A rare cause of chronic mesenteric ischemia from fibromuscular dysplasia: a case report

Schaumann bodies deposited along myenteric plexus of the muscularis propria is a unique histopathological feature of Crohn's disease

AIMS

Schaumann bodies were first identified in sarcoidosis by Dr Schaumann in 1941. They were also detected in 10% of Crohn's disease (CD) cases in a study involving patients with surgically resected CD. However, the characteristics and significance of Schaumann bodies in CD have yet to be fully elucidated. This study aimed to determine the pathological features and diagnostic significance of Schaumann bodies in various bowel diseases.

METHODS

Overall, 278 bowel specimens were collected from patients with CD, intestinal tuberculosis, ulcerative colitis, intestinal schistosomiasis, diverticulosis and idiopathic mesenteric vasculopathy. The frequency, pathology and clinical features of patients with Schaumann bodies were studied.

RESULTS

Schaumann bodies were present exclusively in CD (27.0%, 38 of 141) and were not detected in other intestinal diseases within the series. In CD, Schaumann bodies were deposited along the myenteric plexus of the muscularis propria (84.2%, 32 of 38). These bodies were small (diameter: 60.3±32.7 µm) and exhibited a low density in the intestinal wall (1.1±0.4 per low-power field). The majority were located within the cytoplasm of multinucleated giant cells (84.2%, 32 of 38) and were not found within or adjacent to granulomas. Notably, the number of female patients with CD and Schaumann bodies was higher than that of males.

CONCLUSION

Schaumann bodies are common in resected CD specimens, and their characteristic deposition pattern may serve as a diagnostic indication for CD.

Naturally shrunk visceral artery aneurysms by stenting for the superior mesenteric artery occlusion

A 77-year-old woman who had experienced postprandial abdominal pain for four years was admitted to our institution presenting sudden and severe abdominal pain. Contrast-enhanced computed tomography (CECT) demonstrated complete short-segmented occlusion in the orifice of the superior mesenteric artery (SMA), and saccular aneurysms in the right hepatic artery and the anterior superior pancreaticoduodenal artery. She was diagnosed with abdominal angina due to occlusion of the SMA. The SMA was recanalized by stenting, and a CECT scan confirmed naturally shrunk aneurysms after eight months. The patency of the SMA was maintained at five years after endovascular treatment.

Laser Atherectomy to Treat Severe In Stent Restenosis of the Superior Mesenteric Artery

Chronic mesenteric ischemia is an uncommon disorder in the USA. Frequently, a percutaneous approach is the first therapeutic choice to reduce its symptoms and improve outcomes. After an initial treatment with stents, further interventions might be necessary to address in-stent restenosis and re-establish a better visceral flow. Using laser atherectomy in a similar fashion as used in the peripheral arteries, has proven to be safe helping to achieve a desired final result. We present a case of chronic mesenteric ischemia in a 53-year-old man caused by severe in-stent restenosis who had abdominal pain and weight loss. We used a 0.9 mm laser catheter with low energy and pulse rate as an adjunct to balloon therapy. After revascularization, the patient's symptoms improved dramatically. To the best of our knowledge, this is the first published case in which atherectomy with laser was used to treat severe in-stent restenosis of a mesenteric vessel in chronic mesenteric ischemia. Learning Objective The treatment of severe in-stent restenosis of the superior mesenteric artery using laser atherectomy is safe and can give excellent results when traditional percutaneous therapies fail.

Rare Mesenteric Arterial Diseases: Fibromuscular Dysplasia and Segmental Arterial Mediolysis and Literature Review

Fibromuscular dysplasia (FMD) and segmental arterial mediolysis (SAM) are noninflammatory, nonatherosclerotic arterial diseases that cause aneurysm, occlusion, and thromboses. These diseases are rarely seen in mesenteric arterial lesions; however, as they can be lethal if appropriate management is not provided, the accumulation of clinical information from cases is essential. We herein report the cases of a 57-year-old man diagnosed with FMD and a 63-year-old man diagnosed with SAM. We conclude that an early diagnosis with imaging modalities and clinical information followed by the appropriate treatment improves the prognosis of these arterial diseases.

Diagnosis and management of fibromuscular dysplasia and segmental arterial mediolysis in gastroenterology field: A mini-review

The vascular diseases including aneurysm, occlusion, and thromboses in the mesenteric lesions could cause severe symptoms and appropriate diagnosis and treatment are essential for managing patients. With the development and improvement of imaging modalities, diagnostic frequency of these vascular diseases in abdominal lesions is increasing even with the small changes in the vasculatures. Among various vascular diseases, fibromuscular dysplasia (FMD) and segmental arterial mediolysis (SAM) are noninflammatory, nonatherosclerotic arterial diseases which need to be diagnosed urgently because these diseases could affect various organs and be lethal if the appropriate management is not provided. However, because FMD and SAM are rare, the cause, prevalence, clinical characteristics including the symptoms, findings in the imaging studies, pathological findings, management, and prognoses have not been systematically summarized. Therefore, there have been neither standard diagnostic criteria nor therapeutic methodologies established, to date. To systematically summarize the information and to compare these disease entities, we have summarized the characteristics of FMD and SAM in the gastroenterological regions by reviewing the cases reported thus far. The information summarized will be helpful for physicians treating these patients in an emergency care unit and for the differential diagnosis of other diseases showing severe abdominal pain.

