Evaluation of the causes of delay in the diagnosis of acute mesenteric ischemia

Introduction: Acute mesenteric ischemia (AMI) is an acute abdominal disease with a high mortality rate resulting from sudden insufficiency of blood flow in the mesenteric vessels. Despite its poor prognosis, clinicians are known to have difficulties in diagnosing AMI. In this study, we aimed to evaluate the patients admitted to our emergency department (ED) and diagnosed with mesenteric ischemia with their presentation characteristics, clinical, laboratory, and medical history, and to determine the conditions that may cause a delay in cases with delayed diagnosis. Materials and Methods: Patients diagnosed with AMI who applied to our emergency department between 01.01.2011 and 31.12.2021 were included in the study. The characteristics of these patients at admission to the ED, comorbid diseases, physical examination findings, and laboratory and imaging results were examined, and their in-hospital and 30-day outcomes were investigated. The duration of the request for surgical consultation with the diagnosis of mesenteric ischemia, or if the patient was requested with a different diagnosis in the emergency consultation, the duration of the surgical consultation was determined as the 'admission-diagnosis period'. By examining the diagnosis times of the patients, the patients below 6 hours were evaluated as early diagnosis and the patients above 6 hours as late diagnosis. Factors that may be associated with presentation-diagnosis time and 30-day survival were analyzed. In order to determine the independent risk factors, the relationship between independent variables and dependent variables was determined by binary logistic regression test. In patients with mesenteric ischemia diagnosis, 6 hours later diagnosis was determined as the outcome variable. Results: A total of 102 patients were included in the study. The mean age of the patients was 75.2±11.4 (min: 33-max: 95 years), and 50% of the patients (n=51) were women. When patients who died in the emergency department were excluded, 34 (42.0%) patients had a 30-day survival, and 30 (37,0%) patients were discharged from the hospital. No correlation was found between the gender, age, admission time, and physical examination findings of the patients and 30-day survival. Mortality was higher in patients who applied to the emergency department with a general disability or had a change in consciousness. It was found that the history of previous cerebrovascular accidents was higher in patients with poor outcomes (p= 0.037). It was determined that patients who died within 30 days had lower systolic and diastolic blood pressures, higher creatinine, BUN, lactate, ALT, AST, INR and lactate values in laboratory tests, and lower pH and bicarbonate levels. The median time to diagnosis after admission was 4.5 hours (IQR: 3.0-8.0 hours). Patients diagnosed with a diagnosis below the median had less mortality, but this was not statistically different (OR: 1.928 [95% CI: 0.832-4.468]; p=0.126). There was no correlation between delay in diagnosis and physical examination findings. Abdominal pain complaint at admission (OR: 0.293 [95% CI: 0.111-0.776]), general disability (OR: 2,735 [95% CI: 1.195-6.261]), presence of atrial fibrillation (OR: 2,735 [95% CI: 1.037]) -5.363]), systolic blood pressure (OR: 0.987 [95% CI: 0.976-0.998]), heart rate [95% CI: 1.005-1.044]), and blood gas bicarbonate level (OR: 0.911 [95% 0.834-0.995]) ]) were identified as factors associated with delay in diagnosis. 71.8% of patients with creatinine ≤1.2 were diagnosed within the first 6 hours (OR: 2.348 [95% CI: 1.033-5.336]). In multiple regression analysis, absence of abdominal pain at admission (OR: 2,735 [95% CI: 1.037-5.363]), atrial fibrillation (OR: 2,735 [95% CI: 1.037-5.363]), and low SBP (OR: 2,735 [95% CI: 1.037-5,363]) were determined to have independent risk factors for late diagnosis of mesenteric ischemia patients in our emergency department. Conclusion: Our findings suggest that the clinical condition of the patient is more serious in addition to the complaint of admission to the ED, leading to a delay in diagnosis. Probably because the examination findings are faint and it is common in the older population, physicians turn to alternative diagnoses to explain the clinical situation leading to a delay in the diagnosis of mesenteric ischemia. It is important for early diagnosis that patients with symptoms other than abdominal pain should be evaluated more carefully by emergency physicians and timely use of tests with high diagnostic value.