Eur J Vasc Surg 6, 572-573 (1992)
CASE REPORT
Peritonitis Causing Acute Limb Ischaemia K. Varty and W. B. Campbell Department of Surgery, Royal Devon and Exeter Hospital, Exeter, Devon, EX2 5 D W , U.K. A patient presented with an acutely ischaemic leg and mild abdominal pain. Arteriography showed an iliac occlusion and some distal occlusive disease. At Iaparotomy a perforated gastric ulcer was found, and by the end of this operation the foot was well per~used. This case exemplifi'es the serious reduction in limb blood supply which can be caused by an acute illness, without thrombosis of vessels. It emphasises the importance of general assessment and treatment of any associated acute condition, in cases of acute limb ischaemia. Key Words: Arterial occlusive diseases; Arteriosclerosis; Ischaemia; Peritonitis.
Introduction General assessment is i m p o r t a n t in patients with acute limb ischaemia and m a y reveal a source for embolism or a systemic illness causing thrombosis in situ. Rarely, a generalised illness can cause reversible limb ischaemia due to peripheral s h u t - d o w n alone and be mistaken for embolism or thrombosis.
Case Report A 73-year-old w o m a n p r e s e n t e d as an e m e r g e n c y after awakening with a cold, n u m b , left leg. She gave a history of intermittent claudication and was a h e a v y smoker. She also complained of mild epigastric pain. Examination revealed a regular pulse of 90 beats/min with a blood pressure of 150/80mmHg. There was some mild t e n d e r n e s s in the epigastrium. The left leg was white and cold with no femoral pulse. Sensation was r e d u c e d to mid-thigh but m o v e m e n t was intact. Thrombosis in situ was suspected clinically and an e m e r g e n c y arteriogram was p e r f o r m e d . This s h o w e d a left iliac occlusion but there was good filling of the groin vessels via collaterals (Fig. 1) a n d also Please address all correspondence to: W. B. Campbell, Department of Surgery, Royal Devon and Exeter Hospital, Exeter, Devon, EX2 5DW, U.K. 0950-821X/92/050572+02$08.00/0© 1992Grune & Stratton Ltd.
Fig. 1
some occlusive disease further distally. These appearances explained the history of claudication but it was not entirely clear w h y there had b e e n such an acute deterioration. In view of the left iliac occlusion, and also with the patient's unexplained epigastric pain in mind, it was decided to p e r f o r m a laparotomy. At operation a perforated posterior gastric ulcer was found. The ulcer was excised (and f o u n d histologically benign) a n d the stomach was closed. Peritoneal lavage was
Peritonitis Causing Acute Limb Ischaemia
performed and antibiotics were given systemically. The left foot was then noted to be pink, warm and well perfused and vascular reconstructive surgery was therefore deferred. During the operation two units of colloid and 21 of normal saline had been given. The patient made a good post operative recovery.
Discussion
The dramatic improvement in the limb resulting from treatment of the perforated ulcer suggests that the symptoms of severe acute ischaemia in this case were due to reduced peripheral perfusion alone rather than thrombosis. This is a recognised syndrome but is rare, and the case serves as a useful reminder that florid but reversible acute ischaemia of a limb can be caused by a systemic disturbance in patients with peripheral vascular disease. Reversible peripheral ischaemia due to reduced perfusion was first reported by Fishberg in 1938.1 His observations were on patients with right heart failure where peripheral vasoconstriction was enough to produce gangrene of the extremities. The term "symmetrical peripheral gangrene" was used to describe this phenomenon. Similar reports followed mainly in patients with severe heart failure, 2"3 but also in cases of pneumonia 4 and meningitis 5 due to peripheral shut-down after dehydration and septicaemia. The distribution of the arterial disease in the case reported here resulted in the presentation being asymmetrical. The perfusion of the left leg was
573
already significantly reduced and vulnerable to any further decrease. Vasospasm, toxaemia and a degree of dehydration resulting from the gastric perforation were sufficient to produce acute ischaemia in the leg. Attention to fluid balance, removal of free gastric contents and intravenous antibiotic therapy corrected these changes with improvement in the limb. Acute limb ischaemia associated with a systemic illness results much more commonly from thrombosis in arteries affected by chronic occlusive disease. This situation is not reversible by treatment of the precipitating condition, although this is an important part of management in concert with thrombolytic therapy, heparin, or perhaps arterial reconstruction. The initial clinical assessment of patients presenting with acute limb ischaemia should go beyond simple palpation of pulses. The underlying cause may be a life-threatening condition and until this is correctly treated both the patient and the ischaemic limb will not improve.
References 1 FISHBERCAM. Redistribution of blood flow in heart failure. J Clin Invest 1938; 17: 510, 2 PERRYCB, DAVIETB. Symmetrical peripheral gangrene in cardiac failure. BrMedJ 1939; 1: 15. 3 COHEN H. Peripheral gangrene in a case of myocardial infarction. Br Med J 1961; 2: 1615-1616. 4 STORSTEIN O. Incipient symmetrical gangrene complicating pneumonia. Br Heart J 1951; 13: 411414. 5 W~INER HA. Gangrene of the extremities. A recently recognised complication of severe menengococcic infection. Arch Intern Med 1950; 86: 877.
