A unique case of isolated,spontaneous,symptomatic celiac trunk dissection

Abstract

Cases of isolated spontaneous celiac trunk dissections have been appearing in the literature more recently with the increased availability of high-resolution computerized tomography angiograms. We report a unique case of this entity. A 48-year-old woman presented with acute abdominal pain that radiated to the back and worsened with breathing. This was diagnosed as a celiac trunk dissection by computerized tomography angiogram. She was treated conservatively with antihypertensive medications, anticoagulants, and opioid medication for pain control.

Introduction

Isolated celiac trunk dissections are a rare etiology of acute abdominal pain. These dissections may either be spontaneous or result from a variety of mechanisms: blunt trauma, inflammatory processes, and injury from endovascular procedures are the most common. The first reported case was diagnosed post-mortem in 1956. ¹ By 2001, there were only 13 published cases of isolated spontaneous celiac trunk dissections, ² and since then, they have been appearing more frequently in the literature. This is likely secondary to the availability of high-resolution vascular imaging techniques—specifically computerized tomography (CT) angiograms. ³

Case report

The patient has given consent for this study to be published in a scientific journal. This case was seen at the Grey Nun’s Community Hospital in Edmonton, Alberta. This case does not require ethics approval.

A 48-year-old female, ex-smoker, with a past medical history significant for sarcoidosis in remission, migraine with aura, dyslipidemia, and Huntington’s disease presented to the emergency department with sudden onset epigastric pain for 2 days, radiating to the back. This pain was described as sharp and to be worse with breathing. On exam, her blood pressure was 144/110 mmHg. Laboratory investigations demonstrated an elevated white blood cell (WBC) count of 11.2 × 10⁹/L, normal hemoglobin, and normal platelets. All other labs were normal, except for an erythrocyte sedimentation rate (ESR) of 23 mm/h and a C-reactive protein (CRP) value of 9 mg/L. A lipase returned back negative, to rule out pancreatitis. A CT abdomen demonstrated nonspecific fat stranding near the aorta, which the astute radiologist identified and requested the patient to return to the radiology department for a CT angiogram, which demonstrated a celiac artery dissection. The dissection flap began 1.2 cm proximal to the left gastric artery take off and extended into the origin of the splenic artery (Figures 1 and 2).

Figure 1.

Initial CT angiogram demonstrating the celiac artery dissection (sagittal view).

Figure 2.

Initial CT angiogram demonstrating the celiac artery dissection (axial view).

She was admitted and started on intravenous (IV) unfractionated heparin drip, and started on oral labetolol and nifedipine to maintain a blood pressure less than 140 mmHg systolic. Despite the CT showing no signs of ischemia or hemorrhage, her pain was very severe. She was treated with opioid pain medication to manage this. She was seen by a vascular surgeon who agreed with the medical management. A CT angiogram 5 days later demonstrated no interval change. She was discharged after a short stay in the hospital on warfarin and opioid pain medication. Follow-up at 2 months demonstrated resolution of her symptoms, and CT angiogram revealed a stable celiac trunk dissection with no signs of complications (Figures 3 and 4).

Figure 3.

Follow-up CT angiogram 2 months later demonstrating a stable celiac artery dissection (sagittal view).

Figure 4.

Follow-up CT angiogram 2 months later demonstrating a stable celiac artery dissection (axial view).

Discussion

Isolated spontaneous dissections of the splanchnic arteries are rare entities, of which a celiac artery dissection is the least common. ² They most frequently occur in males between 40 and 70 years old, often associated with hypertension and smoking. Additional identified associations for the development of splanchnic artery dissections include cystic medial necrosis, pregnancy, fibromuscular dysplasia, connective tissue disease, trauma, and inflammatory conditions.^4,5

The common presentations include epigastric pain and diffuse abdominal pain. ⁶ Our case is unique in that our patient presented with epigastric pain that radiated to the back and was worse with respiration. To our knowledge, this has yet to be described in the current literature and should be recognized as a cause of abdominal pain.

The diagnosis of isolated celiac trunk dissection has become easier with the advent of high-resolution CT angiograms. CT angiography is preferred to other imaging techniques because it is easily available, fast, non-invasive, and reliable. There are other imaging techniques that can be used, however, including magnetic resonance (MR) imaging, conventional angiography, and Doppler sonography. ⁶

The most frequent finding identified on CT angiogram is an intimal flap. Other common findings include thrombosed false lumen and aneurysmal dilation. Less common findings include branch involvement, periarterial fatty infiltration, and bowel ischemia. ⁴ The sensitivity of identifying celiac trunk dissections can be improved with multi-planar reformat/maximum intensity projection/three-dimensional (MRP/MIP/3D) rendering. From one study, 30% of additional cases were diagnosed with this technique. ⁷ This case demonstrates that if there are nonspecific signs, such as fat stranding around the aorta on an unenhanced CT abdomen, this should raise suspicion of a splanchnic vessel dissection and an enhanced CT abdomen should be recommended.

Commonly identified complications associated with celiac trunk dissections include bleeding and ischemia. The management of these dissections remains unclear; however, the majority are managed conservatively with blood pressure reduction and anticoagulation. There is a common approach of initial conservative treatment unless specific complications from the dissection require invasive treatment such as rupture or bowel ischemia.^5,6 When there is necessary treatment, the majority undergo endovascular intervention; however, some still undergo open surgical repair. We are unable to draw conclusions regarding the outcomes of surgical or endovascular management due to the nature of publication bias in cases resulting in negative outcomes.

Conclusion

Our case represents yet another case of symptomatic spontaneous celiac artery dissection. This case, however, is a unique addition to the current literature. This was a non-smoking female patient without hypertension. Although her pain was sharp, epigastric, and radiated to the back, it also worsened with respiration, which is a novel presentation. The celiac dissection was identified on CT angiogram. Invasive intervention was avoided as there were no signs of threatening distal ischemia or bleeding, and she was successfully treated with medical management.