Intestinal Ischemia as the Primary Manifestation of Thromboangiitis Obliterans: A Case Report

Abstract

Case presentation: A 52-year-old female presented with a significant smoking history and unexplained abdominal pain. The patient was admitted on multiple occasions and seen in the gastroenterology clinic, and underwent an extensive work-up. Laboratory data, abdominal x-ray, CT abdomen, transabdominal ultrasound, gastric emptying study, EGD, colonoscopy, and CT angiogram of the abdomen all provided no clear diagnosis. While hospitalized, the patient had an acute abdomen with free air demonstrated on CT, and subsequently underwent an exploratory laparotomy. Histology of the removed ileum displayed multiple small- and medium-sized arteries with marked medial and intimal proliferation with focal medial destruction, focal perivascular and intimal lymphocytic infiltrates and organized and recanalized thrombi. There were also organizing venous and capillary thrombi present in small-, medium-, and largesized vessels of the bowel wall and mesentery. The findings are characteristic for Buerger's disease. The patient did return to the OR on two more occasions for increased bowel ischemia, and once for right below-the-knee amputation during the hospitalization. The patient is currently being followed in the gastroenterology clinic. Literature review: Buerger's disease is a rare entity in a female over the age of forty. In our case, the initial presentation of mesenteric involvement in a female is unique. Currently there are no literature reports of a female over the age of forty having the initial presentation of Buerger's disease as abdominal pain without extremity involvement. This case study contributes to the literature by adding a rare case in a previously unidentified patient demographic. Buerger's disease should be added to the differential in similar cases. This extremely rare condition should be evaluated for young female smokers without atherosclerotic disease. However due to its nature, it is difficult to diagnose before bowel gangrene.Table 1: Diagnostic Criteria for Buerger's DiseaseTable 2: Histology CriteriaFigure 1Figure 2Figure 3