A53-28 Pain Out of Proportion: Diagnostic Pitfalls in Non-occlusive Mesenteric Ischemia (NOMI) During Sepsis and Disseminated Intravascular Coagulation (DIC)

Introduction Patients with hematologic malignancies are at increased risk of severe infection relative to the general population. Cancer therapies themselves can compound this risk through endothelial injury and mucosal barrier dysfunction, predisposing to bacterial translocation, sepsis, coagulopathy, and even mesenteric ischemia. We present the case of a patient with chronic lymphocytic leukemia (CLL) who developed catastrophic non-occlusive mesenteric ischemia (NOMI) in the setting of sepsis and disseminated intravascular coagulation (DIC). Case Presentation A 65-year-old man with CLL status-post CAR-T therapy and pirtobrutinib with recurrent disease was admitted for salvage therapy with methylprednisolone and rituximab. Admission labs were notable for lactate of 5, stable from prior. On hospital day 4, he developed tumor lysis syndrome (TLS) treated with intravenous fluids. He subsequently developed acute abdominal pain, with labs notable for hyperlactatemia (>13 mmol/L) and coagulopathy consistent with DIC (PT 29.4 sec, PTT 58.6 sec, INR 2.76, fibrinogen <60 mg/dL). On initial exam, he was afebrile and hemodynamically stable with mild abdominal distention and no rebound or guarding. Given concerns for acute bowel ischemia (with pain out of proportion to abdominal exam), he was transferred to the ICU for further management. CT angiography of the abdomen and pelvis revealed colonic wall thickening but no definitive ischemia, raising concern for NOMI; general surgery was consulted but deferred intervention due to lack of a surgical target. Despite broad-spectrum antibiotics, fluids, and blood products, he developed worsening acidosis and multisystem organ dysfunction. After 6 hours into his ICU stay, he acutely developed rebound and guarding. Surgery was again discussed but was felt to be high risk and inconsistent with his goals of care. Ultimately, he was transitioned to comfort measures and passed away hours later. Blood cultures later grew Escherichia coli and Streptococcus salivarius vestibularis. Discussion This case highlights both the dynamic, devastating natural course of NOMI as well as its diagnostic and therapeutic challenges. CT angiography has a reported sensitivity of ∼75% with false negatives in up to one-quarter of cases in NOMI. In critically ill patients, clinical deterioration should outweigh imaging reassurance, prompting early surgical consultation and goals-of-care discussions, especially when accompanied by DIC and profound lactatemia, which convey a poor prognosis. This case also highlights the vulnerability of immunocompromised hosts to mucosal injury, bacterial translocation, and fulminant septic decompensation following steroids and immunotherapy. This abstract is funded by: None