Acute mesenteric ischemia and duodenal ulcer perforation: a unique double pathology

We report a unique case of a 53 year old Italian lady who presented with acute mesenteric ischaemia and duodenal perforation. This is the first report of massive bowel ischaemia and duodenal perforation with no apparent underlying common pathophysiology leading to this presentation.Early management in the intensive care unit and appropriate surgical intervention maximised the patient’s chances of survival despite the poor prognosis associated with her dual pathology. The rare pathology of the patient described can be explained by two possible hypotheses: peptic ulcer disease causing duodenal ulceration, which precipitated ischaemic infarction of the small bowel. The second hypothesis is the patient developed a stress related ulcer following ischaemic bowel infarction secondary to arterial thrombosis.Acute mesenteric ischemia (AMI) comprises a group of pathophysiologic processes that have a common end point—bowel necrosis. The survival rate has not improved substantially during the past 70 years, and the major reason is the continued difficulty in recognizing the condition before bowel infarction occurs [1,2].Clinical presentation is nonspecific in most cases and can be characterized by an initial discrepancy between severe abdominal pain and minimal clinical findings. In general, patients with AMI have an acute onset of symptoms and a rapid deterioration in their clinical condition. Complications such as ileus, peritonitis, pancreatitis, and gastrointestinal bleeding may also mask the initial signs and symptoms of AMI [2].Acute mesenteric ischemia can be categorized into 4 specific types based on its cause. The most frequent cause is arterial emboli. They are responsible for approximately 40% to 50% of cases [1,3]. Most mesenteric emboli originate from a cardiac source. The second most common cause is acute mesenteric thrombosis accounts for 25% to 30% of all ischemic events [4,5]. Most of the reported cases of mesenteric ischemia due to arterial thrombosis occur wi