to our knowledge the most recent article on celiac dissection was published in 2015 and reported 24 known cases of spontaneous isolated celiac trunk dissection . in our literature review
we did not identify a single case of isolated celiac artery dissection that presented during a hypertensive emergency .
we present a case of hypertensive emergency induced spontaneous isolated celiac trunk dissection , which was managed nonoperatively with a labetalol drip .
the definition of an arterial dissection is the cleavage of the arterial wall by an intramural hematoma located between two elastic layers , . as we are reporting the 25th known case of celiac artery dissection
many of the other reported cases involve other arteries such as the common hepatic , splenic , superior mesenteric , and gastroduodenal , , , , , , .
additionally , while some of those cases reported hypertension as a risk factor , no other case presents as hypertensive emergency with an isolated celiac artery dissection . the first case of visceral artery dissection involved the superior mesenteric artery ( sma ) and
was reported in 1947 , while the first celiac artery dissection was not reported until 1959 .
when they occur in the visceral arteries , the most common location is within the sma , .
celiac artery dissection has been described in blunt abdominal trauma , but it only accounts for 12 percent of all visceral vascular lesions .
to our knowledge the most recent article on celiac dissection was published in 2015 and reported 24 known cases of spontaneous isolated celiac trunk dissection . in our literature review
we did not identify a single case of isolated celiac artery dissection that presented during a hypertensive emergency .
we present a case of hypertensive emergency induced spontaneous isolated celiac trunk dissection , which was managed nonoperatively with a labetalol drip .
the definition of an arterial dissection is the cleavage of the arterial wall by an intramural hematoma located between two elastic layers , . as we are reporting the 25th known case of celiac artery dissection
many of the other reported cases involve other arteries such as the common hepatic , splenic , superior mesenteric , and gastroduodenal , , , , , , .
additionally , while some of those cases reported hypertension as a risk factor , no other case presents as hypertensive emergency with an isolated celiac artery dissection . the first case of visceral artery dissection involved the superior mesenteric artery ( sma ) and
was reported in 1947 , while the first celiac artery dissection was not reported until 1959 .
when they occur in the visceral arteries , the most common location is within the sma , .
celiac artery dissection has been described in blunt abdominal trauma , but it only accounts for 12 percent of all visceral vascular lesions .
a 43 year - old man with a past medical history of uncontrolled hypertension , for which he had reportedly been non - compliant with follow - up , presented with complaints of severe , sudden - onset epigastric pain which was non - radiating and constant for 1  h prior to arrival .
he reported moving his bowels prior to the onset of symptoms , and noted passing flatus after the onset of symptoms .
the patient denied a history of recent abdominal trauma . on initial examination his vital signs consisted of a temperature of 98.1   fahrenheit , heart rate of 78 , respiratory rate of 16 , blood pressure of 234/144 , and 99% oxygen saturation on room air .
his hypertensive emergency in the setting of severe abdominal pain necessitated an emergent vascular surgery consultation .
examination of the abdomen revealed a soft , non - distended , and obese abdomen .
the patient was diffusely tender to palpation , with maximum tenderness overlying the epigastric region .
there was no evidence of voluntary guarding or rebound , and he did not display peritoneal symptoms .
pulse examination was positive for 2 + radial , femoral , dorsalis pedis , and posterior tibial pulses bilaterally .
there was a well - healed , vertical , surgical scar in the left groin from an unspecified procedure secondary to a remote history of traumatic stab wound .
laboratory analyses ( complete blood count , coagulation parameters , comprehensive metabolic panel , lactic acid , and troponin i ) were all within normal limits .
contrast enhanced ( oral and intravenous ) computed tomography of the chest and abdomen / pelvis demonstrated normal course and caliber of the great vessels , ascending aorta , descending aorta , and abdominal aorta without aneurysmal dilatation .
there was no evidence of displaced intimal calcification , intramural hematoma , or dissection flap to suggest an aortic dissection .
an intimal flap was noted within the celiac trunk , starting at the origin and extending into the left gastric , splenic , and the common hepatic arteries .
the true and false lumens of the celiac trunk appeared well perfused . from the level of the bifurcation of the celiac trunk , perfusion of the true lumen of the left gastric , splenic , and common hepatic artery
was noted . the superior mesenteric artery , bilateral renal arteries , inferior mesenteric artery , common iliac arteries , and internal / external iliac arteries were patent without aneurysmal dilatation .
there were no signs of ischemic change of the liver and stomach , and the pancreas was of normal size and contour .
the patient was treated with 8  mg of morphine with only slight relief from his symptoms .
the patient was also treated with 10  mg labetalol iv and his systolic blood pressure improved into the 140s .
an additional 6  mg of morphine was administered for persistent abdominal pain and an additional 10  mg labetalol was prescribed .
the patient was admitted to the cardiac intensive care unit for aggressive blood pressure control and was initiated on a labetalol drip to maintain systolic blood pressure less than 120  mm hg . with aggressive blood pressure control throughout the evening of hospital day 0 and hospital day 1 , the patient s abdominal pain decreased in intensity .
he was then started on a regular diet , which he consumed without nausea , vomiting , or exacerbation of his pain . on hospital day 1 , the patient was weaned off of the labetalol drip , and his blood pressure medication regimen was transitioned to a by mouth route of hydralazine , labetalol , and amlodipine .
