CASE 11023 Published on 11.10.2013

SMA embolism

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Malamouli I., Pappas E., Adoniou A., Krikis P.

Achillopouleio hospital Volos, computerized tomography; Polimeri 132 38221 VOLOS, Greece; Email:mioanna3@gmail.com
Patient

80 years, female

Categories
Area of Interest Abdomen ; Imaging Technique CT
Clinical History
An 80 years old male, with a history of atrial fibrillation, was admitted with upper quadrant abdominal pain and diarrhoea for more than 24h. His laboratory tests showed high white cell count(18000), amylase 140, lipase 99, glu 411, WBC 4, 42. Acute pancreatitis was suspected at first.
Imaging Findings
Abdominal U/S had no signs of pancreatic disease. A CT scan was performed. There was marked thickening of small intestine wall(10mm)[fig.1] with intramural air bubbles in small intestine and transverse colon[fig.2], free air in intrahepatic portal vein branches and SMV[fig.3], thickening of large intestine wall(5mm), a small amount of free air in peritoneal cavity[fig.5] and SMA thrombosis[fig.4]
Discussion
Acute occlusion of SMA typically affects elderly patients. Risk factors include atherosclerosis, valvular/cardiac abnormalities (congestive heart failure, atrial fibrillation, ventricular aneurysm), intra-abdominal malignancy[1, 2, 3]. Thrombus may be located at the origin(15%) or just distal(50%) to the origin of middle colic artery[5]. SMA thrombosis can be life threatening because sma supplies the majority of small bowel and right side of colon. Clinical presentation is variable and often non specific, CT is the most appropriate examination due to its speed, widespread availability and ability to diagnose other abdominal pathology. CT scan findings with a specificity greater than 95% include SMA thrombosis, increased thickness of bowel wall and lack of bowel wall enhancement, ischemia of other organs[4]. Breakdown of the mucosal barrier results in intestinal pneumatosis and formation of porto-mesenteric venous gas, which is the least common but most specific finding of acute ischemia. Transudation into the mesentery of the peritoneal cavity leads to mesenteric stranding or even ascites[6]. Once a diagnosis of acute mesenteric thrombosis is made, the patient should undergo surgery because of the risk of bowel infarction, perforation, peritonitis.
Differential Diagnosis List
Superior mesenteric artery thrombosis
colitis
peritonitis
Final Diagnosis
Superior mesenteric artery thrombosis
Case information
URL: https://eurorad.org/case/11023
DOI: 10.1594/EURORAD/CASE.11023
ISSN: 1563-4086