PMC9458872_01
Timeline with relevant anamnestic, therapeutic, and operative data.
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A timeline with relevant anamnestic, therapeutic, and operative data is presented in Figure 1.
Intravital microscopy measurements. Zero hour (T0), day 3 after ICU admission. Onset of septic shock with generally compromised but the microcirculation was preserved. Twenty four hours (T3), day 4 after ICU admission. Sublingual 24 h (T3): the overall vessel density is higher than in the rectal measurement. Sublingual description: (1): Capillary of about 10 mum diameter. Due to hemodilution caused by the fluid resuscitation, there are heterogeneous aspects in the run of this and other capillaries. In contrast to the rectal vessels, these vessels showed flow after carefully releasing pressure which the probe applied to the tissue. Additionally, the diameter of this vessel only allows one, at most two erythrocytes to move through, so that heterogeneous absorption patterns and even discontinuities can be explained by the folding of erythrocytes. An unimpaired vessel of 70 mum on the other hand should have plenty of moving cells, so that discontinuity and irreversible stagnant flow should not arise. (2): Area with normal vessel density and visible capillaries. Rectal description: (1): Arteriole of about 50 mum diameter. The vessel appears to have multiple lumina as well as a heterogeneous absorption along its run. We suspect this to represent clotting. (2): Arteriole of about 20 mum diameter. The lumen of this vessel is brighter at the center than at the walls, which may also represent clotting. (3): Loop of an arteriole, approximately 20-30 mum. Heterogeneous absorption, apparently multiple lumina and even discontinued run. (4): Area without visible capillaries. All vessels presented no flow. Even with the lowest possible pressure that would still allow seeing the vessels, it was not possible to restore flow, which makes a pressure artifact highly unlikely. Forty eight hours (T4), day 5 after ICU admission. Complete rectal perfusion failure. Color code (based on the MFI): Green: constant flow; Yellow: intermittent/sluggish; Red: no flow.
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Approximately 24 h after the onset of septic shock (T3), perfusion of the oral mucosa was still good, but in the rectal region, an almost complete perfusion failure was observed, suggesting an AMI (Figure 2).
(A): Rectosigmoidoscopy on day 4 and Colonoscopy on day 7 after ICU admission. Day 4: No signs of ischemia or necrosis up to 40 cm after ano. The bowel wall appeared vital. Day 7: Markedly ischemic hemic colon on the left. Rectum appeared to be conditionally vital, the colon from 20 cm to approximately 70 cm showed extensive mucosal necrosis with presumed involvement of all wall layers. (B): Pathohistological picture of the upper rectum. H&E staining magnification 25x (left) 200x (right). (1): Extensive mucosal and partial rectal wall necrosis with granulocytic demarcation; (2): Eosinophilic intravascular fibrin thrombus; (3): Fatty vacuoles.
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The bowel wall appeared vital (Figure 3A). The rectum appeared to be conditionally vital, the colon from 20 cm to approximately 70 cm showed extensive mucosal necrosis with presumed involvement of all wall layers (Figure 3A). The pathological anatomical diagnosis was gangrenous sigmoiditis with purulent peritonitis and ischemic colopathy due to high-grade outflow stenosis (2 mm) of the inferior mesenteric artery (Figure 3B) consistent with an acute on chronic mesenteric ischemia.