S3042 Celiacomesenteric Trunk Variant Occlusion: A Culprit of Mesenteric Ischemia

Abstract

Introduction: Superior mesenteric artery (SMA) usually arises from the abdominal aorta just below the celiac trunk. Celiacomesenteric trunk (CMT) is a rare anatomical variant where the SMA shares the same origin as the celiac trunk. We present a case of mesenteric ischemia due to CMT occlusion. Case Description/Methods: A 78-year-old female with history of CAD, hypertension, diabetes, CVA, and GERD presented with 5 days of abdominal pain, associated with nausea, vomiting, and nonbloody diarrhea. She was prescribed levofloxacin 7 days prior to presentation after COVID-19 diagnosis. Vital signs were normal. Physical exam revealed epigastric tenderness without rebound or guarding. Labs showed WBC 15.5 x 103/uL, lactic acid 2.6 mmol/L, AST 1275 units/L, ALT 1403 units/L, ALP 105 units/L, total bilirubin 1.4 mg/dL, and INR 1.7. Acute hepatitis and autoimmune serologies were negative, as were acetaminophen, salicylate, and ethanol levels. Liver ultrasound with doppler showed patent liver vasculature and chronic parenchymal liver disease. Due to the temporality of levofloxacin prescription, elevated liver enzymes were attributed to drug-induced liver injury. Patient was treated with N-acetylcysteine. Despite initial improvement of liver enzymes, abdominal pain persisted with pain out of proportion to exam. She developed hypotension, and AST and ALT abruptly rose to 3181 units/L and 2701 units/L, respectively, with lactic acid of 13.5 mmol/L. CT abdomen without contrast showed extensive pneumatosis intestinalis with portal venous gas and diffuse colonic wall thickening, consistent with ischemia and necrosis. A CMT with significant atherosclerosis was noted. Given her critical condition, she was transitioned to comfort care and later expired. She was diagnosed with acute mesenteric ischemia due to CMT occlusion from severe atherosclerotic disease and ischemic hepatitis. Discussion: CMT is usually discovered incidentally during imaging, vascular surgery, or anatomic dissection with a prevalence of 0.5-2.7%. In patients with CMT, vessel occlusion can reduce blood supply to both the foregut and midgut, which can lead to life-threatening mesenteric ischemia, as it did in our patient. Our patient's severe atherosclerotic disease likely progressed to CMT occlusion, possibly exacerbated by COVID-19 coagulopathy. Compromised blood flow from the CMT to hepatic artery likely contributed to ischemic hepatitis as well. Gastroenterologists should be cognizant of CMT variant occlusion as a cause of mesenteric ischemia..