Abstract 12186: A Challenging Case of Acute Superior Mesenteric Artery Embolism Diagnosed by Gastroscopy

Abstract

Introduction: Acute superior mesenteric artery (SMA) occlusion is one of the most lethal causes of acute abdomen that we often experience but mistake for gastrointestinal diseases. The golden time for revascularization in cases of SMA main trunk occlusion is within 5 hours of onset, requiring prompt diagnosis and treatment. We describe a challenging case of acute SMA embolism diagnosed by gastroscopy. Case Summary: A 66-year-old man with a history of hypertension presented to the emergency department for marked epigastric pain after eating raw seafoods. On arrival, electrocardiogram showed atrial flutter with no significant ST-segment changes. Despite the elevation of white blood cell count and lactate dehydrogenase in blood exam, computed tomography (CT) indicated no findings to cause his symptoms. Emergency gastroscopy performed on suspicion of anisakiasis demonstrated pallor findings with hematologic material in the duodenum, suggesting intestinal ischemia (Figure A). Since contrast-enhanced CT revealed an occlusion of SMA (Figure B), we diagnosed acute SMA embolism based on the finding of atrial flutter without anticoagulation. After discussion among cardiologists and gastroenterology surgeons, we selected to perform endovascular treatment. The epigastric pain was improved after reperfusion using a self-expandable stent, but flared up as oral intake progressed. Follow-up CT suggested ischemic enteritis of the proximal jejunum, leading to conduct laparoscopic partial jejunectomy. He was discharged 18 days after the operation with the ability to eat a normal diet. Conclusions: This case highlights that we should keep in mind SMA embolism when examining acute abdomen patients with atrial fibrillation or flutter without anticoagulation.