Gut Warning: Acute Mesenteric Ischemia as The First Sign of Hidden Atrial Fibrillation

Abstract

Some surgical abdomens may present with severe pain that appears disproportionate to physical examination findings, a red flag that clinicians must not overlook, as early mucosal ischemia can progress to transmural necrosis and eventual signs of peritonitis. Atrial fibrillation may remain clinically silent until it manifests through a first embolic event, as illustrated in this case. This report highlights the life-saving value of maintaining a low threshold for abdominal CT angiography in patients with atrial fibrillation. We present a 64-year-old male who arrived with acute, severe abdominal pain of sudden onset, persisting for approximately five hours prior to hospital admission. Laboratory findings of leukocytosis and lactic acidosis indicated acute intestinal injury and early tissue hypoxia, prompting a high index of suspicion for acute mesenteric ischemia which was later confirmed by CT angiography of the abdomen. Initial management included intravenous fluids, broad-spectrum antibiotics, rate control, analgesia, and gastrointestinal decompression, followed by definitive treatment via endovascular embolectomy. The patient demonstrated an excellent recovery, with postoperative angiography confirming successful reperfusion, and was discharged after an uncomplicated ICU course on long-term anticoagulation therapy.