Short Bowel Syndrome Following Resection of Gangrenous Bowel due to Superior Mesenteric Artery Thrombosis in a Patient with Systemic Lupus Erythematosus: Lessons Learnt in a Resource-Poor Setting

Introduction: Short Bowel Syndrome (SBS) is an intestinal failure resulting from an inadequate length of the intestine following intestinal resection, which can occur due to other causes such as vascular diseases, neoplasms, or inflammatory bowel disease. Short bowel syndrome following intestinal resection in a patient with systemic lupus erythematosus (SLE) is a therapeutic challenge, given that immunosuppressive therapy, wound healing, nutritional optimization, and other potential complications are taken into consideration. Case Presentation A 23-year-old male diagnosed with SLE presented with acute onset severe diffuse abdominal pain for a sixteen-hour duration associated with vomiting who was tachycardic on admission, and the pulse volume was low. He was septic with uncompensated metabolic acidosis with a lactate level of 5.5 mmol/L. The abdomen was distended and had diffuse tenderness with guarding and rigidity, and the bowel sounds were not heard. A lateral decubitus ultrasound scan revealed free air in the abdomen, and the abdominal X-ray showed distended small bowel loops. Given the working diagnosis of bowel obstruction, an exploratory midline laparotomy was done, revealing a small gangrenous bowel. The superior mesenteric artery was resected during the procedure, where thrombosis was observed. The necrosed bowel segment was resected, and the patient had short bowel syndrome. After about one week of in-hospital stay, the patient developed left side acute lower limb ischemia. The lower limb CT-angiogram revealed that the left common femoral artery embolus and the left lower limb muscles were not viable in all three compartments of the left lower limb. The decision was made for an above-knee amputation. The patient was nutritionally optimized with total parenteral nutrition (TPN), which was later converted to peripheral parenteral nutrition (PPN), and an oral diet was gradually started. The electrolytes were continuously monitored and corrected. At the time of writing this report, the patient is still managed inward for three months with PPN and supportive care and planned to insert a peripherally inserted central catheter for continuous PPN after discharge. Conclusion SLE can be a cause of SBS secondary to bowel gangrene by thromboembolism, and in the case of SLE patients undergoing bowel resection causing SBS is a challenging but feasible situation in terms of medical management, where all the complications should be identified early and managed till the patient achieves a good gut adaptation.