CASE PRESENTATION
CASE PRESENTATION2009-07-10R2
2008 12 watery diarrrhea, 2009 5 nausea, vomiting w/u MEN1 #1
Vomiting #2 H/O pituitary prolactinoma S/P OP -10yrs ago, d/t
amenorrhea, #3 Hypercalcemia #4 Pancreas mass Current medication)
none FHx) - Hx (2-3YA, ) - siblings - 2 O) BP 90-140 / 60-100 #
Ionized Calcium 6.18 iPTH pending # Abdomen & Pelvis CT
(Contrast) + 3D 2.2cm well-demarcated exophytic inhomogeneously
enhancing mass with some tiny calcifications at anterosuperior
aspect of pancreas body r/o MEN 1 Opinion) - basal pituitarary
hormone ; TSH, free T4, ACTH, cortisol, IGF-1, GH, prolactin - iPTH
parathyroid SPECT . - fasting glucose/insulin/c-peptide, glucagon,
gastrin . - autoAb (TBII, antimicrosome Ab, anti-thyroglobulin Ab)
- adrenal mass 15% carcinoid tumors . - MEN 1 MEN1 gene . - f/up .
.1CASE 10229466 M/50 C.C: Epigastric pain ( )PMHx: Appendectomy
1year ago
Multiple endocrine neoplasia (MEN) comprisesvarious genetically
determined disorders with apredisposition to tumor development
within twoor more componenttwo major forms of MENtype 1(MEN 1) and
type 2 (MEN 2)s of the endocrine system.2Spontaneous SMA
dissection2nd m/c peripheral artery affected by spontaneous
dissection
Male, over forty years old
Risk factorhypertension, cystic medial necrosis, AAA most of
patients generally healthy Pathogenesis uncertain
sx: 1) acute onset of epigastric or LUQ pain: m/c vital signs
generally normal 2) hemorrhagic shock by arterial rupture
Spontaneous dissection of the SMA, once believed to be arare
occurrence, has been diagnosed much more frequentlyover the past
several years, likely due to the advancementand more liberal use of
imaging studiesSpontaneous dissection of the superior mesenteric
artery (SMA) isa rare occurrence, especially when not associated
with aortic dissectionchronic intestinal angina, including
postprandial pain,anorexia, and vomiting3Imaging studyOrigin of
dissection: btw 1cm to 6cm from aorta(mean: 2.7cm)
CT scan: initial imaging study of choiceCT findings in six
cases(with other 30 cases)
[Abdom Imaging (2004) 29:153157] Increased attenuation of fat
around SMA : only key to diagnosis during early stage
Arteriography: gold standard for diagnosisworsen arterial tear
of dissected peripheral artery early
Thrombosis in FL or Intramural hematomaIntimal flapEnlarged SMA
diameter att. of fat around SMAMesentery hematoma
4(18)4(24)5(18)51However,because the intimal flap cannot be always
noticed, themural thrombus may be only the clue of the SMA
dissection.Findingsof SMA dissection include mural thrombosis,
intramuralhematoma, or an intimal flap (1). Other CT
findingssuggestive of dissection include an enlarged SMAdiameter
and increased attenuation of the fat around theSMAThe increased
attenuation of fat may be theonly key to the diagnosis during the
early stage, however,it is not specific to SMA dissectionIn
ouropinion, the conventional diagnostic angiography will soonbe
replaced with CT angiography.4
DUIH case M/50
5ManagementNo established opinionConservative
treatmentIschemia(-), sx(-) anticoagulant Regular f/up image:
cannot expect time course
Surgical treatmentRuptureHemodynamic unstable: emergency
operationHemodynamic stable: angiogram operationSevere mesenteric
ischemia
Endovascular treatmentSafe and feasible therapeutic
alternativeproximal SMA segment must be covered by stent
Consequently, the stent for the SMA dissection needsseveral
important characteristics; minimal shortening, goodconformability
and flexibility, and it must not changelocation due to the
continuous movement of themesentery. As in aortic dissection, most
of cases ofsegmental dissection without side branch involvement
ordistal reentry may benefit from implanting a covered stentgraft
over the entry site of the dissection, thus causingthrombosis and
obliteration of the false lumen Patient with difficulty in surgical
approach
6REFERENCESpontaneous SMA dissection: an unusual cause of
abdominal pain j.jemermed.2007.05.054Isolated dissection of the
superior mesenteric artery: CT findings in six cases Abdom Imaging
(2004) 29:153157Spontaneous Dissection of the Superior Mesenteric
Artery Cardiovasc Intervent Radiol (2001) 24:329331
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