Mesenteric Hematoma Research Articles

EP.WE.635The Pied-Piper, How Gastroenteritis Led Us Astray. Fibromuscular Dysplasia: A Surgical Perspective of a Rare Vascular Disorder

Abstract Case A 73-year-old female was admitted for abdominal pain after eating an out-of-date pie. She was treated for gastroenteritis for 48 hours, after which she became unexpectedly haemodynamically unstable. Computerised Tomography (CT) suggested mesocolic arterial bleed with a large mesenteric haematoma. CT angiography confirmed false aneurysms of the middle colic artery and multiple beading of coeliac branches, small mesenteric vessels and the inferior mesenteric artery. Opinion was sought from multiple specialties, pseudoaneurysm embolisation was undertaken and steroids commenced for presumed vasculitis. Vasculitis screen was negative, and PET CT scan showed no metabolically active vasculitis. It was felt a diagnosis of fibromuscular dysplasia (FMD) was likely. Steroids were weaned and the patient is under active observation. Background FMD is a rare idiopathic condition of abnormal cellular growth in medium/large arterial vessel walls. It has a frequency of approximately 0.02%, predominantly affecting middle-aged Caucasian women. It manifests mostly in renal and cerebrovascular arteries and can present as hypertension or stroke. Complications include aneurysms, stenosis and dissections. Characteristic angiographical finding is a “beads on a string” appearance. There is no current cure, but surgical or interventional involvement by angioplasty and stenting may play a role treatment. Discussion And Conclusion This case elegantly highlights the ambiguity in diagnosis of abdominal pain in a general surgical setting; with a wide variety of differentials spanning multiple specialties, it emphasises the importance to consider rare presentations of equally rare pathologies. It is a celebration of the merits of a multi-disciplinary approach to solve complex clinical questions.

1487 The Pied-Piper, How Gastroenteritis Led Us Astray. Fibromuscular Dysplasia: A Surgical Perspective of a Rare Vascular Disorder

Abstract A 73-year-old female was admitted for abdominal pain after eating an out-of-date pie. She was treated for gastroenteritis for 48hours, after which she became unexpectedly haemodynamically unstable. Computerised Tomography (CT) suggested mesocolic arterial bleed with a large mesenteric haematoma. CT angiography confirmed false aneurysms of the middle colic artery and multiple beading of coeliac branches, small mesenteric vessels and the inferior mesenteric artery. Opinion was sought from multiple specialties, pseudoaneurysm embolisation was undertaken and steroids commenced for presumed vasculitis. Vasculitis screen was negative, and PET CT scan showed no metabolically active vasculitis. It was felt a diagnosis of fibromuscular dysplasia (FMD) was likely. Steroids have been weaned and the patient is under active observation. Background FMD is a rare idiopathic condition of abnormal cellular growth in medium/large arterial vessel walls. It has a frequency of approximately 0.02%, predominantly affecting middle-aged Caucasian women. It manifests mostly in renal and cerebrovascular arteries and can present as hypertension or stroke. Complications include aneurysms, stenosis and dissections. Characteristic angiographical finding is a “beads on a string” appearance. There is no current cure, but surgical or interventional involvement by angioplasty and stenting may play a role treatment. Conclusions This case elegantly highlights the ambiguity in diagnosis of abdominal pain in a general surgical setting; with a wide variety of differentials spanning multiple specialties, it emphasises the importance to consider rare presentations of equally rare pathologies. It is a celebration of the merits of a multi-disciplinary approach to solve complex clinical questions.

Multi-center validation of the Bowel Injury Predictive Score (BIPS) for the early identification of need to operate in blunt bowel and mesenteric injuries

IntroductionThe Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study. Materials and methodsPatients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study. ResultsOf 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6–8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7–23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS < 2 (OR, 10.1; 95% CI, 5.0–20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6–0.8), 78% (CI 0.7–0.8), 67% (CI 0.6–0.8), and 82% (CI 0.8–0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3–8) was 70% (CI 0.5–0.9), 92% (CI 0.8–1.0), 82% (CI 0.6–1.0), and 86% (CI 0.7–1.0), respectively. ConclusionThis prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

