Rahil H. Shah, MD1, Juan Carrere, MD2, Brian Baigorri, MD3, Daylem Antunez, MD2; 1Jackson Memorial Hospital, Miami, FL; 2Gastro Health, Miami, FL; 3Intellirad Imaging, Miami, FL
Introduction: Arterial dissections is a tear in the arterial wall creating a false lumen. Mesenteric dissections may occur as a continuation of aortic dissections, but isolated dissections are much rarer. Isolated superior mesenteric artery dissection, ISMAD, has a nonspecific presentation with the potential for high morbidity and mortality. We report the case of a 64-year-old male with an ISMAD that clinically and radiologically mimicked acute pancreatitis.
Methods: A 64-year-old Hispanic male with a past medical history significant for hypertension presented with abdominal pain for 24 hours. Pain began after a fatty meal and was located periumbilical with radiation to the back. He had nausea and two bouts of vomiting. His vitals were normal except for elevated blood pressure (170/87). Physical examination was only remarkable for tenderness to palpation in the epigastric and periumbilical regions. CBC showed leukocytosis with a left shift. Lipase was normal. Abdominal CT without contrast showed distorted anatomy and inflammation around the head of the pancreas. Abdominal CT with contrast revealed a proximal superior mesenteric artery dissection flap measuring 0.5 cm that started 4 cm from the SMA origin. (Image 1) The actual length including thrombosed false lumen is 8.5 cm. The point of greatest luminal narrowing of the true lumen is 74% (Image 2). It was characterized as a type 2b SMA dissection. The patient was hemodynamically stable and managed conservatively with IV heparin drip and blood pressure control. He was discharged on oral coagulation with a target INR of 2-3. Discussion: ISMAD is a rare disease with a nonspecific presentation. This case report demonstrates how ISMAD may present very similarly to acute pancreatitis. There has been no previous case report which shows an ISMAD mimicking acute pancreatitis. The patient technically met the Atlanta classification for acute pancreatitis with clinical signs and radiographic evidence. However, it is not clear if the inflammation seen radiographically is due to the ISMAD or from cellular injury innately from the pancreas. There are currently no guidelines on treatment strategy for ISMAD. For hemodynamically stable patients, conservative management with anticoagulation, and blood pressure control is recommended. Endovascular and surgical intervention should be considered for patients who are hemodynamically unstable or have an enlarging dissection. This case highlights the importance of a complete workup for abdominal pain.
Abdominal CT with IV contrast showing the ISMAD at the level of the fenestration.
Abdominal CT scan with IV contrast showing the area of greatest luminal narrowing, approximately 74% narrowing of the true lumen.
Disclosures: Rahil Shah indicated no relevant financial relationships. Juan Carrere indicated no relevant financial relationships. Brian Baigorri indicated no relevant financial relationships. Daylem Antunez indicated no relevant financial relationships.