Presentation
Small bowel vasculitis. Now increasing abdominal pain, vomiting ?small bowel ischemia.
Patient Data
There is a long segment (approximately 30cm) of infarcted distal small intestine evidenced by lack of mucosal enhancement and florid pneumatosis intestinalis. No perforation. No definite focal vascular occlusion is seen. No evidence of large vessel vasculitis seen. Multiple loops of prominent fluid-filled small intestine are seen, but there is no evidence of intestinal obstruction. There are 2 short segments of proximal small intestine circumferential mucosal thickening along the left flank . There is mottled attenuation of the spleen, with extensive areas of non-enhancement, in keeping with large regions of infarct, substantially progressed compared to the previous study.
Conclusion:
Distal small intestinal infarct, as above. No perforation or collection seen. Large multifocal splenic infarcts, substantially progressed. Short segment small intestinal mucosal thickening, non-specific, possibly inflammatory. No macro-vascular abnormality seen. Changes in the liver, kidneys and spleen consistent with microinfarctions.
Yellow arrow indicates infarcted bowel loop demonstrating pneumatosis intestinalis and non-enhancing bowel wall.
Case Discussion
The patient proceeded to laparotomy and small bowel resection.
Histopathology
Small bowel resection: Hemorrhagic ischemic necrosis. Many abnormal arteries in the mesentery, consistent with chronic stage of healed vasculitis. Viable resection margins.
Comment: Most of the arteries show features consistent with chronic stage of healed vasculitis. No necrotizing vasculitis or granulomas are seen. There are occasional vessels showing slightly more active lymphocytic vasculitis. The overall appearances are not specific regarding the vasculitis subtype. However, given the history of hepatitis B with high serum titer, hepatitis B-associated polyarteritis nodosa is a definite possibility.
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