Intestinal Fatty Acid Binding Protein as a Predictor of Early Mesenteric Injury Preceding Clinical Presentation: A Case Report

Abstract

Introduction: Diagnosing non-occlusive mesenteric ischaemia (NOMI) in patients is complicated, due to poor signs and symptoms and non-specific laboratory tests, leading to a high mortality rate. This case study presents the rare case of a patient who developed mesenteric ischaemia after an emergency thoracic endovascular aneurysm repair (TEVAR) for a type B aortic dissection (TBAD) and peri-operative cardiogenic shock. Study outcomes revealed that intestinal fatty acid binding protein (I-FABP) identified early mucosal damage two days before the clinical presentation.

Report: A 43 year old male patient was admitted to the emergency department with an acute TBAD and a dissection of the superior mesenteric artery (SMA), for which TEVAR was performed with additional stent placement in the SMA. Peri-operatively, the patient went into cardiogenic shock with a sustained period of hypotension. Post-operatively, the plasma I-FABP levels were measured prospectively, revealing an initial increase on post-operative day five (551.1 pg/mL), which continued beyond day six (610.3 pg/mL). On post-operative day seven, the patient developed a fever and demonstrated signs of peritonitis and bowel perforation. He underwent an emergency laparotomy, followed by an ileocaecal resection (<100 cm) with a transverse ileostomy. Pathological analysis confirmed the diagnosis of mesenteric ischaemia.

Discussion: The diagnosis of NOMI in critically ill patients is often complicated, and the currently available diagnostic markers lack the specificity and sensitivity to detect early intestinal injury. This case report highlights that elevated I-FABP in plasma levels may indicate the presence of early mesenteric injury. Further research needs to be conducted before I-FABP can be applied in daily practice.

Keywords: Aortic dissection; Case report; Diagnosis; Intestinal fatty acid binding protein; Non-occlusive mesenteric ischaemia.

Figure 1

Abdominal computed tomography angiography showing a complicated type B aortic dissection of the thoracic and abdominal aorta and a dissection of the superior mesenteric artery with pre-existing atherosclerotic plaques.

Figure 2

Graphs showing different laboratory parameters according to post-operative day. (A) Plasma I-FABP levels (pg/mL) were measured prospectively following the thoracic endovascular aneurysm repair (TEVAR) procedure, with post-operative blood plasma samples collected and analysed for up to nine days post-TEVAR. Measured laboratory parameters included: (B) C reactive protein, (C) lactate, (D) pH, (E) base excess, and (F) leucocytes. Post-TEVAR measurements are indicated by the black arrows, and grey arrows point to the emergency exploratory laparotomy followed by ileocaecal resection and ileostom. If a measured laboratory parameter falls within the white area (reference range), it is considered within normal limits. The upper and lower reference limits are illustrated in the graphs as the grey area. The mean plasma I-FABP levels in a group of healthy controls, set at 217.8 pg/mL, are portrayed in the highlighted grey area. Reference values for each parameter are: C reactive protein (<10 mg/L), lactate (0.5–1.7 mmol/L), pH (7.35–7.45), base excess (−2.5 – 2.5 mmol/L), and leucocytes (3.5–11.0 10⁹/L). All data were collected prospectively.

Figure 3

Abdominal computed tomography angiography of the patient revealed a distended bowel with pneumatosis intestinalis. Focally, the small intestine lacked coloration and showed infiltration of mesenteric fat tissue.