Abdominal Pain in a Young Man With Severe Hypertension
Article Outline
- Answer to the Clinical Challenges and Images in GI Question: Image 2 (page 733): Isolated, Nontraumatic Celiac Artery Dissection
- References
- Copyright
Question: A 35-year-old African-American man presented to the emergency department with a history of non radiating epigastric pain that developed abruptly after a meal 4 days prior, which had acutely worsened for the past 2 hours. The patient's pain worsened after food ingestion and straightening up and was alleviated by leaning forward. The pain was not relieved by antacids or acetaminophen. His laboratory studies showed elevated amylase at 194 U/L and slight elevation of aspartate aminotransferase at 56 U/L and slight leukocytosis at 11 100 μ/L, with normal lipase levels. The patient's past medical history was significant for essential hypertension; however, the patient was not on medications for 6 months. After his emergency department evaluation, the patient was diagnosed as having gastritis with uncontrolled hypertension and was discharged home on antihypertensives and antihistaminics. However, he did not take his prescribed medications owing to fear of worsening of pain.
The patient presented to the emergency department 24 hours later, when he developed postprandial nausea and vomiting. On physical examination, the patient had a blood pressure of 240/155 mmHg with mild epigastric abdominal tenderness but without rebound, guarding, rigidity, or any pulsatile mass. Laboratory studies again showed elevated amylase at 284 U/L and slight elevation of aspartate aminotransferase at 50 U/L and slight leukocytosis at 11 900 μ/L with normal lipase levels. An electrocardiograph revealed left axis deviation with left ventricular and left atrial enlargement. A transthoracic echocardiogram revealed normal left ventricular ejection fraction and left ventricular concentric hypertrophy. A computed tomography angiography scan of the abdomen and pelvis (Figure A) was performed with sagittal (Figure B) and coronal (Figure C) reconstructions.
What is the diagnosis?
Look on page 1067 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Answer to the Clinical Challenges and Images in GI Question: Image 2 (page 733): Isolated, Nontraumatic Celiac Artery Dissection
Computed tomographic angiography images demonstrate a focal area of dissection involving the region of celiac axis, with minimal surrounding hemorrhage with no extension into hepatic or splenic arteries or no evidence of contrast extravasation (Figures D–F).
Isolated, nontraumatic celiac artery dissection is a rare condition. Several risk factors have been implicated but often the exact cause is not identified.1 Hypertension has been implicated as a predisposing factor. However, interestingly, of the various cases reported in the literature only few have been hypertensive at the time of presentation.1, 2 The condition is typically more common in males (4:1) in their fifties. The patients can be asymptomatic or present with epigastric or abdominal pain, which may be postprandial. Reported complications have been splenic infarction, obstructive jaundice, pancreatitis, intraperitoneal hemorrhage, and intestinal ischemia.2, 3
Computed tomographic angiography is increasingly being suggested as the primary modality for evaluation1, 2, 3 on which the characteristic findings are an intimal flap, or an eccentric mural thrombus in the vessel lumen. Other options include Doppler ultrasound, magnetic resonance angiography, and conventional angiography. Because of the entity's rarity, its natural history and optimal management have not been completely defined, but choices include observation and operative or endovascular repair. Surgery has been suggested in patients with hemodynamic instability, persistent pain, failure of medical therapy to control blood pressure, occlusive lesions, development of aneurysm, rupture, or extension into the hepatic arteries.3
Emergency physicians should be alerted to the possibility of celiac artery dissection as a rare differential diagnosis for postprandial epigastric pain, especially in hypertensives.
Our patient's blood pressure was maintained around a systolic pressure of 130 mm Hg in the intensive care unit with a labetalol drip followed by oral labetalol. Follow-up computed tomography 2 days later showed a stable dissection with a slightly less prominent surrounding hematoma. The patient was continued on antihypertensives, proton pump inhibitors, and morphine and was able to tolerate a normal diet. He was discharged home, pain free and otherwise well, 3 days after admission. The patient remains well without recurrence of his presenting symptoms.
References
Conflicts of interest The authors disclose no conflicts.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
PII: S0016-5085(09)02198-2
doi:10.1053/j.gastro.2009.10.061
© 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.
