(388) Quietly Necrotic: A Tale of a Bowel's Silent Scream

Introduction: Acute abdominal pathology is often associated with hemodynamic compromise and elevated laboratory markers, such as serum lactate. However, the absence of laboratory derangements does not exclude such conditions. It is paramount to consider all confounding variables with the physical exam and ancillary testing. We present a patient with acute ischemic bowel devoid of hypotension and lactic acidosis.

Description: A 49-year-old male with alcohol use disorder presented with chest pain and atrial fibrillation. Within 48 hours of admission, the patient developed delirium tremens requiring intubation and intravenous sedation. A computed tomography (CT) scan, prompted by abdominal distention, unveiled cecal and ascending colon pneumatosis and small bowel distention, while lactate levels remained at 1.0 mmol/L. Despite the absence of lactate acidosis and relative hemodynamic stability, an exploratory laparotomy revealed a necrotic right colon. He underwent a right hemicolectomy, terminal ileum resection, and partial omentectomy. An additional CT, due to recurrent fevers, revealed a large subhepatic abscess requiring drain placement. Subsequent CT showed resolution and antibiotics were adjusted per cultures. Due to the difficulties in liberating him from mechanical ventilation, a tracheostomy was necessary to support his recovery.

Discussion: Serum lactate, which may suggest anaerobic respiration due to tissue hypoperfusion, has offered inconsistent results in diagnosing acute intestinal ischemia in regards to extent and presence of disease. These inconsistencies can stem from factors including liver or kidney conditions and differences in sampling methods. D-lactate has failed to show superiority over L-lactate due to variation in gut motility and diet. Diagnostic efficacy varies based on subtype of intestinal ischemia with best results seen in arterial and non-occlusive forms. Despite CT imaging's accuracy, it may overlook early cellular changes. Ultimately, comprehensive analysis encompassing contrast-enhanced imaging, laboratory anomalies, physical examinations, and patient-specific factors is optimal for diagnosis. This case highlights the limitations of serum lactate in the diagnosis of bowel ischemia and its absence should not exclude surgical evaluation and management.