Teaching Case

The patient was brought to the emergency room because of intense pain in the left side of the abdomen and fever (38° C). He had a history of Budd-Chiari syndrome which caused splenectomy few years before. During the hospitalization in our centre severe arteriosus hypertension ( 220/130 mmHg) came out: the actual therapy allowed good pressure values (135/90 mmHg). An abdominal US examination showed an anechogenic voluminous lesion (10 x 8 x 6 cm) in the left hypoconder: it presented mixed echostructure and a hyperechogenic capsule. Therefore the patient underwent a CT examination, which showed many findings: diffuse parietal alteration of abdominal aorta, with obstruction of superior mesenteric artery and left renal artery (the upper pole of the kidney is perfused by capsular branches, while the lower one is hypoperfused); severe stenosis of ostium of right renal artery; in left suprarenal area, behind pancreatic tail, it is evidenced a round expansive lesion (about 6 cm) with well-defined walls and fluid-corpusculated content, probably a hematoma; liver had increased dimensions, irregular (macronodular) parenchymal density and hypoplasia or thrombosis of suprahepatic veins; pancreas presented increased dimensions and edematous body-tail; slight free endoperitoneal collection of fluid. A subsequent aortography confirmed the CT results and therefore a transluminal angioplasty of right renal artery was performed. General and vascular surgeons didn’t suggest hematoma removal and revascularization of left kidney. The patient presented also positive antiphospholipid antibodies test, antinuclear antibody test (ANA) and anti-DNA antibody test.

The anticardiolipin or antiphospholipid antibody syndrome is characterized by an increased incidence of venous and arterial thromboses. This syndrome may occur in association with systemic lupus erythematosus or independently. Gastroenterological manifestations may include Budd-Chiari syndrome, hepatic infarction, pancreatitis. Renal involvement may lead to renal failure or nephrosic syndrome. Treatment with high intensity oral anticoagulation and corticosteroids can resulte in clinical improvement.