940 Mesenteric Haematoma Complicated by A Perforated Sigmoid Diverticulum Following Extracorporeal Shockwave Lithotripsy

Abstract A 78 year old female presented with sudden onset lower abdominal pain, vomiting and fresh rectal bleeding. She had undergone extracorporeal shockwave lithotripsy (ECSL) for a left renal stone two weeks earlier and was taking Rivaroxaban for atrial fibrillation. A CT Abdomen &amp; Pelvis revealed a large mesenteric haematoma and a contained sigmoid perforation secondary to compressive forces of the haematoma on the sigmoid artery, resulting in ischaemia. While mesenteric angiogram-guided embolisation initially controlled the active sigmoid artery bleed, the patient clinically deteriorated the following day warranting a laparotomy. This revealed an ischaemic sigmoid colon with contained faeculent material within the mesentery. An extended left hemi-colectomy with end-colostomy was performed. Despite optimal critical care input, the patient developed multi-organ failure and passed away one week later. Mesenteric haematoma should be considered as a rare complication in patients with sudden onset abdominal pain following ECSL; especially with concurrent anti-coagulation use.

Abdominal Computed Tomography Angiography and Venography in Evaluation of Hemorrhagic and Thrombotic lesions in Hospitalized COVID-19 patients

PurposeTo report imaging findings at computed tomography angiography (CTA) and venography (CTV) of the abdomen and pelvis in evaluation of hemorrhagic and thrombotic lesions in hospitalized patients with COVID-19. MethodsIn this retrospective observational study, patients admitted to a single tertiary care center from April 1 to July 20, 2020, who tested positive for SARS-CoV-2 and developed acute abdominal pain or decreasing hemoglobin levels over the course of hospitalization were included. Abdominal CTA/CTV imaging studies performed in these patients were reviewed, and acute hemorrhagic or thromboembolic findings were recorded. ResultsA total of 40 patients (mean age, 59.7 years; 20 men, 20 women) were evaluated. Twenty-five patients (62.5%) required intensive care unit (ICU) admission and 15 patients (37.5%) were treated in the medical ward. Hemorrhagic complications were detected in 19 patients (47.5%), the most common was intramuscular hematoma diagnosed in 17 patients; It involved the iliopsoas compartment unilaterally in 10 patients, bilaterally in 2 patients and the rectus sheath in 5 cases. Pelvic extraperitoneal hemorrhage was found in 3 patients, and mesenteric hematoma in one patient. Thromboembolic events were diagnosed in 8 patients (20%) including; arterial thrombosis (n = 2), venous thrombosis (n = 2), splenic infarct (n = 1), bowel ischemia (n = 1) and multiple sites of thromboembolism (n = 2). ConclusionOur study highlights that both hemorrhagic and thromboembolic complications can be seen in hospitalized patients with COVID-19. It is important that radiologists maintain a high index of suspicion for early diagnosis of these complications.

Safety and Efficacy of Ultrasound-Guided Percutaneous Core Needle Biopsy of Pancreatic and Peripancreatic Lesions Adjacent to Critical Vessels.

PurposeTo evaluate the safety and efficacy of ultrasound-guided percutaneous core needle biopsy (USPCB) of pancreatic and peripancreatic lesions adjacent to critical vessels.Materials and MethodsData were collected retrospectively from 162 patients who underwent USPCB of the pancreas (n = 98), the peripancreatic area adjacent to the portal vein, the paraaortic area adjacent to pancreatic uncinate (n = 34), and lesions on the third duodenal portion (n = 30) during a 10-year period. An automated biopsy gun with an 18-gauge needle was used for biopsies under US guidance. The USPCB results were compared with those of the final follow- up imaging performed postoperatively. The diagnostic accuracy and major complication rate of the USPCB were calculated. Multiple factors were evaluated for the prediction of successful biopsies using univariate and multivariate analyses.ResultsThe histopathologic diagnosis from USPCB was correct in 149 (92%) patients. The major complication rate was 3%. Four cases of mesenteric hematomas and one intramural hematoma of the duodenum occurred during the study period. The following factors were significantly associated with successful biopsies: a transmesenteric biopsy route rather than a transgastric or transenteric route; good visualization of targets; and evaluation of the entire US pathway. In addition, the number of biopsies required was less when the biopsy was successful.ConclusionUSPCB demonstrated high diagnostic accuracy and a low complication rate for the histopathologic diagnosis of pancreatic and peripancreatic lesions adjacent to critical vessels.

