Overview
Transmural infarction of the intestine, often referred to as transmural bowel infarction, represents a severe and potentially life-threatening condition characterized by complete necrosis of the bowel wall from the mucosa to the serosa. This condition typically arises from prolonged ischemia, often secondary to thromboembolic events, arterial occlusion, or severe systemic hypoperfusion. The clinical presentation is multifaceted, encompassing both acute and chronic symptoms that significantly impact a patient's quality of life and functional status. Early recognition and comprehensive management, particularly in palliative care settings, are crucial for aligning care with patient preferences and improving outcomes. Evidence from various studies underscores the importance of a multidisciplinary approach, integrating palliative care early in the disease trajectory to address both physical and psychosocial aspects of the illness [PMID:37533107][PMID:26187087].
Clinical Presentation
Patients with transmural infarction of the intestine often present with a constellation of symptoms that reflect the severity and extent of the ischemic insult. Acute presentations may include sudden, severe abdominal pain, often described as diffuse or localized to the affected segment, accompanied by signs of systemic inflammatory response such as fever, tachycardia, and leukocytosis. Nausea, vomiting, and bloody stools are also common, indicative of bowel necrosis and potential perforation [PMID:37533107]. Beyond these acute manifestations, chronic symptoms can significantly affect functional status and quality of life. Studies by NINR-IRP researchers emphasize the subjective symptom experiences of patients, highlighting the importance of considering both the biological underpinnings and the patient's subjective experience [PMID:26187087]. These symptoms often include fatigue, malnutrition, and psychological distress, which are critical for holistic clinical assessment and management. Recognizing these diverse symptoms is essential for tailoring interventions that address not only the physical aspects but also the emotional and social well-being of the patient, aligning with the principles of palliative care [PMID:26187087].
Functional decline and malnutrition frequently accompany transmural infarction, often necessitating a comprehensive evaluation of nutritional status and functional capacity. Clinicians should assess for signs of cachexia, weight loss, and decreased physical activity, which are common in advanced stages of bowel infarction. Additionally, cognitive changes and anxiety or depression may manifest, underscoring the need for a multidisciplinary approach that includes psychological support alongside medical interventions. This holistic approach ensures that all facets of the patient's condition are addressed, improving overall care quality and patient satisfaction [PMID:37533107].
Diagnosis
Diagnosing transmural infarction of the intestine typically involves a combination of clinical assessment, laboratory tests, and imaging modalities. Initial clinical suspicion is often raised by the patient's history of acute abdominal pain, systemic signs of infection, and gastrointestinal bleeding. Laboratory findings may reveal elevated inflammatory markers, anemia, and electrolyte imbalances, supporting the diagnosis but not specific to transmural infarction alone. Imaging plays a pivotal role in confirming the diagnosis and assessing the extent of the infarction. Computed tomography (CT) scans with contrast can delineate bowel wall thickening, pneumatosis intestinalis (air in the bowel wall), and portal venous gas, all indicative of transmural necrosis [PMID:37533107]. Endoscopy, particularly colonoscopy or upper endoscopy, may also be utilized to visualize the affected segment directly, although its use is limited by the risk of perforation in critically ill patients. In clinical practice, early and accurate diagnosis is crucial for timely intervention, which can significantly influence patient outcomes and guide appropriate palliative care planning [PMID:37533107].
Given the complexity and severity of transmural infarction, diagnostic workup should be expedited to rule out other causes of acute abdomen and to confirm the extent of bowel involvement. Magnetic resonance imaging (MRI) can offer detailed visualization of the bowel wall and surrounding structures, particularly useful in cases where CT findings are equivocal. However, the availability and accessibility of MRI may vary, making CT the more commonly employed initial imaging modality. Collaboration between gastroenterologists, radiologists, and surgeons is essential to ensure a comprehensive evaluation and timely management decisions [PMID:37533107].
Management
The management of transmural infarction of the intestine is multifaceted, focusing on both acute resuscitation and long-term palliative care strategies to optimize quality of life and align care with patient preferences. In the acute phase, the primary goals include stabilizing hemodynamic status, addressing sepsis if present, and preventing further complications such as bowel perforation. Early surgical intervention may be necessary for definitive treatment, particularly if there is evidence of perforation or extensive necrosis. However, for patients with advanced disease or significant comorbidities, a conservative approach with close monitoring and supportive care might be more appropriate [PMID:37533107].
