Small bowel ischemia - SMA embolus

Case contributed by Michael P. Hartung
Diagnosis almost certain

Presentation

Abdominal pain, recent mitral valve replacement with supratherapeutic INR.

Patient Data

Gender: Female

Hepatic portal venous gas. Patent portal vein. Diffusely dilated small bowel without transition point. Areas of wall thickening, hypoenhancement, and pneumatosis in the left mid-abdomen with mesenteric edema. ?Common origin of the celiac and SMA with diminutive size. Multifocal renal cortical scarring left volume loss and right adrenal myelolipoma.

Case Discussion

OPERATIVE NOTE EXCERPT: 

A fairly clearly demarcated abnormal segment of distal jejunum and proximal ileum was identified. No obstruction was seen during small bowel exploration. Inspection of the small bowel mesentery along the ischemic segment and in non-affected areas of her small bowel confirmed adequate arterial signal by Doppler. However, given the grossly abnormal appearance of this segment of the small bowel, the decision was made to proceed with enterectomy...

This case could present a diagnostic challenge because of the degree of diffuse small bowel dilation, which might tip the reader toward considering a small bowel obstruction. The portal venous gas raises concern appropriately for ischemia, and a cause must be identified. The distal jejunum/proximal ileum in the left mid-abdomen has focally increased wall thickening, hypoenhancement, pneumatosis, and mesenteric ischemia indicating either venous ischemia or reperfusion injury after arterial ischemia. SMV is patent and the history (mitral valve) and supporting findings (heavy vascular calcifications, renal scarring left>right related to embolic disease) support an embolic cause. This was appropriately evaluated and resected surgically. 

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