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Isolated superior mesenteric artery dissection in a patient without risk factors or aortic dissection
Case Reports [4] Miller M, Kortetz Z, Blumenfeld Y, Pomeranz M, Aviram R, Rathaus V, et al. Fetal urinoma as a sign of a dysplastic kidney. Pediatr Nephrol 2003;18(1):65 - 7. [5] Fujita K, Sugao H, Tsujikawa K. Perinephric urinoma secondary to neurogenic bladder with vesicoureteral reflux: report of an adult case. Int J Urol 2004;11(1):53 - 5. [6] Balcells FS, de Torres Mateos JA, Mas AG, Lopes FG. Physiopathology of spontaneous extravasation of urine in the upper urinary tract. A propos of 24 cases. J Urol Nephrol (Paris) 1976;82(6): 385 - 95. [7] Baker JS, Carlin MR, Hammermann H. Pyelosinus extravasation in the acute renal colic patient. Ann Emerg Med 1981;10(8):437 - 40. [8] Bollack C, Levin G, Duffour A, Moritz A, Vanegas M, Pautasso O. Incidents and accidents of ureteral lithiasis. A propos of 395 observations. J Urol Nephrol (Paris) 1975;81(1-2):82 - 8. [9] Eckford SD, Gingell JC. Ureteric obstruction in pregnancy. Diagnosis and management. Br J Obstet Gynaecol 1991;98:1137 - 40. [10] Van Wagenen G, Newton WH. An experimental examination of factors causing ureteral dilatation of pregnancy. J Urol 1939;42:1010. [11] Hamoud K, Kaneti J, Smailowitz Z, Kroll D, Barki Y. Spontaneous perinephritic urinoma in pregnancy. Int Urol Nephrol 1994;26(6): 643 - 6. [12] Meyers SJ, Lee RV, Munschauer RW. Dilatation and non traumatic rupture of the urinary tract during pregnancy: a review. Obstet Gynecol 1985;66(6):809 - 15. [13] Ashebu SD, Elshebiny YH, Dahniya MH. Spontaneous rupture of the renal pelvis. Australas Radiol 2000;44(1):125 - 7. [14] Ataus S, Yaycioglu O, Ondre AU, Onal B, Solok V. Giant spontaneous urinoma draining from the scrotal wall. J Urology 2000;163(6):1874 - 5. [15] Kazoulis S, Tzanakis I, Christoulakis I, Xirakis S, Nomikos M, Hatzillas P. Spontaneous renal rupture due to ureteric calculi in a paraplegic male. Nephron 2002;91:766 - 7. [16] Balcom AH, Pircom R, Worthington D, Carr M. Spontaneous resolution of an in utero perirenal urinoma associated with posterior urethral valves. Urology 1999;54(2):366 - 7. [17] Frank RG. Rupture of a large calyceal diverticulum. Urology 1997; 49(2):265 - 6. [18] Cormio G, Cormio L, Di Gesu` G, Lo Verro G, Selvaggi R. Calyceal rupture and perirenal urinoma as a presenting sign of recurrent ovarian cancer. Gynecol Oncol 2001;83(2):415 - 7. [19] Spurlock JW, Burke TW, Dunn NP, Heller PB, Collins HS, Park RC. Calyceal rupture with perirenal urinoma in a patient with cervical carcinoma. Obstet Gynecol 1987;70(3 Pt 2):511 - 3. [20] Kedar RP, Jagesia DH, Malde HM. Spontaneous perirenal urinoma secondary to cervical carcinoma: diagnosis and management. Can Assoc Radiol J 1993;44(4):298 - 300. [21] Allison MC, McLean L, Robinson LQ, Torrance CJ. Spontaneous urinoma due to retroperitoneal fibrosis and aortic aneurysm. BMJ 1985;291(6489):176. [22] Obrand DI, Mijangos J, Brassard R, Brock G, Steinmetz OK. Uretero pelvic urinary extravasation due to iliac artery aneurysm. Ann Vasc Surg 1998;12(5):468 - 70. [23] Valde´s Ares N, Contreras Duverger DM, Valde´s Ares Y. Ruptura espontanea de la via urinaria superior. A proposito de un caso. Rev Cuba Cir 1998;37(1):66 - 9. [24] Mishriki SF, Hopkinson N, Shepherd DFC, Parham DM. Bilateral rupture of the renal pelvis associated with systemic lupus erythematosus. BJU Int 1999;83(7):865. [25] Eltorai IM, Hovey RM, Ronningen LD, Montroy RE, Gutierrez PA, Aesquivel L. Giant urinoma in spinal cord injury. Report of two cases. J Spinal Cord Med 2003;26(4):404 - 8. [26] Maheshwari Pankaj N, Trivedi NN, Kausik VB, Parmar VP. Emphysematous urinoma. J Postgrad Med 2004;50(3):217 - 8. [27] Huang E, Sayegh R, Craigo S, Chelmow D. Rupture of the renal pelvis associated with intravenous fluid bolus. J Matern Fetal Neonatal Med 2002;11(5):345 - 6.
