The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.05.010
Visual Diagnosis in Emergency Medicine
ACUTE ABDOMINAL PAIN: MIND THE SUPERIOR MESENTERIC ARTERY DISSECTION Nicolas de l’Escalopier, MD,* Guillaume Boddaert, MD,* Thomas Erauso, MD,† and Emmanuel Hornez, MD‡ *Vascular Surgery Department, †Department of Medical Imaging, and ‡General and Gastrointestinal Surgery Department, Percy Military Hospital, Clamart, France Reprint Address: Nicolas de l’Escalopier, MD, Vascular Surgery Department, Percy Military Hospital, Clamart 92140, France
antiplatelet, cholesterol transport inhibitor, and thorough clinical observation. As a result, the patient’s abdominal pain improved significantly. The 24-h monitoring of blood pressure was normal and he was discharged at 72 h. The follow-up consisted of a CT angiogram at 1, 3, 6, and 12 months. No evolution was observed and both lumens remained patent.
CASE REPORT We report the case of a 51-year-old-man who presented to the Emergency Department with abdominal pain of an abrupt onset. The patient had a personal history of tobacco consumption (40 pack-years) and gastroduodenal ulcer. He experienced sudden postprandial upper abdominal pain with no fever, nausea, constipation, or diarrhea. His blood pressure was 140/90 mm Hg. The clinical examination revealed epigastric tenderness without rebound or peritoneal signs. Basic blood tests and liver function were normal. A computed tomography (CT) scan of the abdomen with contrast revealed a spontaneous isolated dissection of the superior mesenteric artery (SMA). The entry tear of the dissection was located 2 cm from the SMA origin, creating a retrograde thrombosed cul-de-sac on 1 cm and a circulating false lumen extending up to the inferior pancreaticoduodenal artery where a distal re-entry tear was identified. Downstream, the false lumen was thrombosed, but extended up to the fifth jejunal artery. The SMA true lumen remained patent, there was no aneurysmal dilatation, and there were no signs of small bowel or colic ischemia (Figures 1 and 2). A conservative approach was decided upon a preserved blood flow in the true lumen of the SMA. Treatment was based on transient bowel rest,
DISCUSSION Spontaneous SMA dissection is rare but increasingly diagnosed. Its etiology has not clearly been established yet, although atherosclerosis, cystic medial necrosis, and fibromuscular dysplasia seem to be implicated and often associated with an untreated hypertension. Most patients present with acute epigastric pain attributed to the dissection itself or to intestinal ischemia. When symptomatic, the signs of dissection are: abdominal pain, nausea, vomiting, melena, and abdominal distension. An abdominal CT scan with contrast is currently the preferred imaging modality to identify and precisely characterize an SMA dissection (1). Four schemes of evolution are possible: 1) stability, implying regular followup; 2) spontaneous thrombosis of the false lumen and artery remodeling, which is the most favorable; 3) true lumen thrombosis, often compensated through
RECEIVED: 24 November 2014; ACCEPTED: 14 May 2015 1
2
N. de l’Escalopier et al.
Figure 1. Computed tomography scan curved multi-planar reconstruction with orthogonal views in thumbnails showing an entry tear located 2 cm from the superior mesenteric artery origin (arrow), creating a retrograde thrombosed cul-de-sac on 1 cm (A) and a circulating false lumen (B) extending up to the inferior pancreaticoduodenal artery where a distal re-entry tear was identified (dotted arrow). Downstream, the false lumen was thrombosed (C).
duodenopancreatic arcades; and 4) aneurysmal dilatation, which may be the worst case (2). Because SMA dissection is rare, there is no standard therapeutic approach
(3,4). Treatment involves medical, surgical, and endovascular procedures. The nonoperative approach has provided good evidence of efficiency, and therefore is the first line of treatment (5–7). It is based on antiplatelet or anticoagulation treatment, transient bowel rest, antihypertension treatment, if necessary, and symptomatic analgesia. Accepted surgical indications are acute mesenteric ischemia, persistence of symptoms under medical treatment, symptomatic secondary thrombosis, and aneurysmal evolution with a diameter >2 cm (8,9). Many procedures have been reported, but aorto- or iliomesenteric bypass remains probably the most accepted (10). However, percutaneous endovascular stenting, intralesional thrombolytic therapy, or thromboaspiration are often preferred, especially for highsurgical-risk patients (11). In the absence of intervention, a follow-up CT scan every 6 months, or yearly in case of strict stability, seem consistent (12). Magnetic resonance or ultrasound imaging may be valuable alternatives without irradiation. REFERENCES
Figure 2. Computed tomography scan three-dimensional volume-rendering reconstruction.
1. Kim HK, Jung HK, Cho J, Lee JM, Huh S. Clinical and radiologic course of symptomatic spontaneous isolated dissection of the
Superior Mesenteric Artery Dissection
2.
