A 38 year old male with no identifiable co-morbidities presented to the emergency department complaining of a 2-day history of progressively worsening abdominal pain, nausea, intractable vomiting and shortness of breath. Examination reveals tachycardia, respiratory distress, and abdominal pain out of proportion to the palpation. Apart from mild leukocytosis and a lactate of 2.2 mmol/L, D-Dimer 2100 ng/ml. All other laboratory investigations were normal. After normal plain films of the abdomen and chest, the patient underwent a computed tomography (CT) scan of the abdomen with contrast.\nThe scan revealed extensive thrombosis of the portal, splenic, superior and inferior mesenteric veins. The mid-portion of the small bowel was suggestive of venous ischemia. No pneumatosis intestinalis was noted. An incidental finding of a totally occluded right pulmonary artery consistent with a pulmonary embolism was noted.\nThe patient received heparin therapy prior to a diagnostic laparoscopy. Intra-operatively a markedly dusky jejunal segment was identified along with turbid fluid in all quadrants. Conversion to open laparotomy ensued followed by resection of the diseased segment with temporary abdominal closure (). The patient was admitted to the ICU for resuscitation and anticoagulation. The patient was later taken to theatre for a side to side anastomosis. The patient was subsequently placed on extracorporeal membrane oxygenation (ECMO) and is currently under care in the intensive care unit (ICU).
A 60 year old hypertensive male presented to our institution with significant respiratory distress. He was subsequently intubated in the ER due to deteriorating respiratory status and reduced level of consciousness. On day 8 of his ICU course, the left lower limb appeared dusky and mottled up to the mid-thigh (). The right distal forefoot displayed a well demarcated discoloration.\nCT angiography revealed; Infra-renal aortic left sided eccentric, non-calcified atheromatous plaque. Significant occlusion of the left common iliac artery extending to infra-popliteal arteries. A joint decision was made to avoid surgery given the poor prognosis associated with severe acute respiratory distress syndrome and high inotropic support. The patient expired the following morning.