385 [28] Rao MS, Bapna BC, Subudhi CL, Rajendran LJ, Shrikhande VV, Vaidyanathan S. Spontaneous rupture of renal pelvis during post obstructive diuresis. Eur Urol 1979;5(3):214 - 5. [29] Caro DJ, Waldbaum RS. Spontaneous rupture of renal pelvis. Urology 1976;8(4):410 - 2. [30] Satoh S, Okuma A, Fujita Y, Tamaka M, Nakano H. Spontaneous rupture of the renal pelvis during pregnancy: a report and review of the literature. Am J Perinatol 2002;19(4):189 - 95.
Isolated superior mesenteric artery dissection in a patient without risk factors or aortic dissection Superior mesenteric artery (SMA) dissection is an unusual disease entity that is often related to dissected aortic aneurysm (DAA). We present a case with isolated dissection of SMA that was diagnosed by abdominal ultrasonography and confirmed by contrast-enhanced computed tomography (CT). Under conservative treatment, he was discharged uneventfully. A 49-year-old man visited our ED because of acute onset of epigastralgia for 5 hours. He also complained of nausea and soft stool passage. He denied history of hypertension, diabetes, dyslipidemia, and recent abdominal trauma. The family history was unremarkable. At arrival, his blood pressure was 160/105 mm Hg, and his pulse was 108 beats per minute. Physical examination revealed tenderness over epigastric area and hypoactive bowel sounds. The laboratory data (including coagulation panel and international normalized ratio) were all within normal limits and plain abdominal films were unremarkable. Abdominal ultrasonography showed dissection of the SMA with intramural thrombus (Fig. 1). A contrastenhanced abdominal CT confirmed the diagnosis and revealed dissection of the SMA, beginning at 1 cm from the SMA orifice and extending for 12 cm, involving several jejunal branches, although bowel wall was well enhanced (Fig. 2). There was no evidence of DAA. He was admitted on the same day with conservative treatment. No anti-
Fig. 1 Three-dimensional abdominal ultrasonography showing dissected flap in the SMA.
386
Fig. 2 Contrast-enhanced abdominal CT demonstrating dissection of the SMA with intimal flap and false lumen; the abdominal aorta is not affected.
