Isolated superior mesenteric artery dissection as a cause of abdominal pain

A 50-year-old male presented with sudden onset of upper abdominal pain. He had no infectious or other gastrointestinal symptoms. He had a background of hypertension, hypercholesterolemia and was a heavy smoker. Biochemistry results showed raised white cell count of 28 × 10⁹/L, elevated creatinine of 130 μmol/L, and venous lactate of 4.7 mmol/L.

Computed tomography (CT) of the abdomen demonstrated a hematoma contained within the lesser sac (Figure 1A). Computed tomography angiography (CTA) revealed an abrupt cutoff of the first branch of superior mesenteric artery (SMA) at the site of hemorrhage suggesting dissection with a distal nonocclusive thrombus (Figures 1B and 2). It was possible that the SMA dissection led to the hematoma within the lesser sac and had tamponade itself. Therefore, there was no active hemorrhage on the subsequent CTA. Given that he was hemodynamically stable with no signs of peritonism, he was managed nonoperatively. He was commenced on lifelong antiplatelet therapy. He had a follow-up CTA which was unremarkable. He remained clinically well.

Patients with isolated superior mesenteric artery dissection (ISMAD) are at risk of intestinal ischemia. Patients usually present with intractable abdominal pain. Other symptoms include diarrhea, nausea, and vomiting. Risk factors for ISMAD include atherosclerotic disease, hypertension, and abdominal aortic aneurysm.¹ CTA is the gold standard for diagnosis. Other imaging modalities include ultrasound and magnetic resonance angiography.²

The management of ISMAD consists of initial resuscitation. Patients with no signs of hemodynamic instability or peritonism can be managed nonoperatively.³ Anticoagulation is the mainstay of nonoperative management. A systematic review and meta-analysis reported that the majority of patients were commenced on anticoagulation therapy.⁴ Antiplatelet therapy has also been used in stable ISMAD patients with success.⁵

Operative management options include surgical or endovascular revascularization. Bypass grafting is the most common surgical procedure. Other surgical methods include thrombectomy or ligation of a branch of SMA.⁴

In conclusion, ISMAD is a rare cause of abdominal pain and prompt treatment is vital due to the risk of intestinal ischemia.

The authors declare no conflicts of interest.

According to the Institutional Review Board (IRB), there is no need for IRB approval for an image review article. A written informed consent was obtained from the patient before starting and the authors followed the principles outlined in the WMA Declaration of Helsinki throughout the writing process.