Celiac trunk occlusion

Case contributed by Sara Abdulbaset hasan


COVID-19 ICU patient presented with progressive abdominal distension and pain with clinical signs suggestive of bowel obstruction.

Patient Data

Age: 50 years
Gender: Female

Complete occlusion of the celiac trunk and its main branches (splenic, hepatic and left gastric). Subsequent infarctions and ischemic injuries to the following:

  • Massive splenic infarction, with sparing of a small area located medially underneath the splenic capsule (less than 10% of splenic volume)
  • The tail of the pancreas infarction (the distal-most 4cm). The pancreatic duct is minimally dilated throughout the body and proximal tail.
  • The gastric mucosa shows linear enhancement, with high suspicion of a solitary tiny gas density underneath, raising the possibility of developing gastric pneumatosis.  The stomach itself is markedly dilated, with an air-fluid level.
  • The portal vein and its branches are well enhanced in the arterial phase. The hepatic artery didn’t show up.
  • The SMA looks patent. The small bowel shows mild diffuse wall thickening, possibly reflecting an element of hypo-perfusion. Multiple small gas densities are seen within, but no evidence of pneumatosis.
  • Mild to moderate ascites.

Other findings:

  • Right lower ureteric stones with subsequent mild hydronephrosis and hydro ureter.
  • Calcified uterine fibroid noted.
  • A nasogastric tube was seen in place.
  • A urinary catheter is seen.
  • L4/5 and L5/S1 posterior disc protrusions.
  • Lower chest cuts show a mixture of ground glass and consolidative areas with atelectatic bands and pleural effusions.          

Case Discussion

In the current era of COVID-19, there are strong associations with thromboembolic vascular events in up to 30% of ICU patients, even with pharmacological thromboprophylaxis.

In some cases, it may be the first presentation, including pulmonary arterial embolism, peripheral circulation of limbs, and/or mesenteric vascular occlusion, as in this case. Thrombotic events are associated with 5.4 times higher risk of mortality.

A recent post-mortem examination has demonstrated severe endothelial injury (inflammatory mediators storm-induced -vascular intima injury and vasculitis) and the intracellular virus within lung autopsies with thrombosis of small and middle-sized pulmonary vessels.

Usually, developing thromboembolic events in COVID cases carries a bad prognosis and is considered a sign of deteriorating clinical condition

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