coagulation medication was given during hospitalization. He was discharged on the second day uneventfully and has remained asymptomatic in the following 3-month period. Entities of acute abdominal pain that are associated with diseases of the SMA include SMA thromboembolism and SMA dissection. Isolated dissection of the SMA without the coexistence of DAA is a rare situation [1,2]. It typically located at the proximal portion of the SMA, sparing the orifice of the SMA exiting site from the aorta [3]. Etiologies of SMA dissection include abdominal trauma, connective tissue disorder, cystic medial necrosis, fibromuscular dysplasia, atherosclerosis, and that associated with DAA [3,4]. Isolated SMA dissection occurred predominantly in the male sex, most of whom were older than 50 years [1,3]. Patients with isolated SMA dissection present from incidental finding [1] to severe abdominal pain [2]. Some were associated with vomiting, diarrhea, or audible epigastric bruit. The diagnosis is difficult because isolated SMA dissection lacks specific and reliable abdominal signs, as well as typical blood test and plain film findings [5]. Because of the unreliability of the clinical symptoms and signs of isolated SMA dissection, various imaging modalities, including ultrasonography, contrast-enhanced CT, and angiography, make early diagnosis and intervention possible. Abdominal ultrasonography, although technique dependent, provides quick and noninvasive diagnostic yield of this rare condition. Computed tomographic scan has been regarded as the standard diagnostic tool for SMA occlusion. In a review of 36 cases of isolated SMA dissection who underwent abdominal CT scan, Suzuki et al [7] listed the common CT findings, including intimal flaps, mural thrombus, enlarged SMA diameters, and attenuated fat plain around the affected SMA, although none had a sensitivity of 100%. In our case, a thrombosed false lumen with filling defect was perfectly demonstrated on the CT scans. The treatment for isolated SMA dissection includes surgery,
Case Reports radiological intervention, pharmacological measures, and, rarely, conservative observation. The variety of surgical techniques include resection of affected segment with graft interposition, arteriotomy with thrombectomy or intimectomy, right gastroepiploic artery bypass, and reanastomosis of the SMA with aorta [3,12]. In a review of 65 patients reported in the literature, conservative treatment was undertaken in 26 of these patients [1-4,6-11,13-18]. Twelve of these 26 patients who received conservative treatment were given anticoagulation medications. Our case provided a successful experience of isolated SMA dissection under conservative treatment. In summary, the incidence of isolated SMA dissection may be underestimated because some patients with this entity undergo a self-limited course. Although it is potentially fatal in some cases, reliable clinical signs and laboratory findings are still lacking. The key to a rapid and correct diagnosis is the appropriate use of several imaging tools. Abdominal ultrasonography provides a quick survey of the abnormality of the SMA. Contrast-enhanced spiral CT is regarded as the standard diagnostic tool, not only because it can reveal the pathology of intra-abdominal great vessels, but it also reveals other conditions in detail, such as bowel ischemia. Most reported patients of isolated SMA dissection underwent surgery; some radiological interventions had been proposed and seemed to be promising. For the emergency physician, though, a high index of suspicion is essential for appropriate management of this rare condition.
Shih-Heng Chang MD Wan-Ching Lien MD Yueh-Ping Liu MD Hsiu-Po Wang MD Department of Emergency Medicine National Taiwan University Hospital Taipei 100, Taiwan E-mail address: [email protected] Kao-Lang Liu MD Department of Radiology National Taiwan University Hospital Taipai 100, Taiwan doi:10.1016/j.ajem.2005.11.003
References [1] Hiroshi Y, Hiroshi S, Tetsuichiro M. Self-limited spontaneous dissection of the main trunk of the superior mesenteric artery. J Vasc Surg 1998;27:776 - 9. [2] Herve S, Djamel FD, Matthieu C, Marie JM, Annie P, Pierre YL. Fatal hemorrhage due to an isolated dissection of the superior mesenteric artery. Intensive Care Med 2003;29:505 - 6. [3] Steven SR. Failure of nonoperative management of isolated superior mesenteric artery dissection. Ann Vasc Surg 2000;14:105 - 9.
