Hrev_master Abstract Spontaneous dissection of the celiac trunk is a rare and uncom- mon cause of acute abdominal pain. Risk factors, natural history and optimal treatment are still unclear due to the rarity of the disorder. Therapeutic strategies and follow-up procedures are based on limit- ed observations, and the absence of guidelines warrants a patient-tai- lored approach. We report the case of a 50-year-old woman who pre- sented to our emergency department for epigastric pain, nausea, and vomiting resulting from a spontaneous dissection of the celiac trunk, successfully treated with endovascular technique. Introduction The diagnosis of abdominal pain is considered a challenge by all the emergency physicians. Isolated spontaneous dissection of the celiac trunk is a rare and unusual cause of epigastric pain that should always be considered in the differential diagnosis of patients presenting with persistent abdominal pain and unspecific clinical and laboratory findings.1 We describe the case of a sponta- neous celiac trunk dissection in a young female patient successful- ly treated with endovascular technique. Case Report A 50-year-old woman presented to our emergency department because of a 6-day history of epigastric pain associated with nau- sea and vomiting. She denied trauma, fever, and back pain. She had a history of a sliding hiatal hernia with reflux oesophagitis for several years for which she was taking proton pump inhibitors, but she reported a different kind of pain unresponsive to treatment. She had no cardiovascular risk factors, but her family history resulted positive for heart attack (the father) and splanchnic artery aneurysm surgically treated (the sister). On admission abdominal palpation revealed a mild tenderness over the epigastrium. Blood pressure, heart rate, peripheral oxygen saturation, respiratory rate and body temperature were 140/80 mmHg, 77 bpm regular, 98% while breathing in room ambient air, 16 breaths/min, and 36 °C, respectively. Point-of-care ultrasound (PoCUS) and an electrocar- diogram (ECG) demonstrated no abnormalities. Laboratory data showed a slight increased white blood count (13.130/mm3, neu- trophils 10.540/mm3) with normal value of C-reactive protein, coagulation time, hepatic and renal function. Troponin I was nor- mal at two consecutive controls. Urine dipstick and gravindex resulted negative. After the administration of paracetamol (1 g iv) and delorazepam (1 g iv) she became asymptomatic, and she was admitted to our Observation Unit. The day after the admission the patient complained of a recurrence of more acute and intense epi- gastric pain. Blood exams resulted unchanged with stable and nor- mal value of haemoglobin (12.8 g/dL). PoCUS and ECG were repeated, and both resulted normal. A contrast enhanced Computed Tomography (CT) of the abdomen was performed documenting a dissection at the origin of the celiac trunk extending along the course of the vessel for approximately 2 cm, with the concomitant presence of intra-mural haematoma (hyperdense already in the basic condition) more evident on the right side of the vascular Emergency Care Journal 2022; volume 18:10988 Correspondence: Poggiali Erika, Emergency Department, Guglielmo da Saliceto Hospital, via Taverna 49, 29121, Piacenza, Italy. Tel.: +39.0523.303044 E-mail: poggiali.erika@gmail.com Key words: Celiac trunk; dissection; abdominal pain; epigastric pain; endovascular repair. Contributions: EP, CN and FM collected details of the case, cared for the patient, and drafted the manuscript. MP and EM performed the radi- ological imaging and procedure. AV critically revised the manuscript. All the authors approved the final version. Conflicts of interest: EP is member of the editorial board of ECJ. The Authors declare no conflict of interest. Availability of data and materials: All data underlying the findings are fully available upon reasonable request to Erika Poggiali, E.Poggiali@ausl.pc.it Ethics approval and consent to participate: As this was a descriptive case report and data was collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board guidelines. Received for publication: 1 November 2022. Revision received: 6 December 2022. Accepted for publication: 6 December 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:10988 doi:10.4081/ecj.2022.10988 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. [Emergency Care Journal 2022; 18:10988] [page 79] A rare and unusual cause of acute abdominal pain: A case of spontaneous isolated dissection of the celiac trunk Erika Poggiali,1 Chiara Negri,1 Federico Mosso,2 Marcello Petrini,3 Emanuele Michieletti,3 Andrea Vercelli1 1Emergency Department, Guglielmo da Saliceto Hospital, Piacenza; 2Vascular Surgery Unit, Guglielmo da Saliceto Hospital, Piacenza; 3Radiology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy Non -co mmerc ial us e o nly Case Report Figure 1. Abdomen CT scan without contrast showing celiac trunk hyperdensity consistent with intramural haematoma (arrow) (panel A). Arterial phase axial view (panel B) and arterial phase with sagittal view (panel C) showing narrowing of the