American Journal of Emergency Medicine 31 (2013) 1000.e3-1000.e5

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American Journal of Emergency Medicine

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Case Report

Spontaneous dissection of the Celiac artery: a case report and literature review?

Abstract

Epigastralgia is a common chief compliant in the emergency department. Most of them are not fetal events, but some are life threatening such as aortic dissection or abdominal aneurysm rupture. Spontaneous Visceral artery dissection is an uncommon occurrence with an unpredictable natural history and is rarely considered in the diagnosis of acute abdominal pain; however, it is as critical as aortic dissection and even easier to be ignored because of its rarity. We present a case of a 48-year-old man who presented to our emergency department with the chief concern of Epigastric pain and diagnosed as having isolated spontaneous celiac artery dissection involving the hepatic artery, gastroduodenal artery, and splenic artery. Most cases required surgical intervention in previous reports; there are some, as in this case, managed well nonoperatively.

A 48-year-old man was sent to our emergency department by ambulance presented with sudden onset of epigastric pain that continued for half a day with increasing in severity. The patient described it as burning, sharp, severe, persisted, radiating to his back, and associated with nausea. He denied vomiting, diarrhea, fever, and any other symptoms. He had a history of long-term medication- controlled hypertension and heavy smoking about 1 pack per day for more than 20 years. At presentation to our emergency department, vital signs were unremarkable, except Elevated blood pressure (163/ 101 mm Hg), and physical examination revealed abdominal tender- ness without rebounding pain. blood works, plain abdominal film, and ultrasonography were unremarkable. To exclude possible aortic dissection, an aortic and Abdominal computed tomography (CT) with contrast was performed and showed narrow celiac trunk from its root and extending into the common hepatic and splenic artery (Fig. 1). The angiography was then performed and revealed thromboembolization of related branches including the following: celiac trunk; common, proper, and bilateral main hepatic arteries; gastroduodenal artery; left Gastric artery; and proximal splenic artery (Fig. 2A). What impressed us was that there was a false lumen with prolonged contrast stasis of nearly 4.5 cm in length at the level around the celiac trunk (Fig. 2B). Under the query, a following abdominal CT was done immediately and showed the contrast stasis not only in the false lumen of abdominal aorta (Fig. 2C) but also in the celiac trunk and common hepatic artery (Fig. 2D), which means that the dissecting starts from the abdominal aorta and extending to the celiac artery and its branches, and the orifice of celiac root across the true lumen and the false lumen. The patient was admitted to cardiovascular surgery service and treated conservatively with Antiplatelet agents and Antihypertensive medications. He was discharged with oral aspirin

? Competing interest: None of the authors have any conflicts to disclose. 0735-6757/$ - see front matter (C) 2013

and steroids 4 days later. A following CT showed much improved of the arteries’ narrowings 4 months later (Fig. 3A, B).

Isolated spontaneous celiac artery dissection is a rare entity, and only about 20 cases are reported in the literature. The etiology has been reported to be iatrogenic or secondary to atherosclerosis, trauma, pregnancy, fibromusclar dysplasia, inflammatory or infec- tious disease, congenital disorder of the vascular wall (Ehlers-Danlos syndrome), cystic medial degeneration (Marfan syndrome), connec- tive tissue disorders, or vasculitis (giant cell arteritis, Takaysau arteritis, and polyarteritis) [1-4]. In addition, a previous abdominal surgery or peritoneal syndrome that could weaken the arterial wall or enhancing hemodynamic shearing forces such as microtrauma caused by exertion or sudden abdominal hyperpressure have been believed to be the possible precipitating events [5].

Spontaneous arterial dissection is more common in men than in women (5:1), with an average age of patients being approximately 55 years [6]. Clinical presentation varies [1], but almost all cases of celiac artery dissection have been characterized by chronic or acute abdominal pain located mainly in the epigastric region [5], associated with nausea, vomiting, or diarrhea [1]. Sudden appearance of epigastric or hypochondrial pain that resolves spontaneously within 1 to 5 days is an important alarm signal causes by irritation of the nearby nerve plexus or initial rupture of the aneurysm [5]. In some cases, an abdominal systolic bruit may be heard [1], although it is a rare finding that may suggest intestinal angina if associated with pancreatitis-like postprandial abdominal angina [5]. However, more atypical symptoms have been described, depending on the location of the arterial lesion, for example, dissection of Superior mesenteric artery, jaundice in association with dissection of the hepatic artery,

Fig. 1. Eccentric thrombus noted over celiac artery (arrow), common hepatic (arrowhead 1), and splenic artery (arrowhead 2).