Case Reports [4] Bauersfeld SR. Dissecting aneurysm of the aorta: a presentation of fifteen cases and a review of the recent literature. Ann Intern Med 1974;26:873 - 89. [5] Williams LF. Mesenteric ischemia. Surg Clin North Am 1988;68: 331 - 53. [6] Hirai S, Hamanaka Y, Mitsui N, et al. Spontaneous dissection of the main trunk of the superior mesenteric artery. Ann Thorac Cardiovasc Surg 2002;8:236 - 40. [7] Suzuki S, Furui S, et al. Isolated dissection of the superior mesenteric artery: CT findings in six cases. Abdom Imaging 2004;29:153 - 7. [8] Iha K, Nakasone Y, Nakachi H, Horikawa Y, Gushiken M, Matsuda H. Surgical treatment of spontaneous dissection of the superior mesenteric artery: a case report. Ann Thorac Cardiovasc Surg 2000;6:65 - 9. [9] Leung DA, Schneider E, Kubik-Huch R, Marincek B, Pfammatter T. Acute mesenteric ischemia caused by spontaneous isolated dissection of the superior mesenteric artery: treatment by percutaneous stent placement. Eur Radiol 2000;10:1916 - 9. [10] Ishida M, Kato N, et al. Dissecting aneurysm of the superior mesenteric artery successfully treated by endovascular stent-graft placement. Cardiovasc Intervent Radiol 2003;26:403 - 6. [11] Froment P, Alerci M, Vandoni RE, Bogen M, Gertsch P, Galeazzi G. Stenting of a spontaneous dissection of the superior mesenteric artery: a new therapeutic approach? Cardiovasc Intervent Radiol 2004;27: 529 - 32.
387 [12] Javerliat I, Becquemin P, d’Audiffret A. Spontaneous isolated dissection of the superior mesenteric artery. Eur J Vasc Endovasc Surg 2003;25:180 - 4. [13] Kochi K, Orihashi K, Murakami Y, Sueda T. Revascularization using arterial conduits for abdominal angina due to isolated and spontaneous dissection of the superior mesenteric artery. Ann Vasc Surg 2003; 19:418 - 20. [14] Tsuji Y, Hino Y, Sugimoto K, Matsuda H, Okita Y. Surgical intervention for isolated dissecting aneurysm of the superior mesenteric artery—a case report. Vasc Endovascular Surg 2004;38:469 - 72. [15] Yoon YW, Choi D, Cho SY, Lee do Y. Successful treatment of isolated spontaneous superior mesenteric artery dissection with stent placement. Cardiovasc Intervent Radiol 2003;26:475 - 8. [16] Ishida M, Kato N, Hirano T, Suzuki T, Shomura Y, Yada I, et al. Dissecting aneurysm of the superior mesenteric artery successfully treated by endovascular stent-graft placement. Cardiovasc Intervent Radiol 2003;26:403 - 6. [17] Nagai T, Torishima R, Uchida A, Nakashima H, Takahashi K, Okawara H, et al. Spontaneous dissection of the superior mesenteric artery in four cases treated with anticoagulation therapy. Intern Med 2004;43:473 - 8. [18] Kim JH, Roh BS, Lee YH, Choi SS, So BJ. Isolated spontaneous dissection of the superior mesenteric artery: percutaneous stent placement in two patients. Korean J Radiol 2004;5:134 - 8.
385 [28] Rao MS, Bapna BC, Subudhi CL, Rajendran LJ, Shrikhande VV, Vaidyanathan S. Spontaneous rupture of renal pelvis during post obstructive diuresis. Eur Urol 1979;5(3):214 - 5. [29] Caro DJ, Waldbaum RS. Spontaneous rupture of renal pelvis. Urology 1976;8(4):410 - 2. [30] Satoh S, Okuma A, Fujita Y, Tamaka M, Nakano H. Spontaneous rupture of the renal pelvis during pregnancy: a report and review of the literature. Am J Perinatol 2002;19(4):189 - 95.
Isolated superior mesenteric artery dissection in a patient without risk factors or aortic dissection Superior mesenteric artery (SMA) dissection is an unusual disease entity that is often related to dissected aortic aneurysm (DAA). We present a case with isolated dissection of SMA that was diagnosed by abdominal ultrasonography and confirmed by contrast-enhanced computed tomography (CT). Under conservative treatment, he was discharged uneventfully. A 49-year-old man visited our ED because of acute onset of epigastralgia for 5 hours. He also complained of nausea and soft stool passage. He denied history of hypertension, diabetes, dyslipidemia, and recent abdominal trauma. The family history was unremarkable. At arrival, his blood pressure was 160/105 mm Hg, and his pulse was 108 beats per minute. Physical examination revealed tenderness over epigastric area and hypoactive bowel sounds. The laboratory data (including coagulation panel and international normalized ratio) were all within normal limits and plain abdominal films were unremarkable. Abdominal ultrasonography showed dissection of the SMA with intramural thrombus (Fig. 1). A contrastenhanced abdominal CT confirmed the diagnosis and revealed dissection of the SMA, beginning at 1 cm from the SMA orifice and extending for 12 cm, involving several jejunal branches, although bowel wall was well enhanced (Fig. 2). There was no evidence of DAA. He was admitted on the same day with conservative treatment. No anti-
Fig. 1 Three-dimensional abdominal ultrasonography showing dissected flap in the SMA.