Accepted 3 February 1992
Eur J Vasc Surg Vol 6, September 1992
CASE REPORT
Peritonitis Causing Acute Limb Ischaemia K. Varty and W. B. Campbell Department of Surgery, Royal Devon and Exeter Hospital, Exeter, Devon, EX2 5 D W , U.K. A patient presented with an acutely ischaemic leg and mild abdominal pain. Arteriography showed an iliac occlusion and some distal occlusive disease. At Iaparotomy a perforated gastric ulcer was found, and by the end of this operation the foot was well per~used. This case exemplifi'es the serious reduction in limb blood supply which can be caused by an acute illness, without thrombosis of vessels. It emphasises the importance of general assessment and treatment of any associated acute condition, in cases of acute limb ischaemia. Key Words: Arterial occlusive diseases; Arteriosclerosis; Ischaemia; Peritonitis.
Introduction General assessment is i m p o r t a n t in patients with acute limb ischaemia and m a y reveal a source for embolism or a systemic illness causing thrombosis in situ. Rarely, a generalised illness can cause reversible limb ischaemia due to peripheral s h u t - d o w n alone and be mistaken for embolism or thrombosis.
Case Report A 73-year-old w o m a n p r e s e n t e d as an e m e r g e n c y after awakening with a cold, n u m b , left leg. She gave a history of intermittent claudication and was a h e a v y smoker. She also complained of mild epigastric pain. Examination revealed a regular pulse of 90 beats/min with a blood pressure of 150/80mmHg. There was some mild t e n d e r n e s s in the epigastrium. The left leg was white and cold with no femoral pulse. Sensation was r e d u c e d to mid-thigh but m o v e m e n t was intact. Thrombosis in situ was suspected clinically and an e m e r g e n c y arteriogram was p e r f o r m e d . This s h o w e d a left iliac occlusion but there was good filling of the groin vessels via collaterals (Fig. 1) a n d also Please address all correspondence to: W. B. Campbell, Department of Surgery, Royal Devon and Exeter Hospital, Exeter, Devon, EX2 5DW, U.K. 0950-821X/92/050572+02$08.00/0© 1992Grune & Stratton Ltd.
Fig. 1
some occlusive disease further distally. These appearances explained the history of claudication but it was not entirely clear w h y there had b e e n such an acute deterioration. In view of the left iliac occlusion, and also with the patient's unexplained epigastric pain in mind, it was decided to p e r f o r m a laparotomy. At operation a perforated posterior gastric ulcer was found. The ulcer was excised (and f o u n d histologically benign) a n d the stomach was closed. Peritoneal lavage was
Peritonitis Causing Acute Limb Ischaemia
performed and antibiotics were given systemically. The left foot was then noted to be pink, warm and well perfused and vascular reconstructive surgery was therefore deferred. During the operation two units of colloid and 21 of normal saline had been given. The patient made a good post operative recovery.
Discussion
The dramatic improvement in the limb resulting from treatment of the perforated ulcer suggests that the symptoms of severe acute ischaemia in this case were due to reduced peripheral perfusion alone rather than thrombosis. This is a recognised syndrome but is rare, and the case serves as a useful reminder that florid but reversible acute ischaemia of a limb can be caused by a systemic disturbance in patients with peripheral vascular disease. Reversible peripheral ischaemia due to reduced perfusion was first reported by Fishberg in 1938.1 His observations were on patients with right heart failure where peripheral vasoconstriction was enough to produce gangrene of the extremities. The term "symmetrical peripheral gangrene" was used to describe this phenomenon. Similar reports followed mainly in patients with severe heart failure, 2"3 but also in cases of pneumonia 4 and meningitis 5 due to peripheral shut-down after dehydration and septicaemia. The distribution of the arterial disease in the case reported here resulted in the presentation being asymmetrical. The perfusion of the left leg was
573
already significantly reduced and vulnerable to any further decrease. Vasospasm, toxaemia and a degree of dehydration resulting from the gastric perforation were sufficient to produce acute ischaemia in the leg. Attention to fluid balance, removal of free gastric contents and intravenous antibiotic therapy corrected these changes with improvement in the limb. Acute limb ischaemia associated with a systemic illness results much more commonly from thrombosis in arteries affected by chronic occlusive disease. This situation is not reversible by treatment of the precipitating condition, although this is an important part of management in concert with thrombolytic therapy, heparin, or perhaps arterial reconstruction. The initial clinical assessment of patients presenting with acute limb ischaemia should go beyond simple palpation of pulses. The underlying cause may be a life-threatening condition and until this is correctly treated both the patient and the ischaemic limb will not improve.
References 1 FISHBERCAM. Redistribution of blood flow in heart failure. J Clin Invest 1938; 17: 510, 2 PERRYCB, DAVIETB. Symmetrical peripheral gangrene in cardiac failure. BrMedJ 1939; 1: 15. 3 COHEN H. Peripheral gangrene in a case of myocardial infarction. Br Med J 1961; 2: 1615-1616. 4 STORSTEIN O. Incipient symmetrical gangrene complicating pneumonia. Br Heart J 1951; 13: 411414. 5 W~INER HA. Gangrene of the extremities. A recently recognised complication of severe menengococcic infection. Arch Intern Med 1950; 86: 877.
Accepted 3 February 1992
Eur J Vasc Surg Vol 6, September 1992
