Abstract
This report describes an 85-year-old man with chronic kidney disease and chronic heart failure with a history of repeated hospitalization due to volume overload. Hemodialysis (HD) was initiated in October 2009. He took warfarin because of chronic atrial fibrillation (Af). To prepare for the establishment of an arterio-venous fistula, we switched warfarin to heparin. Post operatively, warfarin was administered again. On the 11th postoperative day, he complained of abdominal pain after supper. At that time, clinical and laboratory findings were unremarkable. He than received pain-relieving medicine, which masked the symptom and allowed him to sleep during the night. The next morning, abdominal pain was worsening and rebound tenderness was noted. Enhanced computed tomography demonstrated superior mesenteric artery (SMA) occlusion. Since 13 hours had passed from the first symptom, we considered that interventional radiology (IVR) was inadequate and recommended surgery to resect the intestine. The patient and his family rejected surgery and the patient died 42 hours after the abdominal pain had initially occurred. It is still difficult to manage SMA occlusion even though diagnostic imaging and treatment have recently been developed. Even now, the outcome of SMA occlusion is extremely poor. One of the reasons is the difficulty to diagnose the disease soon after the abdominal pain initially occurs as in our case. Although Af is the most frequent cause of SMA occlusion, the indications for warfarin administration in HD patients with Af have not been established, which makes this case more complicated. A strategy for warfarin use in HD patients with atrial fibrillation needs to be investigated.
