Lessons of the month 1: Mesenteric ischaemia secondary to infective endocarditis

A 60-year-old woman presented with sudden-onset epigastric pain, vomiting and small volume rectal bleeding. She had a history of mechanical mitral valve replacement, for which she was on warfarin. Computed tomography (CT) angiography of the abdomen showed gallstones, a fluid-filled stomach and faecal loading. She subsequently deteriorated with worsening abdominal pain and haemodynamic instability. Non-contrast CT showed small bowel ischaemia and infarction. She rapidly deteriorated and a decision was made that surgery was likely to be futile. She died soon afterwards. On review of the initial CT angiography, an occlusion within the superior mesenteric artery (SMA) was visualised. The post mortem showed small bowel infarction due to embolic occlusion of the SMA secondary to bacterial endocarditis of the prosthetic mitral valve. This case should prompt awareness among clinicians that acute mesenteric ischaemia secondary to septic embolisation should be considered in patients with risk factors for infective endocarditis presenting with acute abdominal pain.