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Special Feature
October 2010October 18, 2010

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations: Kyoto Medical Center, Kyoto, Japan.

 

CARL E.BREDENBERGMD

Arch Surg. 2010;145(10):1017. doi:10.1001/archsurg.2010.221-a

A 53-year-old man who had no previous illness recorded had severe paraumbilical pain and underwent open cholecystectomy in which cholecystic and hepatic infarctions were found. A computed tomographic scan of the abdomen and pelvis obtained at postoperative evaluation showed sporadic hepatic infarction (Figure 1) and intestinal dilatation. Three-dimensional reconstructed images of the computed tomographic scan revealed occlusions at the origins of the celiac axis and superior and inferior mesenteric arteries but maintained blood flow in their distal lesions (Figure 2). Abdominal angiograms identified collateral flows from the left internal iliac artery to the superior mesenteric artery through the superior rectal, left colic, and middle colic arteries (Figure 3). Then, intravenous low–molecular weight heparin and prostaglandin E1 were administered. Seven days after the surgery, he developed relapsing abdominal pain, and relaparotomy was performed for the resection of an infarcted small intestine and right colon. Anticardiolipin and anticardiolipin β2-glycoprotein I complex antibodies were detected at 1 and 13 weeks after the second surgery. He was discharged after the administration of total parenteral nutrition and chronic anticoagulation with Fondaparinux but developed ischemic pancreatitis 8 months after the second surgery.

Figure 1.
A computed tomographic scan shows sporadic hepatic infarction.

A computed tomographic scan shows sporadic hepatic infarction.

Figure 2.
Three-dimensional reconstructed images of the computed tomographic scan revealed occlusions at the origins of the celiac axis and superior and inferior mesenteric arteries but maintained blood flow in their distal lesions.

Three-dimensional reconstructed images of the computed tomographic scan revealed occlusions at the origins of the celiac axis and superior and inferior mesenteric arteries but maintained blood flow in their distal lesions.

Figure 3.
Abdominal angiograms identified collateral flow from the left internal iliac artery to the superior mesenteric artery through the superior rectal, left colic, and middle colic arteries.

Abdominal angiograms identified collateral flow from the left internal iliac artery to the superior mesenteric artery through the superior rectal, left colic, and middle colic arteries.

What Is the Diagnosis?

A. Atherosclerotic disease

B. Heparin-induced thrombocytopenia

C. Antiphospholipid antibody syndrome

D. Disseminated intravascular coagulation

Answer

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