, colon, stomach and liver. No further interventions were attempted and she expired.
Nonocclusive mesenteric ischemia is an emerging complication after hemodialysis where patients develop hypotension-hypoperfusion leading to intestinal gangrene even in the absence of significant obstruction. Severe abdominal pain is the main symptom.
NOMI incidence is 2.29 cases per 100 patients/year in dialysis patients with mortality in the first NOMI episode as high as 59 % and the 1-year mortality as high as 85 %. It is critical to try to prevent NOMI; efforts focus on limiting time of dialysis and to prevent hypotension. If NOMI occurs it requires prompt recognition, appropriate resuscitation and early intervention.
We postulate that this patient with severe PVD became hypotensive after dialysis, trigging an acute ischemia in her right stump initially, extended to intraabdominal organs, resulting in NOMI.
This case is unique in that the profound ischemia did not result in an impressive abdominal exam and the symptoms were initially in the lower extremity. The ischemic process affected stomach, small bowel, colon, liver and spleen.
Hospitalists commonly manage patients under hemodialysis and this case should increase our general awareness of NOMI.
Detection of high risk patients is important for prevention and a high clinical suspicion is critical. Considering the increasing incidence, an accurate scoring system for stratification is needed.