The PalliSupport pathway represents a transformative model in managing patients with transmural infarction, emphasizing timely identification of palliative care needs and integrating advance care planning. This pathway involves multidisciplinary team meetings, collaboration between hospital and primary care settings, and follow-up home visits, which have been shown to significantly improve patient outcomes. Studies indicate that this approach leads to more patients dying in their preferred location, thereby enhancing end-of-life care satisfaction and reducing hospital readmissions [PMID:37533107]. The involvement of non-specialists in collaboration with a transmural palliative care team ensures continuity of care and personalized support tailored to individual patient needs.
The NIH Symptom Science Model (NIH-SSM) provides a robust framework for understanding and managing the complex symptomatology associated with transmural infarction. By integrating clinical assessments with biomarker data, clinicians can better characterize symptoms such as pain, nausea, and malnutrition, leading to more precise and effective interventions. This precision medicine approach is particularly valuable in palliative care settings, where symptom management is paramount to improving patient comfort and functional status [PMID:26187087]. Transmural team-based palliative care interventions, especially those involving hospital-based teams with structured community follow-up, have demonstrated significant benefits, including a reduced odds ratio of 0.46 (95% CI 0.34-0.68) for hospital readmissions and increased odds of dying at home [PMID:36541477]. These findings underscore the efficacy of coordinated, multidisciplinary care in managing the multifaceted challenges posed by transmural infarction.
Prognosis & Follow-up
The prognosis for patients with transmural infarction of the intestine is generally guarded, often influenced by the extent of bowel involvement, underlying comorbidities, and the timeliness of intervention. Despite aggressive management, mortality rates remain high due to the severity of the condition and potential complications such as sepsis and multi-organ failure. However, the implementation of structured palliative care pathways, like the PalliSupport model, has shown promising outcomes in improving patient-centered care. Specifically, these pathways have resulted in a higher proportion of patients dying in their preferred location, indicating better alignment with end-of-life preferences and potentially improved psychological well-being for both patients and their families [PMID:37533107].
Follow-up care post-infarction is critical for monitoring recovery, managing chronic symptoms, and addressing ongoing nutritional deficiencies. Regular assessments by a multidisciplinary team, including gastroenterologists, palliative care specialists, and primary care providers, are essential. The pooled evidence suggests that interventions involving hospital-based teams with robust community follow-up demonstrate a significant increase in home deaths, with an odds ratio of 2.19 (95% CI 1.26-3.79), particularly showing a marked effect with hospital-based teams achieving an odds ratio of 4.77 (95% CI 1.23-18.47) [PMID:36541477]. This underscores the importance of continuity of care and community support in enhancing patient comfort and dignity during the terminal stages of the disease.
Long-term follow-up should also focus on psychological support, addressing any lingering anxiety or depression, and ensuring that patients and caregivers receive adequate counseling and resources. Nutritional support remains a key component, with ongoing monitoring and intervention to manage malnutrition and cachexia, which can significantly impact quality of life and functional capacity. Regular reassessment of advance care planning documents ensures that treatment goals remain aligned with the patient's evolving preferences and clinical status [PMID:37533107].
Key Recommendations
References
1 van Doorne I, de Meij MA, Parlevliet JL, van Schie VMW, Willems DL, Buurman BM et al.. More older adults died at their preferred place after implementation of a transmural care pathway for older adults at the end of life: a before-after study. BMC palliative care 2023. link 2 Cashion AK, Grady PA. The National Institutes of Health/National Institutes of Nursing Research intramural research program and the development of the National Institutes of Health Symptom Science Model. Nursing outlook 2015. link 3 Flierman I, Gieteling E, Van Rijn M, Van Grootven B, van Doorne I, Jamaludin FS et al.. Effectiveness of transmural team-based palliative care in prevention of hospitalizations in patients at the end of life: A systematic review and meta-analysis. Palliative medicine 2023. link