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Eighty-year-old woman with acute abdominal pain.

Contributed from the case records of the 
Indiana University Department of Radiology

History:  Eighty-year-old woman with acute abdominal pain.
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Which choice best characterizes the salient finding(s)?

Pancreatic.Renal.Duodenal.Peritoneal.Vascular.
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Eighty-year-old woman with acute abdominal pain.



Same images are again shown below. Which choice best localizes the vascular abnormality?

Aorta.SMA.SMV.Renal vein.None of the above.Click for galleryClick for galleryClick for galleryClick for galleryClick for galleryClick for gallery
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Eighty-year-old woman with acute abdominal pain.

After an emergent laparotomy and arteriotomy with SMA thrombectomy, a CTA chest/abdomen/pelvis was performed which demonstrates the re-perfused small bowel.

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Eighty-year-old woman with acute abdominal pain.

The next set of images (same patient) was taken 3 days later after an acute drop in hemoglobin.  Click to enlarge.

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Can you find the apparent cause of the cause of the hemoglobin drop? (Revealed on next page of the case).

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Eighty-year-old woman with acute abdominal pain.

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Findings:

Initial CT (First 3 images above):  There is an acute occlusive thrombus in the superior mesenteric artery with non-enhancing bowel wall throughout the jejunum and proximal ileum.  No signs of bowel infarction or perforation.

CT four days later (4th image above) following laparotomy and arteriotomy with SMA thrombectomy:  Interval resolution of SMA occlusion with reperfusion and normal bowel wall enhancement of the jejunum and ileum.

 

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Findings (rescanned after acute hemoglobin drop):

Small to moderate amount of hemoperitoneum with an enhancing vessel terminating in a ventral intraperitoneal fluid collection which displays a hematocrit level, likely representing active extravasation.

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Eighty-year-old woman with acute abdominal pain.


Differential diagnosis:
For acute mesenteric ischemia:

  • Acute arterial thromboembolism
  • Hypotension and splanchinic vasoconstriction
  • Mesenteric venous thrombosis
  • Aortic dissection

Informational and key points:

  • Mortality rate for all causes of acute mesenteric ischemia is greater than 80%
  • Time to diagnosis and treatment are greatest determinants of survival
  • Typically presents with acute abdominal pain with or without nausea/vomiting/diarrhea
  • Treatment is embolectomy or bypass with resection of non-viable bowel
  • Most common cause is superior mesenteric artery embolus
  • Most emboli arise from a cardiac source
  • Emboli arising from non-cardiac sources tend to be smaller and come from aortic plaques, aneurysms, or iatrogenic causes from intravascular procedures

References: 

  1. StatDX Superior Mesenteric Artery Embolus by TG Walker. 2011
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Eighty-year-old woman with acute abdominal pain.


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