Presentation
Severe abdominal pain.
Patient Data
The anterior abdomen is cut off from the field-of-view, due to patient's size. There is thickening of the left ventricle indicating hypertrophy. Heterogeneous, patchy perfusion within the liver. Incidental probable pancreas divisum. Patchy areas of hypoenhancement within the majority of the spleen, indicating infarcts. Multiple renal infarcts, which are somewhat difficult to distinguish from the adjacent cysts and due to the presence of patient motion.
There is acute occlusion of the mid superior mesenteric artery, which is somewhat difficult to detect on axial images and due to the presence of motion, possibly easier on sagittal. There is dilation of much of the small bowel, with some areas of abnormal thickening and also mesenteric edema. The proximal descending colon is equivocal for pneumatosis.
Case Discussion
Very challenging case of acute embolus of the superior mesenteric artery in this patient with severe abdominal pain and elevated lactate. The clot is difficult to see because of the underlying motion and phase of examination and because only portal venous phase images were obtained. However, you can have appropriately increased suspicion of the potential of embolus due to multifocal splenic and renal infarcts, and likely some degree of infarcts within the liver as well, accounting for the heterogeneous enhancement. Also, the findings of left ventricular hypertrophy support a potential cardiogenic cause of embolus.
Carefully evaluating the SMA on multiple planes can be particularly helpful in this case. Additionally, observing the underlying bowel changes which are admittedly relatively subtle, but typical for acute ischemia, which can include relative dilation of the bowel, followed by areas of thickening likely related to hemorrhagic transformation. The descending colon may have some areas of pneumatosis, which are equivocal but could be accounted for by watershed infarct. The patient unfortunately passed shortly after the examination.
Unable to process the form. Check for errors and try again.