3.
4. 5. 6.
superior mesenteric artery treated with conservative management. J Vasc Surg 2014;59:465–72. Park UJ, Kim HT, Cho WH, Kim YH, Miyata T. Clinical course and angiographic changes of spontaneous isolated superior mesenteric artery dissection after conservative treatment. Surg Today 2014; 44:2092–7. Li D, He Y, Alkalei AM, et al. Management strategy for spontaneous isolated dissection of the superior mesenteric artery based on morphologic classification. J Vasc Surg 2014;59: 165–72. Satokawa H, Takase S, Seto Y, et al. Management strategy of isolated spontaneous dissection of the superior mesenteric artery. Ann Vasc Dis 2014;7:232–8. Jibiki M, Inoue Y, Kudo T. Conservative treatment for isolated superior mesenteric artery dissection. Surg Today 2013;43: 260–3. Amabile P, Ouaı¨ssi M, Cohen S, Piquet P. Conservative treatment of spontaneous and isolated dissection of mesenteric arteries. Ann Vasc Surg 2009;23:738–44.
3 7. Dong Z, Fu W, Chen B, Guo D, Xu X, Wang Y. Treatment of symptomatic isolated dissection of superior mesenteric artery. J Vasc Surg 2013;57:69S–76. 8. Garrett HE. Options for treatment of spontaneous mesenteric artery dissection. J Vasc Surg 2014;59:1433–14392. 9. Carter R, O’Keeffe S, Minion DJ, Sorial EE, Endean ED, Xenos ES. Spontaneous superior mesenteric artery dissection: report of 2 patients and review of management recommendations. Vasc Endovascular Surg 2011;45:295–8. 10. Katsura M, Mototake H, Takara H, Matsushima K. Management of spontaneous isolated dissection of the superior mesenteric artery: case report and literature review. World J Emerg Surg 2011;6:16. 11. Zhang T, Zhang X, Zhang X, Jiang J, Zhou B. Endovascular treatment of isolated spontaneous celiac artery dissection. Vascular 2012;20:118–20. 12. Sakamoto I, Ogawa Y, Sueyoshi E, Fukui K, Murakami T, Uetani M. Imaging appearances and management of isolated spontaneous dissection of the superior mesenteric artery. Eur J Radiol 2007;64: 103–10.
http://dx.doi.org/10.1016/j.jemermed.2015.05.010
Visual Diagnosis in Emergency Medicine
ACUTE ABDOMINAL PAIN: MIND THE SUPERIOR MESENTERIC ARTERY DISSECTION Nicolas de l’Escalopier, MD,* Guillaume Boddaert, MD,* Thomas Erauso, MD,† and Emmanuel Hornez, MD‡ *Vascular Surgery Department, †Department of Medical Imaging, and ‡General and Gastrointestinal Surgery Department, Percy Military Hospital, Clamart, France Reprint Address: Nicolas de l’Escalopier, MD, Vascular Surgery Department, Percy Military Hospital, Clamart 92140, France
antiplatelet, cholesterol transport inhibitor, and thorough clinical observation. As a result, the patient’s abdominal pain improved significantly. The 24-h monitoring of blood pressure was normal and he was discharged at 72 h. The follow-up consisted of a CT angiogram at 1, 3, 6, and 12 months. No evolution was observed and both lumens remained patent.
CASE REPORT We report the case of a 51-year-old-man who presented to the Emergency Department with abdominal pain of an abrupt onset. The patient had a personal history of tobacco consumption (40 pack-years) and gastroduodenal ulcer. He experienced sudden postprandial upper abdominal pain with no fever, nausea, constipation, or diarrhea. His blood pressure was 140/90 mm Hg. The clinical examination revealed epigastric tenderness without rebound or peritoneal signs. Basic blood tests and liver function were normal. A computed tomography (CT) scan of the abdomen with contrast revealed a spontaneous isolated dissection of the superior mesenteric artery (SMA). The entry tear of the dissection was located 2 cm from the SMA origin, creating a retrograde thrombosed cul-de-sac on 1 cm and a circulating false lumen extending up to the inferior pancreaticoduodenal artery where a distal re-entry tear was identified. Downstream, the false lumen was thrombosed, but extended up to the fifth jejunal artery. The SMA true lumen remained patent, there was no aneurysmal dilatation, and there were no signs of small bowel or colic ischemia (Figures 1 and 2). A conservative approach was decided upon a preserved blood flow in the true lumen of the SMA. Treatment was based on transient bowel rest,
DISCUSSION Spontaneous SMA dissection is rare but increasingly diagnosed. Its etiology has not clearly been established yet, although atherosclerosis, cystic medial necrosis, and fibromuscular dysplasia seem to be implicated and often associated with an untreated hypertension. Most patients present with acute epigastric pain attributed to the dissection itself or to intestinal ischemia. When symptomatic, the signs of dissection are: abdominal pain, nausea, vomiting, melena, and abdominal distension. An abdominal CT scan with contrast is currently the preferred imaging modality to identify and precisely characterize an SMA dissection (1). Four schemes of evolution are possible: 1) stability, implying regular followup; 2) spontaneous thrombosis of the false lumen and artery remodeling, which is the most favorable; 3) true lumen thrombosis, often compensated through