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Fig. 2. A, Thromboembolization of celiac trunk (arrow), common (arrowhead 1), proper hepatic artery (arrowhead 2), gastroduodenal artery (arrowhead 3), left gastric artery (arrowhead 4), and proximal splenic artery (arrowhead 5). B, There was a false lumen with prolonged contrast stasis of nearly 4.5 cm in length at the level around the celiac trunk (arrow). C, The contrast stasis in the false lumen of abdominal aorta (arrow). D, The contrast stasis in the celiac trunk (arrow) and common hepatic artery (arrowhead).

Fig. 3. The narrowing of celiac trunk (arrow) and splenic artery (arrowhead) improved. A, The narrowing of common hepatic artery improved (arrowhead).

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and pancreatitis with elevated serum amylase levels in association with dissection of brunches of pancreatic artery [7]. Acute signs such as bleeding or liver ischemia are poor prognostic factors, associated with more than 40% of deaths [5]. Above all, there are still some patients with celiac artery dissection who are asymptomatic possibly because of the lack of small bowel involvement [6]. Although the case we described here presented only with epigastric pain, it involved all the 3 branches of celiac trunk and would be the first one of celiac artery dissection that involved all the 3 branches (the splenic artery, the left gastric artery, and the hepatic artery).

The diagnosis of celiac artery dissection is largely dependent on the findings of imaging studies [4]. A false lumen, thrombosis, and aneurysm in arteries are typical findings on the abdominal CT scan with contrast injection. The definitive diagnosis usually requires selective arteriography, which also allows precise determination of the extent of involvement, especially of stenosis lesions, evaluation of collateral circulation, and detection of predisposing features [5]. As on angiography, arterial dissection is characterized by double lumina, string sign, tapered occlusions, occlusions at unusual sites, short segmental narrowings, intimal flaps, irregular stenosis, intraluminal defects, distal pouches, and aneurysms [4]. In addition, Doppler ultrasonography is mentioned to use in the initial assessment of a suspected dissection [3]. Moreover, CT angiography is a well- established method of the evaluation of vascular anatomy and disease and has been shown to be as accurate as conventional angiography, with less morbidity, and is less expensive in recent years [2].

Treatment strategy for dissection includes limiting progression of the dissecting hematoma, controlling hypertension, and preventing thromboembolic complications [6]. Surgical reconstruction is man- datory for symptomatic forms of celiac artery dissection to manage the lesion and obtain a definitive histologic diagnosis, but surgical treatment is reserved for the patient who is hemodynamically unstable or has persistent abdominal pain, when medical therapy fails to control blood pressure and when dissection is progressing [3,5,6,8]. Medical treatment includes anticoagulants, anti-inflamma- tory drugs, steroids, and secondary Antiplatelet therapy, which are advisable in patients with stenostic lesions to prevent thrombosis [6,8]. endovascular treatment with a stent or embolization is an attractive option for patients with high surgical risk but fail with medical therapy [5], although the data on its comparison with surgery are not conclusive [3,8]. By far, Surgical repair is the most reliable means as the best overall strategy for preventing fatal risks of acute ischemic or hemorrhagic complications, especially in cases of aneurysm formation, occlusive lesions, arterial rupture, or liver ischemia [2,5].

Acute abdominal pain can be the only symptom of isolated spontaneous celiac artery dissection, which would be as critical as aortic dissection or aneurysm rupture. The patient’s favorable outcome results from early recognition and definite therapy. Therefore, patients presenting with epigastric pain without other obvious cause should be

evaluated for the possible isolated spontaneous celiac artery dissec- tion, although it is extremely rare.

Hsiao-Chia Wang MD

Department of Emergency Medicine, Cathay General Hospital

Taipei, Taiwan

Jiann-Hwa Chen MD, MPH

Department of Emergency Medicine, Cathay General Hospital

Taipei, Taiwan School of Medicine, Fu Jen Catholic University

Taipei, Taiwan

Chieh-Chien Hsiao MD

Department of Emergency Medicine, Cathay General Hospital

Taipei, Taiwan

Chin-Ming Jeng MD, MPH

School of Medicine, Fu Jen Catholic University

Taipei, Taiwan Department of Radiology, Cathay General Hospital

Taipei, Taiwan

Wei-Lung Chen MD, PhD

Department of Emergency Medicine, Cathay General Hospital

Taipei, Taiwan School of Medicine, Fu Jen Catholic University

Taipei, Taiwan E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.02.007

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