ORIGINAL ARTICLE Abnormal Liver Functions as a Risk Factor for Acute Mesenteric Ischemia † Eol Choi, M.D.*, Suk Kyung Hong, M.D., Ph.D.*, Ji Hee Hwang, M.D † Divisions of *Trauma and Surgical Critical Care and Pediatric Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Purpose: Acute mesenteric ischemia (AMI) is a potentially fatal condition resulting from inadequate blood supply to the bowels. The clinical features and prognostic factors of AMI are described to aid physicians in clinical decision making. Methods: The electronic medical records of 39 patients (19 women, mean age: 65.26±11.13 years) who underwent surgery for AMI from 2007 to 2009 were retrospectively collected and analyzed. Clinical variables and laboratory parameters on the day of admission or first day of symptoms were analyzed. The primary outcome of interest was patient survival. Multivariate analysis was performed to identify independent predictive factors associated with poor outcome. Results: Co-morbidities included hypertension (27/39 patients) and diabetes mellitus (14/39). Most patients (23/39) visited the emergency room for AMI-related symptoms, others (16/39) had their first symptom during an unrelated hospitalization. The mean blood pressure at initial assessment was 93.5±23.9 mmHg and pulse rate was 101 beats/min. Fever was experienced by 17/39 and shock by 13/39 patients. Patients underwent bowel resection (32/39) Correspondence to: Suk Kyung Hong, M.D. Ph.D. or diagnostic laparotomy (7/39). The mean intensive care unit stay was 13 postoperative days Division of Trauma and Surgi- and hospital stay, 28.3 days. Twenty-two patients (56.1%) were discharged with improvement, cal Critical Care, Department of and 17 patients (43.9%) died. Acute renal failure, elevated aspartate aminotransferase (AST), Surgery, Asan Medical Center, elevated alanine aminotransferase (ALT), abnormal bilirubin, and shock were significantly University of Ulsan College of associated with death by univariate analysis. Elevated AST and ALT were strongly associated Medicine, 88 Olympic-ro 43-gil, with mortality by multivariate analysis with logistic regression. Songpa-gu, Seoul 138-736, Conclusion: Abnormal liver function indices may be predictive of poor prognosis among Korea patients with AMI. (J Acute Care Surg 2014;4:79-84) Tel: +82-2-3010-3510 Fax: +82-2-3010-6701 Key Words: Mesenteric vascular diseases, Liver diseases, Aspartate aminotransferases, E-mail: [email protected] Bilirubin, Intensive care units Received August 22, 2014, Revised September 14, 2014, Accepted September 15, 2014 Copyright © 2014 by Korean Society of Acute Care Surgery cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ISSN 2288-5862(Print), ISSN 2288-9582(Online) Introduction thromboembolism, ischemic colitis, and global hypoperfusion. Its clinical presentation varies from a mild and limited form Acute mesenteric ischemia (AMI) is a potentially fatal to fulminant transmural bowel necrosis. Patients with AMI face condition resulting from inadequate blood supply to the bowels. a high mortality rate [1], due to the difficulty in diagnosis and It is implicated in various conditions, including acute mesenteric advanced age with multiple associated conditions. Early J Acute Care Surg Vol. 4 No. 2, October 2014 79 J Acute Care Surg Vol. 4, No. 2, Oct. 2014 diagnosis and treatment are crucial for better prognosis [2]. Results To identify patients who require prompt and aggressive evaluation, clinicians must understand the characteristics and Patients predictive factors for poor outcome of AMI. The objective of The 39 patients included 20 men and 19 women, with a this study was to identify predictive factors for poor outcome mean age of 65.26±11.13 years. Table 1 shows the demographic in patients with AMI who require surgical resection, in order to aid physicians in clinical decision making. Table 1 . Characteristics of patients and clinical findings at initial assessment Methods Survivor Nonsurvivor Characteristic p-value (n=22) (n=17) The electronic medical records of 39 patients who underwent Age (y) 68.64±10.3 60.8±10.9 NS surgery for AMI at Asan Medical Center (Seoul, Korea) from Men 11 (50.0) 9 (52.9) NS Comorbidities 2007 to 2009 were retrospectively analyzed. Patients with a Hypertension 15 (68.2) 12 (70.6) NS mechanical condition (e.g., strangulation of the bowel) Diabetes mellitus 7 (31.8) 7 (41.2) NS responsible for the bowel ischemia were excluded from the Arrhythmia 8 (36.4) 7 (41.2) NS Chronic renal failure 0 (0) 3 (17.6) NS study. Clinical variables, including age, sex, past medical Heart failure 3 (13.6) 5 (29.4) NS history, symptoms, signs, and hemodynamics, and laboratory Vasculopathya) 7 (31.8) 7 (41.2) NS parameters obtained