Acute bowel ischemia in the absence of radiological findings

Rationale: In cases of suspected acute mesenteric ischemia, current guidelines recommend computed tomography angiography as the initial diagnostic modality, with direct laparoscopy advised in uncertain cases. However, the occurrence of nontherapeutic laparoscopies remains a clinical concern. Notably, endoscopy is not yet incorporated into standard diagnostic algorithms. Patient concerns: Here, we report the case of 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. His medical history included a large chronic left-sided inguinoscrotal hernia, which was reducible and painless at admission. Both clinical symptoms and radiological findings were inconclusive for bowel ischemia. Diagnoses: Since both clinical symptoms and radiological findings were unspecific, endoscopy was performed, and identified transmural bowel ischemia, highlighting its potential role as a valuable, minimally invasive tool in the diagnostic pathway for intestinal ischemia. Interventions: In uncertain cases, current guidelines recommend diagnostic laparotomy to diagnose bowel ischemia. However, unnecessary or nontherapeutic laparotomies are a serious concern, which can lead to morbidity and even death. Gastrointestinal endoscopy is a common procedure available worldwide. Despite its safety and availability, it is not mentioned in the current guidelines for the diagnosis of bowel ischemia. Outcomes and lessons: Although the patient died due to his several comorbidities, this case demonstrates that endoscopy can detect intestinal ischemia even when radiological findings are inconclusive. This case clearly suggests that endoscopy should be incorporated into the diagnostic algorithm in patients with suspected mesenteric ischemia.