(b) postoperative 3 year abdominal enhanced CT scan show a thrombosed false lumen completely resolved without progressive dilation of ULP. Case 3 A 47-year-old man with a 5-day history

of acute epigastric pain with radiation to the back was admitted. No associated symptoms of fever, nausea, constipation or diarrhea were present. He was previously healthy and had no cardiovascular risk factors and recent trauma. On physical examination, mild tenderness over the epigastrium without signs of peritonitis sign was observed, and no bruit was audible. Laboratory tests and abdominal radiography were unremarkable. Contrast-enhanced CT revealed a thin flap of the SMA, which began from just after the orifice of the SMA and separated the SMA into TEW-7197 ic50 two distinct lumina; the resulting false lumen was AZD6094 purchase thrombosed in the mid to distal portion of the SMA. Three-dimensionally reconstructed images demonstrated severe stenosis of the SMA, but no sign of bowel ischemia caused by prominent collateral flow from the celiac artery and inferior mesenteric artery (figure 3a). We chose conservative treatment without anticoagulation therapy. The abdominal pain completely disappeared on day 2 and he was discharged on day 4. The patient was symptom free 4

years after discharge with no recurrent symptoms and disease progression. One year after surgery, a thrombosed false lumen completely resolved with ULP on follow up CT (figure 3b). Figure 3 Sakamoto’s type III find more dissection of the SMA. (a) preoperative three-dimensionally reconstructed images showing

severe BCKDHA stenosis of the SMA with ULP, and the collateral flow from the celiac artery and inferior mesenteric artery. (b) postoperative 1 year abdominal enhanced CT scan show a thrombosed false lumen completely resolved without progressive dilation of ULP. Discussion and review of the literature Spontaneous dissection of the SMA is a rare condition and is not associated with aortic dissection. It was first described by Bauerfield in 1947 [19]. In previously reported cases before 1972, the prognosis was very poor [19, 20]. However, the prognosis has improved significantly since 1975 as a result of advancements in surgical techniques and imaging modalities [1–4]. The etiology of the disease has not yet been established, but atherosclerosis, cystic medial necrosis, and fibromuscular dysplasia have been implicated, often associated with untreated hypertension [3]. Solis et al. [21] have hypothesized that dissection usually begins 1.5-3 cm from the orifice of the SMA, thus sparing the origin of the artery. This segment of the SMA corresponds with the exit of the artery from the pancreas and is exposed to shearing force because this area forms the border zone between the fixed retropancreatic portion and the more distal mobile mesenteric portion.