Acute superior mesenteric artery occlusion

Case contributed by Hoe Han Guan
Diagnosis certain

Presentation

Abdominal pain with profuse diarrhea and vomiting

Patient Data

Age: 60 years
Gender: Female

The small bowel loops (jejunum and ileum) are mildly dilated. A long segment of filling defect seen at the distal two-third of superior mesenteric artery, as well as involving the ileal and ileocolic-right colic branches. The ileum, cecum and proximal ascending colon have edematous bowel wall without bowel wall enhancement. Most of the jejunum bowel loops maintain their normal bowel enhancement. The rest of large bowel loops are not dilated with normal mucosal and bowel wall enhancement. No intramural gas, pneumoperitoneum and portal venous gas. Minimal ascites noted at the perihepatic, pelvic, and right inframesocolic region.

Annotated image

Sagittal view is crucial plane to assess the contrasted superior mesenteric artery to look for thrombus and embolus, especially the proximal superior mesenteric artery near to its origin which is the common location for superior mesenteric artery thrombosis.

Maximum intensity projection (MIP) is a useful tool for quick and effective assessment of the overall bowel wall enhancement distribution in coronal view.

Case Discussion

As this patient has a known case of atrial fibrillation, for which she has defaulted her anticoagulation treatment, the most likely cause of the superior mesenteric artery occlusion is due to embolus rather than thrombosis.

Acute superior mesenteric artery occlusion results in ileal, cecal and proximal ascending colonic ischemia due to the long segment of embolus lodged within the distal superior mesenteric artery and the respective branches. The jejunal branch and middle colic artery are spared therefore explaining the respective bowel loops maintained their vascular supply and bowel wall enhancement.

This patient underwent urgent small bowel resection and right hemicolectomy.

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