[Non-occlusive Mesenteric Ischemia caused by Diabetic Ketoacidosis - Pneumatosis intestinalis and Portal Venous Gas as an Indication of Mesenteric Ischemia]. / Nicht-okklusive Mesenterialischämie bei diabetischem Koma.

HISTORY: A 67-year-old woman was found lying naked on the bathroom floor for at least the last 12 hours. She had a medical history of insulin-dependent diabetes mellitus type 2 and a resection of the cecal pole. EXAMINATIONS: The patient was hypotonic (60/40 mmHg), hypothermic (29 °C) and hyperglycemic. The bowel sounds were sparse. There was a severe metabolic acidosis (pH 6.7). A Urinalysis showed a high concentration of ketone bodies. An abdominal ultrasonography revealed air reflexes in the liver parenchyma. A computer tomography was used to diagnose an acute mesenteric ischemia (AMI) with pneumatosis intestinalis and portal venous gas. TREATMENT: In an exploratory laparotomy the finding of necrotic bowl made it necessary to resect 160 cm of the small intestine as well as the remaining ileum and right hemikolon during a second surgery on the following day. Histopathologically there was no evidence for an occlusive genesis in the resected specimen. CONCLUSION: The clinic of the AMI is manifold - with fatal consequences in case of delayed diagnosis. Serum parameters are often overestimated. In this case report a diabetic coma was responsible for the AMI. The diagnosis was based on sonographic imaging followed by computed tomography, so that the life-saving operation could be performed. Therefore, sonography should be considered as a mandatory examination of critically ill patients.