Cannot Miss Diagnosis

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Acute arterial occlusion secondary to embolising is a well known complication following certain conditions like atrial fibrillation, valvular disease, previous cardiac surgery artificial valve replacement, atherogenic disease of the aorta etc. Very rarely embolus from the venous side could go to the arterial side through a septal defect (paradoxical embolism) and reach different parts of the systemic artery circulation and cause embolic effects. The symptoms most often are dramatic and in elderly people may be subtle and have to be actively looked for. An atheromatous block from a major blood vessel can break loose and obstruct the distal blood vessel at the bifurcation.


In atrial fibrillation which accounts for most of the cases, the left atrium is the source of thrombi and fragments detach from the atrial wall and reach different blood vessels and cause occlusive disease. This can happen in a patient whose blood vessels are normal prior to the episode or in vessels already undergoing athero sclerotic changes. Depending upon the status of the vessels some collateral circulation could have been established which might make the symptoms less dramatic and less obvious in certain cases. But in all patients with atrial fibrillation this complication has to be sought after under such conditions.

The signs and symptoms are pain, pallor, absent pulsations, paraesthesia, paralysis and perishing cold (six Pís). All these symptoms may not be present in a given patient, but even if one or two of the symptoms are present, or there is colour change of the foot compared to the other side, an acute embolic disease has to be considered. This is one diagnosis that a Family Practitioner cannot afford to miss because the results of such a miss would lead to disastrous complications. The mortality and morbidity of ischemic limb disease is significant and the chances of a viable extremity after an embolic episode is considerably less.


Diagnosis : The diagnosis in such cases is one of clinical suspicion and awareness. Once clinically suspected, no major further study is required under normal circumstances. The doppler studies may further strengthen the clinical diagnosis
or at times rarely rule out the same. A routine angiogram under the circumstances is not warranted as it is time consuming, labour intensive and less productive. This is utilised only under circumstances where clinical presentation is not clear.
Tumour emboli is a rare event and it is always preferred to send the material removed from the arteries for pathological evaluation.
Once the diagnosis is made, keeping the foot covered by heating pads does not help the situation. Cold compress and keeping the foot lower down, although theoretically helpful, becomes practically difficult. The initial therapy includes pain relief with pethidine when necessary and heparinization (start with a full dose of heparin and maintain continuous I.V. heparin drip). Heparin is used because of the ability to control and reverse when necessary,quickly.
Embolic disease can happen in any part of the arterial systems and depending upon the site of artery the end results may vary. The involvement of the extremities upper or lower is relatively easy to diagnose and can be taken care of promptly by emobolectomy, on the other hand embolic involvement of mesenteric circulation and other areas may have much more serious consequences.

*In patients with atrial fibrillation, routine physical examination should include all the peripheral pulses, particularly when symptoms are not clear.
*Diagnosis of arterial occlusive disease made early in the course can help reverse the circulatory status back to normal and an awareness of this possibility should be in the minds of the practitioner.
*Patients with known coronary disease, artrial fibrillation, valvular disease and those with prosthetic valves should be under the surveillance for possible thrombo embolic disease and necessary precautions should be taken in terms of therapy with anti-coagulant, ASA etc when indicated.

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Monte 

probably i m also facing the same problem since yesterday, so can you tell me about the duration until which such torsions in testes are reversible. please reply me quickly. here also the swelling is observed first time in my 19 years & is a bit painful too.

soroush 

it was better if you mentioned that his pain was acute onset or not

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