Progress in multi-slice CT diagnosis of atherosclerotic mesenteric ischemia

The incidence of atherosclerotic mesenteric ischemia increases gradually with the aging of the population and rising of the incidence of atherosclerosis. In the last decade, mesenteric atherosclerosis has become the most common cause of acute and chronic mesenteric ischemia. Atherosclerotic mesenteric ischemia often presents with an insidious onset and slow evolvement, and is easily overlooked. The CT manifestations of advanced mesenteric ischemia are classic with high diagnostic accuracy, and the specific findings of CT angiography include: thromboembolus and stenotic or occlusive mesenteric artery in acute stage, single or multiple calcified or non-calcified plaques, and multiple stenotic and stiff mesenteric arteries with reduced branching vessels in chronic stage. Early mesenteric ischemia, however, has no or nonspecific CT sign and is difficult to detect. This article discusses the diagnostic value and limitations of multi-slice CT in atherosclerotic mesenteric ischemia as well as some new imaging techniques for diagnosis of this condition.

Massive mesenteric panniculitis due to fibromuscular dysplasia of the inferior mesenteric artery: a case report

Background

Fibromuscular dysplasia (FMD) is a nonatheromatous, noninflammatory arterial disorder of unknown etiology resulting in vessel stenosis and/or aneurysm formation. The renal and cephalocervical (mainly carotid arteries) arterial beds are classically involved; involvement of visceral arteries is rare. Mesenteric panniculitis (MP) is an inflammatory process of mesenteric fat considered to be of unknown etiology. The majority of cases involve the small bowel mesentery; colorectal MP is rare. To our knowledge, no example of MP due to FMD has been described.

Case presentation

A 52 year old man presented with steadily worsening lower abdominal pain. Investigation revealed ischemic rectosigmoid mucosa associated with a large mesenteric mass of unknown nature. Angiography showed the disease was limited to the distribution of the inferior mesenteric artery. Subsequent symptoms of large bowel obstruction necessitated a left hemicolectomy. Pathologic examination showed bowel wall necrosis and massive panniculitis of the rectosigmoid due to FMD. Subsequent angiographic imaging of other vascular beds was negative.

Conclusions

Several features of this case are noteworthy: FMD limited to the inferior mesenteric artery has not been previously reported, FMD has not previously been implicated as a cause of MP, and the massive extent of panniculitis. An accompanying literature review of cases of visceral FMD, traditionally believed to almost exclusively affect females, highlights a greater than anticipated number of males (33 %), and a gender difference regarding concomitant involvement of cephalocervical and/or renal vascular beds (32 % in males versus 80 % in females). The latter observation may have implications regarding the value of radiologic screening of other vascular beds, particularly in asymptomatic males, in patients presenting with visceral artery FMD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0303-5) contains supplementary material, which is available to authorized users.

Radiology and mesenteric ischaemia

This review focuses on the radiology of mesenteric ischaemia. Covering the acute and chronic presentations, both of which result from impaired vascularisation of the gastrointestinal tract, we evaluate the role of radiographs, ultrasound, CT, MRI, and catheter angiography in the diagnosis of these conditions. Looking to the future, we also assess some of the emerging imaging techniques. Across medicine and surgery there has been a significant shift towards minimally invasive interventions. Although percutaneous revascularisation of chronic mesenteric ischaemia has been performed for some time, there has been a developing trend for the use of such techniques in acute mesenteric ischaemia. We evaluate the available evidence for the use of these percutaneous interventions and assess how they compare with or in some instances compliment traditional surgical alternatives.

Pressure wire used to measure gradient in chronic mesenteric ischemia

Chronic mesenteric ischemia is a rare disorder in the United States. Frequently, its symptoms correlate poorly with the angiographically apparent degree of mesenteric artery stenosis. Measuring the pressure gradient with a small-caliber catheter is an established means of determining whether a particular stenosis is flow-limiting, thus guiding the interventional decision when stenoses are of indeterminate angiographic significance. Using a 0.014-in guidewire, however, is potentially more accurate because it eliminates any measurement error attributable to the use of a larger, potentially obstructive catheter. We present a case of chronic mesenteric ischemia in a 70-year-old woman who had abdominal pain with multiple possible causes. We used a 0.014-in pressure wire to calculate pressure gradients and guide our decision to stent tandem lesions in the superior mesenteric artery. After revascularization, the patient's symptoms improved dramatically. To the best of our knowledge, this is the first published case in which a pressure wire was used to measure a pressure gradient in chronic mesenteric ischemia.