A Case Report of Delayed Patchy Bowel Necrosis Due to Nonocclusive Mesenteric Ischemia Despite a Functioning Stoma

BackgroundSmall bowel obstruction in the elderly carries high morbidity, and postoperative stoma complications and non-occlusive mesenteric ischemia pose difficult diagnostic challenges. This case is novel because it reports a sequential and paradoxical scenario: superficial stomal mucosal necrosis that resolved without surgery, immediately followed by silent non-occlusive mesenteric ischemia that developed proximal to a healthy, functioning stoma while therapeutic anticoagulation was being administered, exposing a critical clinical pitfall. Case presentation An 80-year-old woman with hypertension and ischemic heart disease presented with severe abdominal pain, distension, and vomiting. Examination revealed tachycardia, hypotension, and abdominal tenderness. Laboratory tests showed a white blood cell count of 10,500/µL, elevated lactate, and elevated C-reactive protein. Computed tomography demonstrated small bowel obstruction with signs of ischemia. Emergency laparotomy identified 180 cm of gangrenous ileum caused by an adhesion band. Because of intraoperative hemodynamic instability, a double-barrel ileostomy was performed. On postoperative day 2, superficial mucosal necrosis appeared above the stoma fascia; the stoma remained functional and lactate normalized, so conservative management was pursued. On postoperative day 4, the patient developed an abrupt decline in consciousness without abdominal signs or change in stoma output. A second laparotomy revealed 50 cm of patchy gangrenous bowel 20 cm proximal to the patent stoma, consistent with non-occlusive mesenteric ischemia. The necrotic segment was resected and the stoma revised. The patient stabilized and was discharged on day 12. strong>Conclusions A well-functioning stoma does not rule out ongoing proximal bowel ischemia from non-occlusive mesenteric ischemia. In elderly surgical patients, unexplained neurological deterioration should prompt immediate suspicion of mesenteric ischemia, even in the absence of abdominal tenderness or stoma changes, and despite therapeutic anticoagulation. Superficial stomal mucosal necrosis in a viable stoma can be managed conservatively. High vigilance, early imaging, and readiness for re-exploration are essential.