[N A J Med Sci. 2017;10(1):24-27. DOI: 10.7156/najms.2017.1001024]
Meenal Sharma, MD; Zhongren Zhou, MD, PhD*
Small bowel ischemic necrosis secondary to idiopathic intimal and medial hyperplasia of mesenteric small vessels is rare. The mesenteric vascular diseases were recently classified as two vascular diseases: fibromuscular dysplasia (FMD) of artery and mesenteric arteriovenous dysplasia/vasculopathy (MAVD/V). FMD usually involves medium size mesenteric arteries in younger individuals. In contrast, MAVD/V tends to affect multiple small mesenteric arteries and veins without vascular lesions in other organs. We reported that a 54-year-old female presented to emergency room with acute onset abdominal pain, nausea and vomiting. CT angiography showed “string of beads” in mesenteric vessels, but did not reveal any vascular narrowing elsewhere in the full body scan. The patient had small bowel ischemic necrosis secondary to idiopathic intimal and medial concentric smooth muscle hyperplasia in mesenteric vessels. The overall picture is consistent with MAVD/V.
Key Words: mesenteric arteriovenous dysplasia/vasculopathy, small bowel ischemic necrosis, idiopathic intimal hyperplasia, fibromuscular dysplasia, idiopathic medial hyperplasia
Fibromuscular dysplasia (FMD) is an uncommon, non-inflammatory arteriopathy that most commonly affects the renal and internal carotid arteries, but has been reported to affect nearly every arterial bed in the body.1,2 FMD is categorized into intimal, medial and adventitial type and also classified as local and multifocal disease. In the United States registry of FMD, however, only 8 cases were reported to cause mesenteric ischemia.1 Actually more mesenteric FMD cases in children and adults were also reported.3-14 Recently, Patil and colleague reported 11 cases with non-inflammatory, non-atherosclerotic mesenteric arteriovenous dysplasia/vasculopathy (MSVD/V) that is distinct from typical FMD.15 They set up three criteria for MSVD/V:(1) concentric/eccentric smooth muscle collarette around the tunica media of both the artery and the vein in ≥2 foci, (2) varying degrees of intimal and medial hyperplasia and adventitial fibrosis, and (3) lack of inflammation or thrombi.15 Only 2 of 11 cases showed small bowel transmural ischemic necrosis. Here we reported one case with acute transmural ischemic necrosis in whole small bowel secondary to idiopathic intimal and medial hyperplasia in small mesenteric arteries and veins, but the patient does not have history of Crohn’s disease, mass lesions, operation and heart attack.
A 54-year-old female had acute onset abdominal pain, nausea and vomiting. Her past medical history was significant for anxiety for which she was being treated with sertraline (Zoloft). She was a former smoker (30 pack years). She did not use oral contraception pills (OCPs) and had no known prior history of venous thromboembolism. On presentation her blood lactate level was 4.9 with normal WBC count. Imaging (CT angiography) was read as bowel ischemia of ileal loops with intraluminal hemorrhage and beaded appearance of the mesenteric vessels, suggesting a possible vasculitis (Figure 1, A and B). She was originally managed with NG tube for decompression and antibiotic coverage in addition to intravenous fluids. Coagulation profile was not concerning for a hypercoagulable state. Complete lab work up was normal and ANA screen was negative. A thorough evaluation for thrombosis by imaging and laboratory work was negative for thromboembolism. Due to worsening pain, she was taken to operating room for an exploratory laparotomy resulting in small bowel resection with primary anastomosis. About 120 cm of the small bowel was resected and the small bowel necrosis was felt to be in an arterial distribution. However no thrombosis was appreciated in gross examination.
Gross examination revealed a segment of small bowel with ischemic necrosis (120 cm in length x 2 cm in diameter). The specimen was opened to reveal almost entire intestinal wall with intense dark purple hemorrhagic mucosa that was sharply demarcated from the adjacent viable pink appearing normal mucosa (Figure 1, C and D). The small bowel and mesenteric vessels were extensively sampled for microscopic examination. Microscopic examination revealed small bowel with transmural hemorrhage, inflammation, edema, ulceration, mucosal necrosis, consistent with acute ischemic change (Figure 2, A). Focal mesenteric small arteries and vein were narrowed with intimal thickening and smooth muscle hyperplasia (Figure 2, B-E). No inflammation or any lipid accumulation was identified. Smooth muscle and collagen hyperplasia was mixed together in intimal and medial layers (Figure 2, B-E). A few mesenteric small arteries had concentric smooth muscle collarette around the tunica media of the artery (Figure 2, F-I). The trichrome, elastin special stains, and smooth muscle actin (SMA) immunohistochemical stains highlighted extensive smooth muscle hyperplasia (Figure 2, G-I). There was complete absence of inflammatory cells or post-inflammatory scarring together with the architectural preservation of the vascular wall. Based on the small bowel ischemic change and small mesenteric arteriovenous wall hyperplasia, the diagnosis of mesenteric arteriovenous dysplasia/vasculopathy was rendered.