Successful conservative management of small bowel obstruction secondary to jejunal mesenteric haematoma after blunt abdominal trauma.

Successful conservative management of small bowel obstruction secondary to jejunal mesenteric haematoma after blunt abdominal trauma.

A case of spontaneous mesenteric hematoma with diagnostic difficulty

BackgroundSpontaneous mesenteric hematoma (SMH) is a rare condition characterized by intraperitoneal hemorrhage of unknown etiology. SMH without worsening of general status allows conservative management; however, patients showing chronological changes on imaging require surgical intervention to rule out possible malignancy.Case presentationA 69-year-old man was referred to our hospital to evaluate an abdominal mass with no associated clinical symptoms. He had a history of chronic hepatitis C and diabetes mellitus. Six months earlier, computed tomography (CT) revealed a 75-mm tumor arising from the jejunum, suspected to be a gastrointestinal stromal tumor (GIST) of the small intestine. Following a further 6 months of observation, the patient was referred to our hospital. Abdominal contrast-enhanced CT revealed a well-defined heterogeneous round tumor with a maximum diameter of 75 mm adjacent to the upper jejunum. The tumor was accompanied by calcification at the periphery, with no evidence of augmentation over the prior 6 months. Diffuse lymphadenopathy was observed around the aorta and splenic artery. Under the diagnosis of GIST arising from small intestine, the patient underwent elective surgery. The resection revealed an elastic soft tumor at the mesentery adjacent to the upper jejunum with severe adhesion between the tumor and jejunum. The tumor origin was unclear; thus, we performed mesenteric excision and partial enterectomy without lymph node dissection.The tumor was surrounded by fibrous capsular tissue containing massive hemosiderin deposits and cholesterol crystals showing partial calcification, resulting in a diagnosis of spontaneous hematoma of the mesentery.ConclusionsWe report a case of SMH mimicking small intestinal GIST. It is difficult to diagnose long-established SMH because its radiological features change with time, and more case reports are needed to improve the accuracy of diagnosis.

Mesenteric Hematoma: Challenges in Diagnosis and Management.

Null.

Is Specialisation Needed in Laparoscopic Cholecystectomy? A Retrospective Cohort Study of 5122 Patients

Background: Gallstone disease is a common problem and laparoscopic cholecystectomy (LC) is a common elective procedure. This operation was performed by a general surgeon, colorectal surgeons, breast and vascular surgeons according to the largest UK's audit (CholeS study). Objectives: To compare the outcomes of laparoscopic cholecystectomy performed by a specialist upper gastrointestinal (UGI) surgeon to that of CholeS and large international studies. Our hypothesis is: UGI specialist is producing better outcomes for LC patients. Methods: All patient who underwent LC between 1999 and 2019 at one hospital by an UGI consultant and 2014-2019 at another hospital by another UGI consultant surgeon were included. The inclusion criteria were LC performed by UGI surgeon. Lost to follow up, procedures done by trainees and gallbladder cancer patients were excluded. The outcome measures of bile leak, bile duct injuries, bleeding, infectious complications, bowel injuries, vascular injuries and pseudoaneurysms, neuralgia, port site hernia, mesenteric haematoma, 30-day mortality and conversion to open were reported. Statistical tests were used to assess the significant differences, the confidence interval was 95% and the p-value was taken as 0.05. Results: Two UGI specialists performed 5122 LC, 4396 (86%) were female and 715 (14%) male. The age was 13-93 year (median of 48 years). 3681 (72 %) was done as a day surgery case. 1431(28%) as an inpatient and 287 (5.6%) emergency LC. There was no death in the 30 days periods of surgery, 8 (0.15%) biliary leak from the duct of Luschka, 4 (0.19%) common bile duct (CBD) injuries, 9(0.02%) conversions and 17(0.33%) procedures were abandoned. There were significant differences in the above complications between our study and the CholeS report. Conclusions: Laparoscopic cholecystectomy is associated with acceptable outcomes, low risk of bile duct injury and no mortality when performed by a specialist upper GI surgeon.

