Presentation
Severe epigastric tenderness, nausea and vomiting. uss nad. pyrexial overnight and o/e very tender guarding in upper epigastric region ? intra abdominal sepsis, rule out perforation.
Patient Data
Isolated loop of distended non-enhancing jejunum within the left upper quadrant.
Thrombus in the proximal superior mesenteric artery.
The remainder of the large and small bowel are normal.
Solid organs normal.
No evidence of free fluid. No free air.
Histology
Information: theater appearances mechanical ? internal hernia. 45 mm from DJ flexure - 20 cm in length.
Specimen
Jejunal resection.
Macroscopic: Approximately 250 mm of jejunum. The small bowel shows transmural ischemia apart from two short lengths measuring 28 mm and 35 mm respectively at the end margins. The surface mucosa in these areas appears normal. The ischemic portion also shows no focal mucosal abnormalities. The area of ischemia appears well delineated macroscopically. The mesenteric structures appear normal. Designation of Blocks A&B = Cut end resection margins C = Junction and abnormal and normal jejunum D = Central abnormal area E - G = Mesenteric structures
Microscopic: The jejunum shows extensive established ischemic change involving the mucosal and submucosal compartments. There is associated active non- specific chronic inflammation which extends through the full thickness of the deep muscle component. There is a variable surface serositis. No definite evidence of perforation is seen. Similar areas of minor focal mucosal ischemia are present at the cut end resection margins but most of the small bowel mucosa at these sites appears normal. There is no evidence of any form of background primary inflammatory or infective process. There is no evidence of neoplasia. Extensive sampling of the jejunum and adjacent mesenteric structures show multiple small thrombi within small vascular structures, including small vascular arteries, small veins and capillaries. There is no associated evidence of recent or previous vasculitis. No atherosclerosis or other underlying structural change is present within the vascular supply structure.
Comment: The overall appearances of the jejunal resection confirm the presence of extensive transmural ischemia. The presence of intra-vascular thrombi raises the possibility of an underlying primary thrombo-embolic condition. Similar features can be seen as a secondary phenomenon in ischemia resulting from other causes, such as mechanical obstruction with vascular compression. This would seem less likely given the nature and distribution of the vascular changes present. Further clinic-radiological correlation is advisable.
Diagnosis: Jejunal resection - · Transmural jejunal ischemia. · Multifocal vascular thrombo-embolic changes - cause unknown. · Likely primary vascular cause for small bowel ischemia. ·
Case Discussion
Classic appearances of ischemic bowel due to an arterial thrombosis.