A 66-year-old man presented with diabetic ketoacidosis due to new-onset type 1 diabetes mellitus following recent immunotherapy with durvalumab for lung cancer. Imaging revealed incidental pneumatosis intestinalis and elevated lactate levels in the setting of a benign abdominal examination. Mesenteric ischemia was later confirmed during surgical exploration, necessitating multiple operations and repeat bowel resections. The bowel was left in discontinuity with temporary abdominal closure, and the patient was admitted to the intensive care unit. Ultimately, the course was fatal due to insufficient viable bowel length to sustain life. This case highlights two rare but critical immune-mediated adverse effects likely associated with the recent initiation of durvalumab, a programmed death ligand 1 (PDL1) inhibitor, for lung cancer treatment. The development of new autoimmunity or coagulopathy in patients recently treated with PD-L1 immunotherapy for cancer should prompt consideration of a potential causal relationship and early multidisciplinary discussion involving surgery and hematology-oncology.

Small intestinal neuroendocrine tumors are rare gastrointestinal malignancies (< 0.5% of all cancers). Complications at presentation include bleeding, abdominal pain, and bowel obstruction; small bowel ischemia and bowel necrosis are rare. A 63-year-old patient was referred from a rural hospital to Acute Care Surgery with bowel obstruction, and arrived in septic shock. He was resuscitated, diagnosed with mesenteric ischemia, and underwent an exploratory laparotomy which identified an internal hernia (which was released), and small bowel ischemia and necrosis which were resected. The incidence of acute mesenteric ischemia < 0.2% of all acute surgical admissions. Nonocclusive mesenteric ischemia accounts for 20% of all etiologies and was evident in this case. The superior mesenteric artery pulse was clinically palpable and there were no signs intraoperatively of venous stasis at the root of the mesentery. Pathology confirmed multiple small bowel mesentery neuroendocrine tumor nodules. Surgical resection remains the mainstay of treatment.

Antiphospholipid syndrome (APS) is one of the many causes of hypercoagulability which often presents with vascular thrombosis in the presence of antiphospholipid antibodies. Symptoms vary depending on the location of the thrombosis. Gastrointestinal symptoms such as paralytic ileus is one of the rare symptoms in APS. The main therapy for APS is use of anticoagulants, but this becomes difficult when there is ongoing bleeding. We report a successful but challenging treatment of a 42-year-old patient who presented with paralytic ileus due to APS with cofounded on-going renal bleeding caused by renal angiomyolipoma.