Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

Acute Superior Mesenteric Artery Thrombus in a 39 Year Old Female
Campbell, K, D.O., Dabulis, S, M.D.
Kent County Hospital, Emergency Medicine Residency Program, Warwick, RI
Introduction: It is crucial to evaluate and recognize patients clinically and
historically at increased risk for acute ischemic bowel. In this particular case,
although rare, ischemic bowel must be considered in high risk as well as lower risk
patients and therefore necessitates further evaluation in any patient that presents to
the emergency room with nausea, vomiting, abdominal pain out of proportion to
exam, and/or patients that do not respond to typical therapy.
Case: An otherwise healthy 39 year old female presented to the emergency
department with a chief complaint of new onset vomiting and abdominal pain for the
8 hours prior to arrival. Emesis described as only appearing like what she has
attempted to eat or drink, is non-bloody, non-bilious, and non-feculent. Vital signs,
laboratory evaluations including CBC, CMP, Lipase, Lactic Acid, UA were all within
normal limits. CT of the abdomen and pelvis were completed showing complete
opacification within the proximal 3cm of the superior mesenteric artery from its
origin. The patient was taken to the operating room emergently by vascular surgery
and underwent a failed thrombectomy and subsequent SMA bypass utilizing a
reverse greater saphenous vein graft. Repeat CTA of the vasculature was obtained
and demonstrates successful reprofusion of the proximal SMA via bypass graft.
Discussion: The four major causes of acute mesenteric ischemia are superior
mesenteric artery embolism (50%), superior mesenteric artery thrombosis (15 to
25%), mesenteric venous thrombosis (5%), or non-occlusive ischemia (20 to 30%)
[2,5]. One theory that may apply to this specific case involving an apparent lower
risk patient is non-occlusive mesenteric ischemia (NOMI). NOMI is thought to occur
as a result of splanchnic hypoperfusion and vasoconstriction [24]. Although the
“typical” comorbidities seen in acute mesenteric ischemia are also prominent in the
diagnosis of NOMI, several cases resulting from cocaine use have been described
[8,9]. This is thought to be secondary to the vasospasm classically seen with
cocaine use. Although no drug screen was conducted, it could serve as a potential
source for this otherwise healthy female. NOMI accounts for 20 to 30 percent of
patients with acute mesenteric ischemia , when it occurs, NOMI results in mortality
of nearly 70 percent of cases because of the difficulty in making the diagnosis and
reversing the ischemia once it has started [10,11]. The severity and location of the
abdominal pain that accompanies NOMI is usually more variable than the classic
severe pain of acute occlusive mesenteric ischemia. A high index of suspicion in
elderly patients, those with increased risk factors contributing to this diagnosis, or
those with risk factors for NOMI is imperative for prompting further evaluation and
making a prompt diagnosis.