Superior mesenteric artery thrombosis

Snekapriya, N. Bhuvaneswari, N. Maahira Reshmi

Department of Dietetics, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

*Correspondence: dietary.kcn@kauveryhospitals.com

Background

Superior mesenteric artery thrombosis (SMAT) is a condition with an unfavorable prognosis. Treatment of this condition is focused on early diagnosis, surgical or intravascular restoration of blood flow to the ischemic intestine and supportive intensive care. In the report, we have described the dietary management of a 51- years-aged male who developed a thrombosis in the superior mesenteric artery, which provides the primary arterial supply to the small intestine and ascending colon.

Case Presentation

The patient was a 51-years-aged male with a personal history of smoking 10 – 15 cigarettes/ day and alcohol addiction. There was no family history of hypertension and diabetes. No known genetic history of significance, or previous surgery.

The patient came with the chief complaint of 6 – 7 episodes loose stools with altered brown colored stools. Sudden onset of diffuse abdominal pain had occurred, over epigastrium and hypogastrium which started 30 mins after food intake, associated with 2 episodes of vomiting. Patient had decreased appetite. Patient was initially treated elsewhere; anti-platelets and heparin were given and patient was referred here for further management.

Patient was admitted, blood investigations were done. (Hb, platelets, sodium, potassium, RFT, magnesium, phosphorus) were taken. Patient co- managed with vascular surgeon. In view of mesenteric arterial ischemia, patient and attender were explained about the need for surgery. Pre-operative anesthetic assessment and cardiologist opinions were obtained.

Patient underwent SMA thrombectomy + fixation of intima+ vein patch closure + two segmental bowel resection were done. Post operatively patient shifted to ICU requiring ventilator support and heparin infusion. APTT monitored and heparin infusion titrated as per vascular surgeon orders. 48 hours later patient underwent Relook laparotomy, further small bowel resection, ileostomy +mucus fistula. (double barrel).

Anthropometric Data:

Height : 162 cm

Weight : 60 kg

BMI : 22.9 kg/m2

Diet History:

Diet habit : Non veg

Food allergy : Nil

Nutritional Goal:

Energy: To provide adequate calories to maintain optimal body weight.
Carbohydrates: To provide moderate carbohydrates to prevent the protein metabolism.
Protein: To provide protein in order to aid in tissue repair and growth
Fat: To provide moderate fat to aid in optimal growth
Fluids: To provide liberal fluids.

Target Nutrients:

Energy : 1500 @25 kcal/kg

Carbohydrates : 55-60% of total calories

Protein : 90 @1.5 gm/kg

Fat : 20-25% of total calories

Fluids : Liberal

Vitamins : As per RDA

Discussion

Post operatively, he was shifted to ICU with ventilator support. Patient was on NPO for SMA thrombectomy procedure for two days. Next two days patient was on NPO.

Then he was initiated on TPN (Total parenteral nutrition). Three chamber bag was used, containing 1100 kcal and 58g of protein, 38g of fat. We started TPN 50ml/hr, 1171 kcal and 61.7 g of protein was achieved. Next day TPN was increased 100ml /hr, patient tolerated, and the same feed was continued.

Patient was on NPO for tracheotomy. After 4 hours, we initiated clear liquids in RT feeds 30ml/2hr along with TPN 100ml/hr. Next day, Increased RT FEED 30ml to 50ml/2hr along with TPN 100ml/hr. We continued same feed, and gradually increased RT feed and decreased the TPN 75ml/hr. We started artificial supplement + kitchen feed 90ml/hr, TPN was stopped. Patient shifted to ward, tracheotomy care given. Trial oral normal liquids along with RT feed, patient tolerated. RT tube was removed. We started small frequent amount of semi solids along with normal liquids. Patient was on NPO for decannulation after 4 hours. We started low fat semi solid diet. We encouraged oral low fat semi solids diet. At the time of discharge patient tolerated 1650 kcal and 60 g of protein.

Result

The patient tolerated oral feed, The patient was advised to follow a Low fat -High protein diet. Patient was discharged in stable and good condition.

Superior mesenteric artery thrombosis