Man With Left Upper Quadrant Pain

Abstract

A 59-year-old man presented to the emergency department with sudden-onset, sharp, left upper quadrant abdominal pain radiating to the back, and diaphoresis. He had poorly controlled hypertension, with chronic type B abdominal aortic dissection beginning 1 year earlier and coexisting alcoholic liver cirrhosis. On physical examination, the patient was conscious, with a pulse rate of 80 beats/min and blood pressure of 136/85 mm Hg, and he was afebrile. Tenderness was noted over the left upper quadrant on palpation. Point-of-care ultrasonography of the abdomen was performed (Figure 1 and Video) and the diagnosis was confirmed by contrast-enhanced computed tomography (CT) (Figure 2) and maximum intensity projection (a CT image reconstruction) (Figure 3).Figure 2Contrast-enhanced CT confirming isolated splenic artery dissection (white arrow) and evacuated hematoma around the pancreas. Chronic aortic dissection was also noted (arrowhead).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3An intimal flap in the splenic artery, sparing the celiac trunk (arrow), was found on maximum-intensity-projection reconstructed image of contrast-enhanced CT. In addition, previous abdominal aortic dissection with atherosclerosis (arrowhead) was noted.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Isolated splenic artery dissection. After the patient was admitted to the vascular surgery department, abdominal pain improved, with labetalol to control blood pressure. He was asymptomatic at discharge 5 days later and on follow-up 1 month later. Visceral artery disease should be considered an uncommon cause of left upper quadrant pain; splenic artery dissection is a rare but potentially deadly consequence.1Merrell S.W. Gloviczki P. Splenic artery dissection: a case report and review of the literature.J Vasc Surg. 1992; 15: 221-225Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Splenic artery dissection should be considered in a patient with previous visceral artery disease, trauma, pregnancy, or connective tissue disorders.2Desinan L. Scott C.A. Piai I. et al.Sudden death due to spontaneous rupture in splenic artery atypical dissection with features of vasculitis: case report and review of the literature.Forensic Sci Int. 2010; 200 (e1-5)Google Scholar In patients presenting with sudden left upper quadrant pain, point-of-care ultrasonography of the abdomen is a good screening tool for vascular lesions. Treatment of splenic artery dissection depends on the symptoms, and surgery is indicated if symptoms progress.3Jung S.C. Lee W. Park E.A. et al.Spontaneous dissection of the splanchnic arteries: CT findings, treatment, and outcome.AJR Am J Roentgenol. 2013; 200: 219-225Crossref PubMed Scopus (35) Google Scholar, 4Nahas R. Pain T. Goulden P. A rare cause of epigastric pain in a middle-aged man.BMJ Case Rep. 2013; https://doi.org/10.1136/bcr-2013-009605Crossref Scopus (4) Google Scholar eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4MzljNDgzNDI5YzcxYTk0MzRjYTYzOTRiYmY2YmYxZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3NzIwMTc2fQ.R9VXm-UMWBo33NCsKvgIuU5S8P4_TesAwFZG28rviE6ItKdrYtk9fSRI-tCvc3QROc9qI8OXIRs1n_2ZoNAkryNgNvNJi8n0KpkfFF7F-7OU-iaisyZDtBozgiBwwXHPUMcaNtNpte4l1MvooodQmjhP2QixrJekeUKQ39784EOgA26t36F4FqDSuPhfyh66pJz8oMJk4A5bMpY8uCGeUQlh89Rd2R5_xFgHQnH_uZqPKAyXGxuUt9t68p04UGXvE8RHr6MuF58Snut8yP0HhBZgjBXokulyly0_vdqkECp6q4ySk-DsshdBxkHukfpErZXwEJQLi0e29nwZ-KKSsg Download .mp4 (4.1 MB) Help with .mp4 files VideoPoint-of-care ultrasonography of the epigastrium, showing an intimal flap in the splenic artery (visible at 00:00 to 00:03 and again at 00:10 to 00:15) and heterogeneous density around the pancreas, implying extravasation or necrotizing pancreatitis. Chronic aortic dissection can be identified clearly at 00:05 to 00:09.