The Journal of Emergency Medicine, Vol. 49, No. 1, pp. e35–e36, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.12.087
Visual Diagnosis in Emergency Medicine
IDENTIFICATION OF SUPERIOR MESENTERIC ARTERY SYNDROME FROM VASCULAR ANGLE MEASUREMENTS Ryan Gould, MD,* Claire K. Sandstrom, MD,† and Jared Strote, MD, MS* *Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, Washington and †Department of Radiology, University of Washington, Seattle, Washington Corresponding Address: Jared Strote, MD, MS, Division of Emergency Medicine, Department of Medicine, University of Washington Medical Center, Box 356123, 1959 NE Pacific Street, Seattle, WA 98195
CASE REPORT A 55-year-old man presented to the Emergency Department by medics with sudden-onset constant, severe, generalized abdominal pain and distention 1 h prior to presentation. The pain was made worse with any movement. Associated symptoms included persistent nausea and vomiting of stomach contents. Specifically, he had no change in bowel or bladder function, difficulty breathing, chest pain, change in diet, or recent weight loss. The patient had no medical history and took no medications. He drank alcohol and smoked cigarettes intermittently and denied drug use. On arrival his vital signs were normal, but he was in severe distress. His abdomen was rigid and distended with involuntary guarding and rebound tenderness. Bowel sounds could not be heard. The rest of the examination was within normal limits. Laboratory studies were within normal limits except for a mild leukocytosis, mild lactic acidosis, and mild lipase elevation. A one-view upright abdominal x-ray study showed no abnormalities other than a relative paucity of bowel gas in the upper and right abdomen. A computed tomography (CT) scan of the abdomen and pelvis was performed with intravenous contrast showing
Figure 1. Coronal image through the stomach from a contrast-enhanced computed tomography of the abdomen. The gastric lumen and proximal segments of the duodenum are markedly distended. Interspersed with areas of normal mucosa enhancement are areas of decreased or absent mucosal enhancement and pneumatosis in the stomach (black arrows). In addition, gas is seen in the intrahepatic portal veins (black arrowheads).
Reprints are not available.
RECEIVED: 9 August 2014; FINAL SUBMISSION RECEIVED: 6 November 2014; ACCEPTED: 21 December 2014 e35
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Figure 2. Axial image. Axial image through the stomach from a contrast-enhanced computed tomography of the abdomen. The gastric lumen (S) and proximal segments of the duodenum (D) are markedly distended and the distal duodenum (d) and jejunum (j) are decompressed. There is pneumatosis in the proximal duodenum (curved white arrows). Gas is seen in small veins draining the greater gastric curve (small white arrows). The horizontal segment of the duodenum narrows abruptly as it passes between the SMA and the aorta, which are separated by a distance of
http://dx.doi.org/10.1016/j.jemermed.2014.12.087
Visual Diagnosis in Emergency Medicine
IDENTIFICATION OF SUPERIOR MESENTERIC ARTERY SYNDROME FROM VASCULAR ANGLE MEASUREMENTS Ryan Gould, MD,* Claire K. Sandstrom, MD,† and Jared Strote, MD, MS* *Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, Washington and †Department of Radiology, University of Washington, Seattle, Washington Corresponding Address: Jared Strote, MD, MS, Division of Emergency Medicine, Department of Medicine, University of Washington Medical Center, Box 356123, 1959 NE Pacific Street, Seattle, WA 98195
CASE REPORT A 55-year-old man presented to the Emergency Department by medics with sudden-onset constant, severe, generalized abdominal pain and distention 1 h prior to presentation. The pain was made worse with any movement. Associated symptoms included persistent nausea and vomiting of stomach contents. Specifically, he had no change in bowel or bladder function, difficulty breathing, chest pain, change in diet, or recent weight loss. The patient had no medical history and took no medications. He drank alcohol and smoked cigarettes intermittently and denied drug use. On arrival his vital signs were normal, but he was in severe distress. His abdomen was rigid and distended with involuntary guarding and rebound tenderness. Bowel sounds could not be heard. The rest of the examination was within normal limits. Laboratory studies were within normal limits except for a mild leukocytosis, mild lactic acidosis, and mild lipase elevation. A one-view upright abdominal x-ray study showed no abnormalities other than a relative paucity of bowel gas in the upper and right abdomen. A computed tomography (CT) scan of the abdomen and pelvis was performed with intravenous contrast showing
Figure 1. Coronal image through the stomach from a contrast-enhanced computed tomography of the abdomen. The gastric lumen and proximal segments of the duodenum are markedly distended. Interspersed with areas of normal mucosa enhancement are areas of decreased or absent mucosal enhancement and pneumatosis in the stomach (black arrows). In addition, gas is seen in the intrahepatic portal veins (black arrowheads).
Reprints are not available.
RECEIVED: 9 August 2014; FINAL SUBMISSION RECEIVED: 6 November 2014; ACCEPTED: 21 December 2014 e35
e36
R. Gould et al.
Figure 2. Axial image. Axial image through the stomach from a contrast-enhanced computed tomography of the abdomen. The gastric lumen (S) and proximal segments of the duodenum (D) are markedly distended and the distal duodenum (d) and jejunum (j) are decompressed. There is pneumatosis in the proximal duodenum (curved white arrows). Gas is seen in small veins draining the greater gastric curve (small white arrows). The horizontal segment of the duodenum narrows abruptly as it passes between the SMA and the aorta, which are separated by a distance of