Figure 1. (A) CT angiography sagittal section shows beaded appearance of the mesenteric vessels. (B) CT scan (Axial section) shows thickened edematous small bowel loops suggesting ischemic changes (horizontal arrows). (C) The ischemic necrosis of small bowel is dark and congested; (D) Ischemic necrosis of small bowel sharply demarcated from adjacent viable bowel.
We report one case with acute whole small bowel ischemic necrosis secondary to small mesenteric vessels narrowing and occlusion. The idiopathic intimal and medial hyperplasia was present in small mesenteric arteries and veins. There was complete absence of inflammatory cells or post inflammatory scarring together with the architectural preservation of the
vascular wall. This excludes any possibility of a vasculitis or a healed previous inflammatory lesion. The small bowel ischemic necrosis is not rare disease. However, the small bowel ischemic necrosis secondary to idiopathic intimal or medial hyperplasia of the small arteries and veins is rarely reported.
Figure 2. Histology of small bowel and vessels. (A) Transmural ischemic necrosis in small bowel; Small artery and vein showed intimal hyperplasia and lumen narrowing with H&E stain (B), elastin stain (C), trichrome stain (D) and smooth muscle actin immunostain (E). Small artery with concentric medial smooth muscle hyperplasia and lumen narrowing with H&E stain (F), elastin stain (G), trichrome stain (H) and smooth muscle actin immunostain (I).
The terminology of mesenteric vascular diseases is not very clear. FMD was reported in previous years involving focal and multiple organs.1,2 Focal disease is usually caused by intimal hyperplasia; multifocal disease manifests with the classic “string of beads” appearance and manifests as vascular stenosis, aneurysms or dissections in medium-sized arteries.1 The histological characters include the deposition of collagen fibers amidst degenerating elastic fibrils involving the intimal, medial, or adventitial compartments of the artery and the medial smooth muscle hyperplasia.16,17 In the United States FMD registration, only 8 cases had mesenteric ischemia in adults, but no child was reported for mesenteric ischemia.1 Recently, Patil et al. reported a group of distinct MAVD/V, which is characterized by (1) concentric/eccentric smooth muscle collarette around the tunica media of both the artery and the vein in ≥2 foci, (2) varying degrees of intimal and medial hyperplasia and adventitial fibrosis, and (3) lack of inflammation or thrombi.15 FMD usually involves in medium size mesenteric arteries such as superior mesenteric and celiac arteries in younger individuals. The majority of patients show features of ischemic colitis with “beads of string” in CT angiography. In contrast, MAVD/V involves
multiple small mesenteric arteries and veins without vascular lesions in other organs and may or may not have vascular change on angiography. Our case showed “string of beads” in mesenteric vessels by CT angiography, but did not reveal vascular narrowing elsewhere in the full body scan. In addition, both small arteries and veins were involved in attached mesenteric adipose tissue and some small arteries showed concentric smooth muscle hyperplasia (Figure 2, F-I). The overall picture is suggestive of MAVD/V. However, our case showed almost whole small bowel acute ischemic necrosis and “string of beads” in mesenteric vessels, which is difficult to interpret by focal small vascular occlusion. In addition, most of MAVD/V cases had Crohn’s disease (45%) or mass lesions (27%). Seven patients had a previous history of surgery and 4 patients with history of cardiac disease. Our patient is a 54-year-old female and a smoker without history of chronic gastrointestinal condition or a mass. She did not use oral contraception pills and did not have deep vein thrombosis. Our patient presented to emergency room with acute onset abdominal pain, nausea and vomiting. Only 2 of 11 previously reported MAVD/V cases had acute transmural ischemic change similar to our case.
At present, the mechanism of vascular change in both FMD patients and MAVD/V is unclear. Cigarette smoking, increased estrogen levels, mechanical trauma, and genetic factors have been proposed for the pathogenesis of FMD.18-22 From 11 MAVD/V cases, it does appear to be more common in women, none of the subjects in their cohort has a history of long-term oral contraceptive pill or hormone supplement intake. It is less likely that nonsteroidal anti-inflammatory drug use (2/11 patients), smoking history (4/11 patients), or medications alone could contribute to these vascular abnormalities. Although 7/11 patients had history of surgery, but the interval between previous history and vessel-related intestinal resection is variable from 5 months to 13 years.15
In conclusion, we reported a unique case that fits the new category of mesenteric arteriovenous dysplasia/vasculopathy proposed by Patil and colleague. However, we did find “string of beads” in CT angiography. It suggests the possibility of mixed vascular change in both mesenteric medium-sized arteries and small arteriovenous vessels.