386
Fig. 2 Contrast-enhanced abdominal CT demonstrating dissection of the SMA with intimal flap and false lumen; the abdominal aorta is not affected.
coagulation medication was given during hospitalization. He was discharged on the second day uneventfully and has remained asymptomatic in the following 3-month period. Entities of acute abdominal pain that are associated with diseases of the SMA include SMA thromboembolism and SMA dissection. Isolated dissection of the SMA without the coexistence of DAA is a rare situation [1,2]. It typically located at the proximal portion of the SMA, sparing the orifice of the SMA exiting site from the aorta [3]. Etiologies of SMA dissection include abdominal trauma, connective tissue disorder, cystic medial necrosis, fibromuscular dysplasia, atherosclerosis, and that associated with DAA [3,4]. Isolated SMA dissection occurred predominantly in the male sex, most of whom were older than 50 years [1,3]. Patients with isolated SMA dissection present from incidental finding [1] to severe abdominal pain [2]. Some were associated with vomiting, diarrhea, or audible epigastric bruit. The diagnosis is difficult because isolated SMA dissection lacks specific and reliable abdominal signs, as well as typical blood test and plain film findings [5]. Because of the unreliability of the clinical symptoms and signs of isolated SMA dissection, various imaging modalities, including ultrasonography, contrast-enhanced CT, and angiography, make early diagnosis and intervention possible. Abdominal ultrasonography, although technique dependent, provides quick and noninvasive diagnostic yield of this rare condition. Computed tomographic scan has been regarded as the standard diagnostic tool for SMA occlusion. In a review of 36 cases of isolated SMA dissection who underwent abdominal CT scan, Suzuki et al [7] listed the common CT findings, including intimal flaps, mural thrombus, enlarged SMA diameters, and attenuated fat plain around the affected SMA, although none had a sensitivity of 100%. In our case, a thrombosed false lumen with filling defect was perfectly demonstrated on the CT scans. The treatment for isolated SMA dissection includes surgery,
Case Reports radiological intervention, pharmacological measures, and, rarely, conservative observation. The variety of surgical techniques include resection of affected segment with graft interposition, arteriotomy with thrombectomy or intimectomy, right gastroepiploic artery bypass, and reanastomosis of the SMA with aorta [3,12]. In a review of 65 patients reported in the literature, conservative treatment was undertaken in 26 of these patients [1-4,6-11,13-18]. Twelve of these 26 patients who received conservative treatment were given anticoagulation medications. Our case provided a successful experience of isolated SMA dissection under conservative treatment. In summary, the incidence of isolated SMA dissection may be underestimated because some patients with this entity undergo a self-limited course. Although it is potentially fatal in some cases, reliable clinical signs and laboratory findings are still lacking. The key to a rapid and correct diagnosis is the appropriate use of several imaging tools. Abdominal ultrasonography provides a quick survey of the abnormality of the SMA. Contrast-enhanced spiral CT is regarded as the standard diagnostic tool, not only because it can reveal the pathology of intra-abdominal great vessels, but it also reveals other conditions in detail, such as bowel ischemia. Most reported patients of isolated SMA dissection underwent surgery; some radiological interventions had been proposed and seemed to be promising. For the emergency physician, though, a high index of suspicion is essential for appropriate management of this rare condition.
