Repetitive Non-occlusive Mesenteric Ischemia Accompanied with Bradycardia and Portal Venous Gas

Abstract

We report an 88-year-old man suffering from repetitive non-occlusive mesenteric ischemia (NOMI) accompanied with bradycardia and portal venous gas. He was admitted to hospital with acute onset epigastralgia and vomiting. Consciousness was clear, but he was pale and had a cold sweat. Vital signs were normal except for sinus bradycardia (HR 42). Abdominal CT revealed portal venous gas. Over 14 months, he had three recurrences of symptoms. We administered a muscarinic antagonist that improved the symptoms at the first and the second recurrence; however, at the third recurrence, the antagonist was ineffective, and the patient had increased portal venous gas, intestinal intramural gas, and hyperlacticacidemia. We performed emergent operation because of the possibility of bowel necrosis. Intraoperative laparoscopy revealed no obvious necrosis, and indocyanine green fluorography revealed no vascular insufficiency. These findings suggested the involvement of NOMI in acute mesenteric ischemia. After surgery, isosorbide dinitrate transdermal patch was administered to prevent NOMI by inhibiting mesenteric artery spasm. A 4-year follow-up revealed no recurrence of NOMI. We report the first case of repetitive NOMI accompanied with bradycardia and portal venous gas and its successful treatment.