Acute bowel ischemia in the absence of radiological findings: A case for endoscopy.

Endoscopy successfully identified transmural bowel ischemia in a case where both clinical symptoms and radiological findings were inconclusive.

• The patient was a 73-year-old man admitted to the intensive care unit in septic shock.
• Laboratory tests showed markedly elevated inflammatory markers, creatine kinase, and lactate levels.
• Computed tomography angiography, the guideline-recommended initial diagnostic modality, did not provide conclusive findings for bowel ischemia.
• Endoscopy was subsequently performed and identified transmural bowel ischemia, which radiological workup had missed.

The patient had a large chronic left-sided inguinoscrotal hernia that was reducible and painless at admission, contributing to diagnostic uncertainty.

• The hernia was part of the patient's medical history and was noted to be reducible and painless at the time of admission.
• The combination of an atypical hernia presentation and nonspecific clinical and radiological findings made diagnosis of bowel ischemia particularly challenging.
• This clinical ambiguity was a key factor leading to the decision to perform endoscopy.

Current guidelines do not incorporate endoscopy into the standard diagnostic algorithm for acute mesenteric ischemia, despite its safety and worldwide availability.

• Current guidelines recommend computed tomography angiography as the initial diagnostic modality for suspected acute mesenteric ischemia.
• Direct laparoscopy is advised in uncertain cases under current guidelines.
• The authors note that gastrointestinal endoscopy is a common procedure available worldwide but 'is not mentioned in the current guidelines for the diagnosis of bowel ischemia.'
• Nontherapeutic laparoscopies and laparotomies remain a clinical concern, with unnecessary procedures potentially leading to 'morbidity and even death.'

The patient died due to several comorbidities, despite endoscopic identification of the bowel ischemia.

• The authors explicitly state that 'the patient died due to his several comorbidities.'
• The fatal outcome was attributed to the patient's underlying comorbid conditions rather than a failure of endoscopic diagnosis.
• The authors nonetheless concluded that the case demonstrates the diagnostic value of endoscopy in detecting intestinal ischemia when other modalities are inconclusive.

The authors argue that endoscopy should be incorporated into the diagnostic algorithm for patients with suspected mesenteric ischemia as a minimally invasive alternative in uncertain cases.

• Endoscopy is described as 'a valuable, minimally invasive tool in the diagnostic pathway for intestinal ischemia.'
• The authors position endoscopy as a potential means to reduce nontherapeutic laparotomies in cases where radiological findings are inconclusive.
• The case is presented as evidence that endoscopy 'can detect intestinal ischemia even when radiological findings are inconclusive.'
• The authors state the case 'clearly suggests that endoscopy should be incorporated into the diagnostic algorithm in patients with suspected mesenteric ischemia.'