Shih-Heng Chang MD Wan-Ching Lien MD Yueh-Ping Liu MD Hsiu-Po Wang MD Department of Emergency Medicine National Taiwan University Hospital Taipei 100, Taiwan E-mail address: [email protected] Kao-Lang Liu MD Department of Radiology National Taiwan University Hospital Taipai 100, Taiwan doi:10.1016/j.ajem.2005.11.003
References [1] Hiroshi Y, Hiroshi S, Tetsuichiro M. Self-limited spontaneous dissection of the main trunk of the superior mesenteric artery. J Vasc Surg 1998;27:776 - 9. [2] Herve S, Djamel FD, Matthieu C, Marie JM, Annie P, Pierre YL. Fatal hemorrhage due to an isolated dissection of the superior mesenteric artery. Intensive Care Med 2003;29:505 - 6. [3] Steven SR. Failure of nonoperative management of isolated superior mesenteric artery dissection. Ann Vasc Surg 2000;14:105 - 9.
Case Reports [4] Bauersfeld SR. Dissecting aneurysm of the aorta: a presentation of fifteen cases and a review of the recent literature. Ann Intern Med 1974;26:873 - 89. [5] Williams LF. Mesenteric ischemia. Surg Clin North Am 1988;68: 331 - 53. [6] Hirai S, Hamanaka Y, Mitsui N, et al. Spontaneous dissection of the main trunk of the superior mesenteric artery. Ann Thorac Cardiovasc Surg 2002;8:236 - 40. [7] Suzuki S, Furui S, et al. Isolated dissection of the superior mesenteric artery: CT findings in six cases. Abdom Imaging 2004;29:153 - 7. [8] Iha K, Nakasone Y, Nakachi H, Horikawa Y, Gushiken M, Matsuda H. Surgical treatment of spontaneous dissection of the superior mesenteric artery: a case report. Ann Thorac Cardiovasc Surg 2000;6:65 - 9. [9] Leung DA, Schneider E, Kubik-Huch R, Marincek B, Pfammatter T. Acute mesenteric ischemia caused by spontaneous isolated dissection of the superior mesenteric artery: treatment by percutaneous stent placement. Eur Radiol 2000;10:1916 - 9. [10] Ishida M, Kato N, et al. Dissecting aneurysm of the superior mesenteric artery successfully treated by endovascular stent-graft placement. Cardiovasc Intervent Radiol 2003;26:403 - 6. [11] Froment P, Alerci M, Vandoni RE, Bogen M, Gertsch P, Galeazzi G. Stenting of a spontaneous dissection of the superior mesenteric artery: a new therapeutic approach? Cardiovasc Intervent Radiol 2004;27: 529 - 32.
387 [12] Javerliat I, Becquemin P, d’Audiffret A. Spontaneous isolated dissection of the superior mesenteric artery. Eur J Vasc Endovasc Surg 2003;25:180 - 4. [13] Kochi K, Orihashi K, Murakami Y, Sueda T. Revascularization using arterial conduits for abdominal angina due to isolated and spontaneous dissection of the superior mesenteric artery. Ann Vasc Surg 2003; 19:418 - 20. [14] Tsuji Y, Hino Y, Sugimoto K, Matsuda H, Okita Y. Surgical intervention for isolated dissecting aneurysm of the superior mesenteric artery—a case report. Vasc Endovascular Surg 2004;38:469 - 72. [15] Yoon YW, Choi D, Cho SY, Lee do Y. Successful treatment of isolated spontaneous superior mesenteric artery dissection with stent placement. Cardiovasc Intervent Radiol 2003;26:475 - 8. [16] Ishida M, Kato N, Hirano T, Suzuki T, Shomura Y, Yada I, et al. Dissecting aneurysm of the superior mesenteric artery successfully treated by endovascular stent-graft placement. Cardiovasc Intervent Radiol 2003;26:403 - 6. [17] Nagai T, Torishima R, Uchida A, Nakashima H, Takahashi K, Okawara H, et al. Spontaneous dissection of the superior mesenteric artery in four cases treated with anticoagulation therapy. Intern Med 2004;43:473 - 8. [18] Kim JH, Roh BS, Lee YH, Choi SS, So BJ. Isolated spontaneous dissection of the superior mesenteric artery: percutaneous stent placement in two patients. Korean J Radiol 2004;5:134 - 8.