Multifocal Infarction Along the Alimentary Canal in the Context of Ostensible Salmonellosis: A Case Report

Ischemic and/or infarction events of the alimentary canal are uncommon but potentially disastrous injuries of the digestive system that often portend a poor prognosis. Alimentary ischemia occurs when the vascular supply to one of the component conduit organs is disrupted or blocked, resulting in decreased tissue perfusion, subsequent necrosis, perforation, and even death if proper perfusion is not restored. We report a case here of a 67-year-old female who originally presented to the emergency department (ED) with nausea, vomiting, diarrhea, and progressively worsening abdominal pain. Conservative therapies that were initially employed failed to provide lasting symptom relief, and the patient was admitted for a more in-depth diagnostic workup and closer monitoring. During subsequent days of her resulting hospital stay, the patient had a positive result for Salmonella spp. on a stool PCR assay, an increasing leukocytosis, and the presence of several other worrisome laboratory abnormalities. Despite appropriate antibiotics and aggressive fluid resuscitation efforts, the patient's abdominal pain and laboratory profile continued to progressively worsen. At one point, the patient's condition perilously worsened, necessitating an emergent exploratory laparotomy. During the course of this surgery and subsequent surgeries, the patient was found to have multiple areas of infarction present including at her esophagus, stomach, duodenum, proximal jejunum, and right colon. Additionally, evidence of a metastatic neuroendocrine tumor of gastrointestinal (GI) origin was also incidentally found. Several subsequent surgical operations were required to repair the extensive tissue damage that the patient had sustained, and the patient's resulting hospital stay was complicated repeatedly by several different secondary infections and surgical complications. Attempts to determine the underlying cause for the ischemic events this patient experienced failed to yield definitive results, and no evidence for any arterial insufficiency or emboli was ever discovered. Despite this, a review of the histopathologic and laboratory findings from the tissue resected from the patient did find information to suggest that a relatively localized but severe venous thrombotic process likely occurred in the patient's alimentary vasculature that directly led to her presentation. Venous thrombosis of the mesenteric vessels and in the other vascular planes of the alimentary canal is often insidious in its presentation and poses a unique diagnostic challenge to clinicians. This case is significant because it illustrates the diagnostic complexity and difficulty imposed by mesenteric ischemia, especially cases resulting from mesenteric venous thrombosis (MVT) due to their often more indolent and atypical presentation. In short, a high level of clinical suspicion and familiarity with this ailment and its risk factors should be maintained because, in the absence of timely intervention, significant morbidity and/or mortality are likely to result.