Bowel necrosis caused by mesenteric hematoma after blunt abdominal trauma: Report of a case

Bowel necrosis caused by mesenteric hematoma after blunt abdominal trauma: Report of a case

Intraoperative Indocyanine Green Fluorescence Angiography was Useful for Reducing the Extent of Bowel Resection Needed in a Case of Blunt Abdominal Trauma with Mesenteric Hematoma Formation

Intraoperative Indocyanine Green Fluorescence Angiography was Useful for Reducing the Extent of Bowel Resection Needed in a Case of Blunt Abdominal Trauma with Mesenteric Hematoma Formation

Safety and Efficacy of Embolization Using N-Butyl Cyanoacrylate via a Percutaneous Direct Approach for Endoleaks after Abdominal/Thoracic Endovascular Aortic Repair.

Purpose: To elucidate the safety and efficacy of embolization using N-butyl cyanoacrylate (NBCA) for endoleaks after abdominal/thoracic endovascular aortic repair (EVAR/TEVAR) via a direct percutaneous approach versus a transarterial approach.Materials and Methods: The retrospective design of the study was approved by the institutional ethics committee, and the requirement for informed written consent was waived. Sixteen patients underwent embolization for endoleaks after EVAR/TEVAR, which was diagnosed as type II, from March 2010 to December 2013 at our institution. The number of embolization sessions was 21. A direct percutaneous approach was used in 10 sessions, and a transarterial approach was used in 11 sessions. There were 11 and 15 embolic sites for the two approaches, respectively. The procedure time, amount of contrast media used, therapeutic effect, and complications were evaluated.Results: The mean procedure time (per embolic site) was 100 min (53-170) in the direct percutaneous approach, which was significantly shorter than the 191 min (76-275) in the transarterial approach. The mean amount of contrast media used during the procedure (per embolic site) was 12.8 ml (3-25) by the direct percutaneous approach, which was significantly lesser than the 71.8 ml (30-180) in the transarterial approach. Local control of the embolic site and interval increase in the size of aneurysm after embolization were not significantly different between the two approaches. In one case each, mesenteric hematoma and migration of the embolic agent occurred with a direct percutaneous approach, and a small arterial injury occurred with the transarterial approach; aneurysmal rupture/perianeurysmal hematoma and neurological dysfunction were not observed.Conclusion: A direct percutaneous approach is a feasible procedure for embolization of endoleaks after EVAR/TEVAR.

Spontaneous bleeding of the inferior pancreatic-duodenal artery in median arcuate ligament syndrome: do not miss the diagnosis

Median arcuate ligament syndrome (MALS) is a rare condition in which the median arcuate ligament (MAL) causes compression of the coeliac trunk. The chronic compression leads to coeliac trunk luminal narrowing and reduced blood supply to the abdominal splanchnic organs with possible local complications such as pseudo-aneurysms and spontaneous bleeding. Its incidence is probably underestimated due to the poor availability of color Doppler ultrasonography (CD-US), especially in an Emergency Department (ED) setting.A 44-year old woman presented to Pisa University Hospital ED with acute abdominal pain. An abdominal ultrasonography scan (US scan) was performed showing the presence of free liquid in the Douglas pouch. The abdominal computed tomography scan (CT scan) highlighted the presence of a large mesenteric hematoma. A CD-US revealed a significant stenosis of the coeliac artery. A selective angiography confirmed the diagnosis of MALS with a pseudo-aneurysm of the inferior pancreatic-duodenal artery, which was successfully embolized.

Hematoma mesentérico espontáneo asociado a warfarina con resolución quirúrgica

Spontaneous mesenteric hematoma isinfrequent. It has been related to prolonged anticoagulation, mainly with warfarin. No definitive treatment has been established; A treatment is suggested in hemodynamically stable patients, while in patients in shock, the surgical treatment is suggested. Our goal is topresent the case of a mesenteric hematoma associated with prolonged conservative anticoagulation with surgical resolution. Female patient with 67 years old, consulted for 24 hours of evolution abdominal pain and signs of peritonism; Computed tomography was performed with a diagnosis of spontaneous mesenteric hematoma. In the context of a clinically stable patient anticoagulated with warfarin, emergency laparotomy with intestinal resection of the segment affected by the hematoma was decided. Pathological anatomy reports massive submucosal hemorrhage. Conclusion: Surgical behavior in patients with hemodynamically stable peritonism can be safe and effective

