A 47‐year‐old woman presented with a 2‐day history of lower back pain and acute onset of abdominal pain that was associated with an episode of nausea and emesis. She was afebrile with elevated blood pressure. She was tender to palpation in the epigastric region and left upper quadrant with no rebound or guarding. The lower back pain was aggravated by lying down and relieved by sitting. The patient reported a history of hypertension, gastroesophageal reflux, gastric ulcers, and gastric bypass surgery. Review of systems was significant for a 1‐day episode of gastroenteritis the previous week. CT scan showed stranding and inflammatory changes surrounding the celiac artery with focal dilatation of 8 mm at the trifurcation. CT angiogram revealed moderate segmental narrowing of the proximal and midceliac axis with distal dilatation. A soft‐tissue density surrounded the celiac axis and common hepatic artery and extended to the level of the porta hepatis. Both studies were suggestive of vasculitis.
Laboratories studies were unremarkable on admission. Erythrocyte sedimentation rate, C‐reactive protein, C3, C4, ANA, antineutrophil cytoplasmic antibody (ANCA) panel, rapid plasma reagin, cardiolipin antibodies, HIV, and hepatitis serology were all normal. Patient was initiated on a 3‐day course of pulse steroids with a probable diagnosis of celiac artery vasculitis. Her abdominal and lower back pain resolved with treatment, and we discharged her on a steroid taper.
Abdominal pain is a common problem encountered by the general internist. It is important to have a method in identifying the etiology of pain in order to avoid missing fewer common diagnoses. One method is to identify each abdominal organ and determine if the problem is secondary to an infectious, ischemic, functional, or traumatic insult. Our patient had inflammatory changes in her celiac artery. These vasculitic changes may have caused pain secondary to ischemic changes in the region. Vasculitides are often a result of immune‐mediated or infectious causes. Immune‐mediated processes can be secondary to immune‐complex deposition, ANCAs, or antiendothelial cell antibodies that directly or indirectly induce vascular injury. Infectious vasculitides may be secondary to direct invasion or hematogenous spread. It is important to identify the etiology because steroids and anti‐inflammatory agents are used for immune‐mediated vasculitides. Diagnosis is based on clinical presentation, serologic markers, biopsy, and imaging. With laboratory results pending, our patient responded to empiric treatment with pulse steroids. Serological and inflammatory markers indicative of a vasculitis were normal, which speaks against the diagnosis. Her imaging studies and clinical response to therapy suggested an isolated celiac artery vasculitis without systemic involvement.
Although uncommon, vasculitides can have various presentations. It's important for the internist to recognize this disease as a possibility when faced with common symptoms such as abdominal pain.
J. Nguyen ‐ none; C. Tyson ‐ none; M. Glass ‐ none
To cite this abstract:Nguyen J, Tyson C, Glass M. Celiac Curveball. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 351. https://www.shmabstracts.com/abstract/celiac-curveball/. Accessed December 10, 2018.