true lumen (arrow). [page 80] [Emergency Care Journal 2022; 18:10988] Figure 2. Fluoroscopic images confirming dissection of celiac trunk (arrow in A), treated with endovascular stent-graft (arrow in B). Arterial phase CT in sagittal view of the stented celiac trunk (arrow in C). Non -co mmerc ial us e o nly lumen, with a thickness of about 4 mm. The celiac trunk appeared dilated overall, with a diameter of 11 mm and a reduced residual lumen of 3 mm (Figure 1). A diagnosis of isolated spontaneous dis- section of celiac trunk was done. Selective angiography of the celi- ac tripod confirmed the presence of dissection involving the hepat- ic artery (Figure 2 A). The patient was immediately treated with endovascular stent-graft placement without complication (Figure 2 B-C), and then admitted to the vascular surgery unit. The patient’s postoperative course was uneventful, hepatic laboratory tests remained always normal, and the CT-angiography performed before her discharge confirmed the regular patency of the stent and tripod division branches. The patient was discharged completely asymptomatic 4 days later. A combined antiplatelet therapy (acid acetylsalicylic 100 mg and clopidogrel 75 mg daily) was started and continued for three months with no recurrence of symptoms. On follow-up ultrasound imaging performed 3 months postopera- tively, the graft remained patent, and there was no evidence of endoleak or celiac artery aneurysm. A regular 6-month follow-up has been planned in the outpatient vascular surgery clinic. Discussion Spontaneous isolated dissection of the celiac trunk is an uncommon visceral artery dissection, rarely considered in patients presenting with acute onset of epigastric pain. Since it can be com- pletely asymptomatic and detected incidentally for other condi- tions, the true incidence of this disease in unknown, even if an increased number of case reports have been reported in literature in the last decade.2,3 The most common presenting symptoms are abdominal pain, nausea, and back pain, but also chest pain, syn- cope and jaundice have been reported.3 When dissection of the celiac trunk is suspected, CT angiography is the best diagnostic technique. The risk factors, causes, and natural history of sponta- neous isolated visceral artery dissection are still unclear. Median Arcuate Ligament Syndrome (MALS) can contribute to the aneurysmal celiac trunk dissection. MALS is a chronic pathogenic process occurring when the median fibrous arcuate ligament and muscular diaphragm fiber have a relatively low insertion, causing extrinsic compression and luminal narrowing of the celiac trunk.4 In view of its rarity, the management of the spontaneous isolated dissection of the celiac trunk still remains a matter of debate and there is no consensus on the optimal management. Treatment with open surgery, endovascular stenting, or anticoagulation therapy has been proposed. In a systematic review by Wang et al. conser- vative treatment, including medical therapy and observation, is recommended for asymptomatic patients.1 Although there is no consensus on the duration of conservative therapy, treatment with anticoagulant or antiplatelet agents from 3 weeks to 6 months with a target international normalized ratio of 2.0 to 3.0, has been reported to achieve good outcomes.5 If abdominal pain is persis- tent, endovascular stenting may stabilize or improve the pain, and surgical reconstruction can be done for aneurysmal degeneration or occlusion, both unusual events.6 If the patients had bowel infarc- tion or necrosis, peritonitis, or aneurysm rupture, open surgery was reported to be the initial treatment.1 Liver function tests may be helpful in determining if there is hepatic malperfusion and ischemia due to the involvement of the hepatic artery, that might prompt more aggressive management. In conclusion, in absence of guidelines a patient-tailored approach is recommended, and in case of conservative medical treatment, cardiovascular risk factor mod- ification, limiting the propagation of the dissection and reducing the risk for rupture, must be warranted. References 1. Wang J, He Y, Zhao J, et al. Systematic review and meta-anal- ysis of current evidence in spontaneous isolated celiac and superior mesenteric artery dissection. J Vasc Surg 2018;68:1228–40. 2. Hoglund JR, Blackwell JH, Gibbs MA. Spontaneous celiac artery dissection. Am J Emerg Med 2020;38:1545. 3. Neychev V, Krol E, Dietzek A. Unusual presentation and treat- ment of spontaneous celiac artery dissection. J Vasc Surg 2013;58:491–5. 4. Li S, Luo J, Yin L, et al. Aneurysmal celiac trunk dissection caused by median arcuate ligament syndrome successfully treated by endovascular technique: a case report. AME Case Rep 2021;5:37. 5. Zhang WW, Killeen JD, Chiriano J, et al. Management of symptomatic spontaneous isolated visceral artery dissection: is emergent intervention mandatory? Ann Vasc Surg 2009;23:90– 4. 6. DiMusto PD, Oberdoerster MM, Criado E. Isolated celiac artery dissection. J Vasc Surg 2015;61:972–6. Case Report [Emergency Care Journal 2022; 18:10988] [page 81] Non -co mmerc ial us e o nly