Intestinal thromboangiitis obliterans: a case report

Abstract

Background: Thromboangiitis obliterans or Buerger's disease is a form of peripheral vascular disease in young male smokers. The involvement of the intestine occurs in only about 2% of the cases, when they may present as acute abdomen due to mesenteric ischemia. The uncommonness of the condition makes it a less suspected differential diagnosis, leading to a delay in appropriate management, thereby increasing chances of morbidity or mortality. Cessation of smoking is known to stall the disease progression including visceral involvement, but may not always be the case as happened in the case being presented.

Case presentation: Our Indian Hindu male patient, a known smoker, presented with diffuse abdominal pain along with bouts of vomiting and loose motions. He had a prior history of amputation of the right foot, 4 years before. At presentation he had abdominal distension with diffuse tenderness and guarding. An omental band attached to the tip of the appendix was discovered at the initial exploration along with dilated proximal bowel loops, for which a release of the omental band along with appendectomy was done. He developed an enterocutaneous fistula on the 6th postoperative day for which he had to be reexplored, and multiple jejunal perforations were found. Segmental jejunal resection and a Roux-en-Y gastrojejunostomy with distal ileostomy were done along with a feeding jejunostomy. The patient however again had feculent discharge from the wound for which a third exploration was done. The gastrojejunostomy and feeding jejunostomy sites were leaky, both of which were repaired primarily. The patient developed septicemia which progressed to refractory septic shock, and he ultimately succumbed to his illness on the 23rd postoperative day of the index surgery.

Conclusion: Acute abdomen in a young man who is a chronic smoker and having an antecedent history of amputation of some part of an extremity for a nontraumatic cause should raise the suspicion of Buerger's disease of the intestine. Although it is a progressive disease and the situation has already progressed by the time intestinal symptoms manifest, early detection may give some scope of salvage and decrease the morbidity and mortality.

Keywords: Acute mesenteric ischemia; Buerger’s disease; Case report; Smoking; Thromboangiitis obliterans.

Fig. 1

First exploration: band adherent to the appendix

Fig. 2

Black arrow showing multiple areas of perforation in the second exploration

Fig. 3

Leak from the gastrojejunostomy site in the third exploration

Fig. 4

a Low magnification showing an intestinal ulcer (hematoxylin and eosin, × 20). b Changes in the blood vessels (thin black arrows) highlighted at the base of an ulcer (thick black arrow) (hematoxylin and eosin, × 40). c The arteries showing typical changes with luminal occlusion, myxoid subintimal matrix, and hypertortuous eosinophilic internal elastic lamina (hematoxylin and eosin, × 200). d One of the veins showing occlusive fibrin-rich thrombus (hematoxylin and eosin, × 100)