Meenal Sharma, MD; Zhongren Zhou, MD, PhD*
Departments of Pathology and Laboratory Medicine, University of Rochester; NY
CONFLICT OF INTEREST
Authors declare that they have no conflict of interest.
- Green R, Gu X, Kline-Rogers E, et al. Differences between the pediatric and adult presentation of fibromuscular dysplasia: results from the US Registry. Pediatr Nephrol. 2016;31(4):641-650.
- Olin JW, Froehlich J, Gu X, et al. The United States Registry for Fibromuscular Dysplasia: results in the first 447 patients. Circulation. 2012;125:3182-3190.
- Mitchell A, Caty V, Bendavid Y. Massive mesenteric panniculitis due to fibromuscular dysplasia of the inferior mesenteric artery: a case report. BMC Gastroenterol. 2015;15:71.
- Kimura K, Ohtake H, Kato H, Yashiki N, Tomita S, Watanabe G. Multivisceral fibromuscular dysplasia: an unusual case of renal and superior mesenteric involvement. Ann Vasc Dis. 2010;3:152-156.
- Bonvini RF, Rastan A, Sixt S, Righini M, Hofstetter R, Zeller T. Diffuse fibromuscular dysplasia successfully treated with scoring balloon angioplasty in a 3-year-old boy. Heart Vessels. 2009;24:460-462.
- Mertens J, Daenens K, Fourneau I, Marakbi A, Nevelsteen A. Fibromuscular dysplasia of the superior mesenteric artery–case report and review of the literature. Acta Chir Belg. 2005;105:523-527.
- Kaneko K, Someya T, Ohtaki R, et al. Congenital fibromuscular dysplasia involving multivessels in an infant with fatal outcome. Eur J Pediatr. 2004;163:241-244.
- de Vries RR, Nikkels PG, van der Laag J, Broere G, Braun KP. Moyamoya and extracranial vascular involvement: fibromuscular dysplasia? A report of two children. Neuropediatrics. 2003;34:318-321.
- Horie T, Seino Y, Miyauchi Y, et al. Unusual petal-like fibromuscular dysplasia as a cause of acute abdomen and circulatory shock. Jpn Heart J. 2002;43:301-305.
- Meacham PW, Brantley B. Familial fibromuscular dysplasia of the mesenteric arteries. South Med J. 1987;80:1311-1316.
- Aboumrad MH, Fine G, Horn RC, Jr. Intimal hyperplasia of small mesenteric arteries. Occlusive, with infarction of the intestine. Arch Pathol. 1963;75:196-200.
- Price RA, Vawter GF. Arterial fibromuscular dysplasia in infancy and childhood. Arch Pathol. 1972;93:419-426.
- Hansen HJ, Christoffersen JK. Occlusive mesenteric infarction. A retrospective study of 83 cases. Acta Chir Scand Suppl. 1976;472:103-108.
- Hansen HJ, Jorgensen SJ, Engell HC. Acute mesenteric infarction caused by small vessel disease. Acta Chir Scand Suppl. 1976;472:109-111.
- Patil DT, Kissiedu J, Rodriguez ER, et al. Mesenteric Arteriovenous Dysplasia/Vasculopathy Is Distinct From Fibromuscular Dysplasia. Am J Surg Pathol. 2016;40:1316-1325.
- Harrison EG, Jr., McCormack LJ. Pathologic classification of renal arterial disease in renovascular hypertension. Mayo Clin Proc. 1971;46:161-167.
- Oxman HA, Sheps SG, Bernatz PE, Harrison EG Jr. An unusual cause of renal arteriovenous fistula–fibromuscular dysplasia of the renal arteries. Report of a case. Mayo Clin Proc. 1973;48:207-210.
- Olin JW, Gornik HL, Bacharach JM, et al. Fibromuscular dysplasia: state of the science and critical unanswered questions: a scientific statement from the American Heart Association. Circulation. 2014;129:1048-1078.
- Kiando SR, Tucker NR, Castro-Vega LJ, et al. PHACTR1 Is a Genetic Susceptibility Locus for Fibromuscular Dysplasia Supporting Its Complex Genetic Pattern of Inheritance. PLoS Genet. 2016;12:e1006367.
- Guo DC, Duan XY, Regalado ES, et al. Loss-of-Function Mutations in YY1AP1 Lead to Grange Syndrome and a Fibromuscular Dysplasia-Like Vascular Disease. Am J Hum Genet. 2017;100:21-30.
- Kiando SR, Barlassina C, Cusi D, et al. Exome sequencing in seven families and gene-based association studies indicate genetic heterogeneity and suggest possible candidates for fibromuscular dysplasia. J Hypertens. 2015;33:1802-1810; discussion 1810.
- Shivapour DM, Erwin P, Kim E. Epidemiology of fibromuscular dysplasia: A review of the literature. Vasc Med. 2016;21:376-381.