Diagnosis: Sub-acute thromboembolism of SMA

History: 47 year old, with 12 day hx of steadily worsening, crampy abdominal pain. Pt reported experiencing sudden onset of pain on the morning of 01 Jan and worsening over the course of day. Pt presented to local ED and underwent CT and US (both negative), was diagnosed with viral vs bacterial gastroenteritits, and released. Pt and family returned to his geographical home, however the pain did not subside, and pt presented to the local hospital 2 days later (9 days prior to current presentation). Pt was seen in the family health clinic and was referred to GI for workup and treatment for gastric ulcer. He was started on prevacid and zantac, and sent home. H pylori test at that time was negative. The pain did not improve over the course of the next several days, and steadily worsened. He stated that eating made it worse, and that curling into a fetal position helped. On the morning of 13 Jan he presented to the ED again, stating that the pain peaked the night before, and the pain is as low as it has been in days. Negative nausea or vomiting. + fever and chills on initial presentation 01Jan, however currently afebrile.

Findings: Abdominal CT (with contrast):1. Mild stranding focally in the lesser sac, medial to the second portion of the duodenum, anterior to the third portion of the duodenum, posterior to the pancreas and just inferior to the pancreatic head, with mild stranding adjacent to the SMA.2. Possible mild narrowing of the third portion of the duodenum between the SMA and aorta.Addendum: Small thrombus within the proximal portion of the SMA. Distal to this region the contrast is not as bright as the proximal SMA, with mild adjacent inflammatory changes adjacent to the SMA consistent with SMA Syndrome.

Ddx: 1. Thrombus of SMA 2. Mild focal pancreatitis 3. Small perforation of medial 2nd portion of duodenum

Exam: Gen: 47 y/o healthy, caucasian male, in mild distress CV: Reg rhythm, slightly tachicardic, no rubs/murmurs/gallops Pul: Clear to ascultation bilaterally ABD: Slightly tender to palpation in R and L upper quadrant. +Bowl sounds; Non-distended; neg Murphy’s; No guarding or rebound Pulses: 2+ throughout Ext: No clubbing/cyanosis/edema CBC: 10.7> 15.4/46.4 < 495