RECEIVED: 24 November 2014; ACCEPTED: 14 May 2015 1
2
N. de l’Escalopier et al.
Figure 1. Computed tomography scan curved multi-planar reconstruction with orthogonal views in thumbnails showing an entry tear located 2 cm from the superior mesenteric artery origin (arrow), creating a retrograde thrombosed cul-de-sac on 1 cm (A) and a circulating false lumen (B) extending up to the inferior pancreaticoduodenal artery where a distal re-entry tear was identified (dotted arrow). Downstream, the false lumen was thrombosed (C).
duodenopancreatic arcades; and 4) aneurysmal dilatation, which may be the worst case (2). Because SMA dissection is rare, there is no standard therapeutic approach
(3,4). Treatment involves medical, surgical, and endovascular procedures. The nonoperative approach has provided good evidence of efficiency, and therefore is the first line of treatment (5–7). It is based on antiplatelet or anticoagulation treatment, transient bowel rest, antihypertension treatment, if necessary, and symptomatic analgesia. Accepted surgical indications are acute mesenteric ischemia, persistence of symptoms under medical treatment, symptomatic secondary thrombosis, and aneurysmal evolution with a diameter >2 cm (8,9). Many procedures have been reported, but aorto- or iliomesenteric bypass remains probably the most accepted (10). However, percutaneous endovascular stenting, intralesional thrombolytic therapy, or thromboaspiration are often preferred, especially for highsurgical-risk patients (11). In the absence of intervention, a follow-up CT scan every 6 months, or yearly in case of strict stability, seem consistent (12). Magnetic resonance or ultrasound imaging may be valuable alternatives without irradiation. REFERENCES
Figure 2. Computed tomography scan three-dimensional volume-rendering reconstruction.
1. Kim HK, Jung HK, Cho J, Lee JM, Huh S. Clinical and radiologic course of symptomatic spontaneous isolated dissection of the
Superior Mesenteric Artery Dissection
2.
3.
4. 5. 6.
superior mesenteric artery treated with conservative management. J Vasc Surg 2014;59:465–72. Park UJ, Kim HT, Cho WH, Kim YH, Miyata T. Clinical course and angiographic changes of spontaneous isolated superior mesenteric artery dissection after conservative treatment. Surg Today 2014; 44:2092–7. Li D, He Y, Alkalei AM, et al. Management strategy for spontaneous isolated dissection of the superior mesenteric artery based on morphologic classification. J Vasc Surg 2014;59: 165–72. Satokawa H, Takase S, Seto Y, et al. Management strategy of isolated spontaneous dissection of the superior mesenteric artery. Ann Vasc Dis 2014;7:232–8. Jibiki M, Inoue Y, Kudo T. Conservative treatment for isolated superior mesenteric artery dissection. Surg Today 2013;43: 260–3. Amabile P, Ouaı¨ssi M, Cohen S, Piquet P. Conservative treatment of spontaneous and isolated dissection of mesenteric arteries. Ann Vasc Surg 2009;23:738–44.
3 7. Dong Z, Fu W, Chen B, Guo D, Xu X, Wang Y. Treatment of symptomatic isolated dissection of superior mesenteric artery. J Vasc Surg 2013;57:69S–76. 8. Garrett HE. Options for treatment of spontaneous mesenteric artery dissection. J Vasc Surg 2014;59:1433–14392. 9. Carter R, O’Keeffe S, Minion DJ, Sorial EE, Endean ED, Xenos ES. Spontaneous superior mesenteric artery dissection: report of 2 patients and review of management recommendations. Vasc Endovascular Surg 2011;45:295–8. 10. Katsura M, Mototake H, Takara H, Matsushima K. Management of spontaneous isolated dissection of the superior mesenteric artery: case report and literature review. World J Emerg Surg 2011;6:16. 11. Zhang T, Zhang X, Zhang X, Jiang J, Zhou B. Endovascular treatment of isolated spontaneous celiac artery dissection. Vascular 2012;20:118–20. 12. Sakamoto I, Ogawa Y, Sueyoshi E, Fukui K, Murakami T, Uetani M. Imaging appearances and management of isolated spontaneous dissection of the superior mesenteric artery. Eur J Radiol 2007;64: 103–10.