on the day of admission or on the first Smoking 4 (18.2) 3 (17.6) NS Clinical findings day of symptoms were analyzed. To identify significant Inpatient occurrenceb) 5 (22.7) 11 (64.7) 0.011 predictive factors, the clinical status (including presence of ER visit for symptoms 17 (77.3) 6 (58.8) 0.030 c) shock, acute renal failure [ARF], and other organ failure) when Fever 7 (31.8) 10 (58.8) NS Mean BP (mmHg) 98.3±22.7 87.4±24.7 NS the first symptom developed was also analyzed. Operative Pulse rate (beats/min) 98.1±22.9 103.6±27.4 NS findings, including etiology of AMI, surgical procedure, and Shockd) 4 (18.1) 9 (52.9) 0.039 e) location of mesenteric ischemia, were recorded. Acute renal failure 6 (27.3) 11 (64.7) 0.026 Initial laboratory parameters ＞ ARF was defined as serum creatinine 1.8 mg/dl or urine WBC (×103/μl) 14.4±6.4 17.5±9.04 NS output ＜0.5 ml/kg/h. Shock was defined as a mean blood Hb (g/dl) 12.7±2.3 11.6±3.30 NS pressure (MBP) ＜65 mmHg or use of a vasopressor to BUN (g/dl) 27.7±17.5 36.1±18.6 NS Creatinine (mg/dl) 1.4±0.9 2.01±0.90 0.048 maintain tissue perfusion. Fever was defined as a body AST ＞40 IU/L 6 (27.3) 14 (82.4) 0.001 temperature ＞37.2oC. ALT ＞40 IU/L 1 (4.6) 9 (52.9) 0.001 Data are presented as means±standard deviations or numbers Bilirubin (mg/dl) 1.42±0.94 7.44±10.1 0.008 PT (INR) 1.9±1.0 2.33±1.24 NS with percentages. Statistical analysis was performed with SAS aPTT (s) 46.6±21.2 51.66±40.30 NS software (version 9.1; SAS Institute Inc., Cary, NC, USA). CRP (mg/dl) 11.9±8.7 13.3±14.4 NS Patients were divided into two groups (survivors and non- Values are presented as mean±standard deviation or number (%). survivors), which were compared by univariate analysis. Quali- NS: nonsignificant, ER: emergency room, BP: blood pressure, WBC: white blood cells, Hb: hemoglobin, BUN: blood urea nitro- tative variables were compared with two-sided tests at the 5% gen, AST: aspartate aminotransferase, ALT: alanine aminotrans- significance level and with the chi-square test as applicable. ferase, PT: prothrombin time, INR: international normalized ratio, aPTT: activated partial thromboplastin time, CRP: C-reactive protein. Logistic regression was performed to identify independent a)Vascular disease, including artherosclerosis obliterans, coronary factors associated with poor outcome. heart disease, and cerebral infarction; b)onset of symptom during hospitalization for another disease; c)body temperature ≥37.2oC; d)mean BP ＜65 mmHg or using inotropics to maintain BP; e)serum creatinine ＞1.8 mg/dl or oliguria ＜0.5 ml/ kg/h. 80 www.jacs.or.kr Eol Choi, et al: Predictive Factors in Acute Mesenteric Ischemia and clinical characteristics of patients and clinical findings on Table 2 shows the etiology of AMI. Superior mesenteric initial assessment. Patients had various comorbidities, including artery (SMA) obstruction, superior mesenteric vein (SMV) hypertension (69.2%), diabetes (35.9%), arrhythmia (38%), obstruction, and nonocclusive mesenteric ischemia (NOMI) chronic renal failure (7.7%), heart failure (20.5%), and vasculo- were found in 33.3%, 12.8%, and 53.8% of patients, respec- pathy (35.9%). None of the comorbidities showed significant tively. Cases of AMI with SMV obstruction showed a trend association with mortality. More than half of the patients (23/39, of good prognosis, but the association was not statistically 58.9%) visited the emergency room for their AMI-related significant. The location of the involved intestine is shown in symptoms. Others (16/39. 41.1%) had their first symptom Table 3. Right colon ischemia was more common (48.7%) than during hospitalization for another illness. In these 16 patients, left colon ischemia. Total colon involvement was found in 6 patients were postoperative state of cardiac surgery. And three 28.2% (11/39) of patients, and 30.7% (12/39) of patients had patients were postoperative state of surgery for abdominal aortic simultaneous small bowel ischemia and right or left colon aneurysm. Two patients were postoperative state of trans- ischemia. The location of the mesenteric ischemia showed no plantation. One underwent liver transplantation, the other significant association with mortality. underwent kidney transplantation. Four patients admitted to the Regarding the surgical procedure, 32 patients (82.0%) hospital due to heart, lung and kidney problem (e.g., acute underwent bowel resection, and seven patients (17.9%) had myocardial infarction, acute respiratory distress syndrome). At diagnostic laparotomy. Among the seven patients, four patients the initial assessment, the MBP and pulse rate of patients were were inoperable because no viable intestine remained, and three 93.5±23.9 mmHg and 101±24.6 beats/min, respectively.