03:54 PM Abstract No. 157 Single-institution experience of suction thrombectomy with veno-venous bypass (Angiovac Device): various applications and team-based approach

To evaluate the efficiency and safety of suction trombectomy with veno-venous bypass in a tertiary care center. To discuss various clinical applications of the device and the procedure. Retrospective evaluation of patients who have received treatment with the Angiovac device (Angiodyamics, Latham, NY) were analyzed from 2013 through 2018. 40 patients who received treatment were identified (16 male, 14 female, age range: 17-83 years). To our knowledge, this is the highest number of procedures reported by a single institution. Twenty-two patients received treatment for iliocaval DVT (8 patients IVC filter related), 15 patients for atrial clot (8 patients with atrial clot with submassive/massive pulmonary embolism, 2 for right atrial clot with ASD, 5 for valve vegetations) and, 2 patients for embolic protection during mesenteric thrombotic clot removal through transjugular intrahepatic portosystemic shunt. Successful clot removal was achieved in 25/30 patients (all patients with iliocaval DVT). Complete clot removal failed in 3 cases with right atrial clot, two of which were chronic, and both cases of mesenteric venous thrombosis. Three major (mesenteric hematoma, intraprocedural non clinical PE, massive PE resulting in death 22 days after a successful procedure) and two minor (access site hematoma) complications were noted. Two patients died prior to discharge for reasons unrelated to the procedure. 28 patients received imaging follow up which confirmed absence of clot. An “Angiovac Team” with members consisting of a cardiothoracic surgeon, a perfusionist, a cardiac anesthesiologist, an inteventional radiologist, experienced technologists and company representatives were established and each case was performed within 24-48 hours of a decision to perform the procedure in an effective manner. Suction thrombectomy utilizing the Angiovac device achieves rapid removal of acute or subacute high burden clot in an effective and safe manner. The logistical burdens could be overcome with a well-established interventional team consisting of various specialties leading to safe and reproducible results.

Intussusception Caused by a Mesenteric Hematoma in the Setting of Trauma

Intussusception Caused by a Mesenteric Hematoma in the Setting of Trauma

Imaging features of atypical bleeds in young patients with hemophilia.

Hemarthroses and muscle bleeds are well-known and well-documented complications in pediatric and young adult hemophilia patients. In contrast, deep bleeds in atypical locations can be a diagnostic challenge, since clinicians and radiologists are often unfamiliar with their clinical and radiological features. Some atypical bleeds, however, can be life-threatening or severely disabling, highlighting the need for prompt, accurate diagnosis. Rare bleeds include central nervous system bleeds (including intracranial and spinal hematomas), urogenital bleeds, intra-abdominal bleeds (mesenteric and gastrointestinal wall hematomas) and pseudo tumors in unusual locations like the sinonasal cavities. Because clinical assessment can be difficult, clinicians and radiologists should be aware of the possibility of these rare complications in their hemophilia patients, so that they can avoid unnecessary invasive diagnostic and surgical procedures and institute prompt, appropriate treatment. The purpose of this review is to illustrate the imaging features of bleeds that occur in rare locations in young (i.e., children and young adults) patients with hemophilia to make the reader more familiar with these conditions.

Encapsulating Peritoneal Sclerosis Complicated by Encapsulating Mesenteric Hematoma: The Threshold for Diagnostic Certainty

Encapsulating Peritoneal Sclerosis Complicated by Encapsulating Mesenteric Hematoma: The Threshold for Diagnostic Certainty

Traumatic mesenteric bleeding: early diagnosis and interventional management.

We report a rare case of mesenteric bleeding following blunt abdominal trauma successfully treated with transcatheter arterial embolization (TAE) of the ileal artery branch. A 27-year-old man presented with mesenteric bleeding after motorcycle accident. Computed tomography (CT) demonstrated mesenteric hematoma with extravasation of contrast material, and no associated major injuries to other organs. A superior mesenteric angiogram revealed pseudoaneurysm of the ileal branch. After TAE with a single microcoil, control angiography showed cessation of bleeding. There was no need for repeat embolization or additional surgery due to mesenteric bleeding nor ischemic gastrointestinal complications during the 5 months following TAE. In isolated mesenteric injuries, TAE may be a reasonable minimally invasive alternative to emergency laparotomy.