Isolated Dissection of Superior Mesenteric Artery
A 48-year-old man was admitted to our hospital with a sudden onset of epigastric pain, nausea, and vomiting commencing three hours previously. He had no history of hypertension or diabetes, but he had smoked one pack of cigarettes daily for the previous ten years. He had a permanent pacemaker, implanted one year before because of symptomatic bradycardia. Physical examination revealed a normal blood pressure (137/87 mmHg) and mild tenderness over the epigastric area with no peritoneal signs. On admission in the emergency room due to left bundle branch block in the electrocardiogram () and epigastric pain, thrombolytic therapy was done on suspicion of acute myocardial infarction. The patient was transferred to the cardiac care unit (CCU), where he continued to complain of severe abdominal pain, especially after eating. The patient was kept fasting, and a nasal gastric tube was, therefore, employed and Enoxaparin, Aspirin, and Clopidogrel were continued. Laboratory tests, including complete blood count, amylase, liver enzymes, and cardiac markers, were normal. Endoscopic examination revealed no remarkable finding. Coronary angiography was normal, but superior mesenteric angiography showed a dissected non-flow limiting lesion at the proximal part (). In CT angiography, the aorta and the other visceral vessels were normal and a dissection was detected at the proximal part of the SMA, which extended only about two centimeters. The false lumen was occluded by a thrombus (). Despite our recommendation, the patient refused to accept SMA stenting and conservative therapy was, consequently, continued. The patient was kept fasting for five days; at first, the epigastric pain decreased but was thereafter exacerbated by eating. As a result, he was kept fasting for one more week, at the end of which he started eating gradually. The patient was discharged after two weeks. In the first month, he preferred to have a low calorie, low volume diet to reduce the pain, but afterwards he became completely asymptomatic and was able to tolerate food normally.