Death by midgut infarction: clinical lessons from 88 post-mortems in Auckland, New Zealand

Background:  Mortality rates from acute arterial mesenteric ischaemia remain high. Early diagnosis is of prognostic importance; however, early features are often non-specific, necessitating a high index of suspicion and knowledge of the at-risk patient. This study reviewed three decades of fatal cases in Auckland, New Zealand, to identify risk factors and associated pathologies that might help guide early diagnosis. Diagnostic delay was also evaluated. Methods:  Cases were identified through a pathology database maintained from 1977 to 2006. Autopsy reports were assessed together with available clinical detail. Results:  Eighty-eight cases were recovered. Mean age was 75.4 years, with women predominating (57%). Thromboembolic occlusion was the leading cause, followed by thrombotic occlusion. Embolic sources included atrial disease, aortic disease and myocardial infarction. Patients routinely showed extensive comorbidities, especially cardiovascular. Pain was the most constant presenting symptom, but features were often subtle and clinicians frequently misdiagnosed more minor ailments. Of operated patients, 36% received operations within 6 h of admission, 33% within 24 h, 17% at between 1 and 2 days, and the remainder between 2 and 12 days. Conclusion:  Knowledge of risk factors defined here is important to guide early diagnosis of mesenteric ischaemia. Diagnostic delay is again shown to be significant and case experience gathered in this series may improve doctors’ discernment when meeting this condition.