Reviewed by Reza Lankarani M.D

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Published: 24 June 2025

https://doi.org/10.1186/s13017-025-00632-4

World Journal of Emergency Surgery

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This prospective observational study by Zhu et al. (2025) investigates serum homocysteine (HCY) as a predictor of irreversible transmural intestinal necrosis (ITIN) in patients with adhesive small bowel obstruction (ASBO). The study demonstrates that elevated HCY levels are strongly associated with ITIN, outperforming established biomarkers and radiological signs in diagnostic accuracy.

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Below is a critical assessment of its key strengths:

1. Methodologically Sound & Clinically Focused: The study excels in addressing the critical need for timely bowel necrosis detection in ASBO. Its prospective design, adherence to clinical guidelines (Bologna), clear outcome definition (pathology/surgery-confirmed ITIN), rigorous patient selection (n=221), and appropriate statistical analyses (multivariable regression, ROC curves) ensure robust and reliable findings.

2. Superior Biomarker Performance & Practical Utility: HCY demonstrates exceptional diagnostic power for ITIN, significantly outperforming standard biomarkers (endotoxin, Hs-CRP, PCT) and clinical signs (like peritonitis, especially in the elderly):

●High Accuracy: Outstanding AUC (0.9253), sensitivity (89.71%), and specificity (83.08%).

■Clinical Advantages: Test is rapid (<3h), inexpensive (ELISA), avoids radiation, and has a high PPV (91.18%). The established cutoff (15.53 µmol/L) aligns with known hyperhomocysteinemia thresholds.

●High-Value Application: Particularly effective in elderly patients (≥65 yrs) where classic signs like peritonitis are often absent (only 29.41%).

■Potential to Improve Care: Monitoring HCY could prevent unnecessary surgeries (reducing complications) and dangerous delays in operating on necrotic bowel, potentially lowering mortality. Extremely high HCY (>35.5 µmol/L) correlated with 30-day mortality in elderly surgical patients, adding prognostic value.

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In conclusion, this study provides compelling and methodologically robust evidence that serum HCY is a highly sensitive, specific, rapid, and cost-effective biomarker for predicting ITIN in ASBO. Its superior performance compared to current standards (including CT and other biomarkers) and its particular utility in high-risk elderly populations represent a significant potential advance in the management of this common surgical emergency.

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Reza Lankarani MD

#homocysteine #intestinalnecrosis #biomarker #transmuralnecrosis #guthealth #intestinalischemia #inflammationmarkers #intestinaldisease #earlydiagnosis #medicalbiomarkers #digestivehealth #clinicalresearch #vascularhealth #intestinaldamage #necrosisprediction