the most common symptom in patients with celiac artery dissection is acute or chronic epigastric or abdominal pain , , , . in many of the case studies the patient presented to the emergency department with sudden onset epigastric pain , , .
other manifestations include obstructive jaundice , pancreatitis , intestinal angina , tachycardia , hemorrhage , and hypertension , , .
interestingly , patients do not usually present with nausea , vomiting , or peritoneal symptoms , , .
another case study had a patient present with hematemesis , melena , and postprandial pain .
one of the more unique presentations was in a patient who had a history of long - term energy drink consumption and intense exercise routines .
patients with celiac artery dissection may also have a self - limited course of these aforementioned symptoms .
extensive of the dissection may occur into adjacent arterial walls , including those of the splenic artery and proximal hepatic arteries .
renal arteries and the splenic artery may also infarct in the first week after celiac dissection . the hepatic artery may develop an aneurysm .
there was one patient who experienced a sequential sma dissection in the subsequent week   during his hospital stay our patient did not experience any of these complications .. the crux of the diagnosis of this condition relies on contrast enhanced ct ( ct ) .
other modalities that can be used are ct angiography ( cta ) , magnetic resonance imaging ( mri ) , magnetic resonance angiography ( mra ) , and doppler ultrasonography ( us ) .
cta is used for definitive diagnosis as it allows precise determination of collateral circulation , .
us is of some efficacy because one can assess areas of abnormal flow in the proper habitus .
other cases have found infiltration of the fat surrounding the celiac artery or celiac artery aneurysm , .
intramural hematoma has been identified on ct and may lead to moderate narrowing of the vessel .
another reported a length of 812 millimeters . in the one patient that presented with upper gastrointestinal hemorrhage ct showed enhancement of perigastric and gastric intramural vascular collaterals due to chronic ischemia secondary to celiac artery dissection .
another case study repeated the ct scan as early as 12  h  later .
regardless of the timeline chosen , it is imperative to have serial ct scans to monitor for the potential serious complications of celiac artery dissection .
there are many identifiable and accepted risk factors for celiac artery dissection , , , , , , .
hypertension is an identified risk factor , though celiac artery dissection as the presenting symptom for hypertensive emergency has yet to be described until now .
in addition to hypertension , the other known risk factors are atherosclerotic disease , abdominal aortic aneurysm , cystic medial necrosis , fibromuscular dysplasia , connective tissue disorders such as ehlers - danlos syndrome , trauma , previous abdominal surgery , stenosis or occlusion of a major artery , syphilis , polyarteritis nodosa , and pregnancy , , , , .
one case series noted that the two most common risk factors for celiac artery dissection were hypertension followed by vasculitis ( particularly polyarteritis nodosa ) .
anti - inflammatory drugs and steroids may be indicated to treated underlying conditions such as polyarteritis nodosa .
the duration of anticoagulant and antiplatelet therapy is variable but it is thought 36 months is sufficient . ,   for anticoagulation heparin or lovenox bridging to warfarin is recommended , .
anticoagulation is essential in order to prevent thromboembolic complications , . in order to reduce the risk of propagation of the dissection and rupture ,
one retrospective review of 19 patients with celiac artery dissection , published in 2015 , notes that long term anticoagulation is not needed in patients undergoing endovascular stenting .
complications such as occlusive lesions , aneurysm formation , arterial rupture , hemodynamic instability , persistent pain , uncontrolled hypertension , ischemia , end organ damage , or dissection extensive are indications for operative treatment , , , . when surgical intervention is necessary , a vascular surgeon should be consulted emergently .
operative treatment may entail resection and anastomosis , prosthetic bypass , or endovascular stenting , , .
follow - up for the patient population with celiac artery dissection should include ct scan with iv contrast at 3- and 6-month intervals to evaluate for stability of the dissection .
earlier imaging may be obtained should patients become increasingly symptomatic on a more accelerated timeline . in patients with contraindications
to iv contrast injection , ultrasound in conjunction with mri may suffice as an alternative option . it is reported that celiac artery dissection has a poor prognosis .
this prognosis , though , depends on the extent of involvement of subsegmental branches , .
involvement of the renal , hepatic , or splenic arteries can cause detrimental end - organ damage .
going forward his prognosis will ultimately depend on control of his blood pressure . in the event that his symptoms recur
, he will be a surgical candidate ( fig . 1 , fig . 2 , fig . 3 , fig .
to the best of our knowledge , we present the 25th case of isolated celiac artery dissection .
this is the first case of hypertensive emergency induced spontaneous isolated celiac trunk dissection in literature .
visceral artery dissection is a rare commodity , and celiac artery dissection is less common than dissection in the sma . it is a difficult diagnosis to make on history and physical alone , necessitating contrast enhanced ct imaging . in patients who present with acute onset abdominal pain in the setting of hypertension , we recommend an immediate contrast enhanced ct scan . in patients with contraindications
no research conducted on patient and he has given approval - steven d. kozusko on behalf of all authors .
written informed consent was obtained from the patient for publication of this case report and accompanying images - steven d. kozusko on behalf of all authors .
swergold data collection  dr . swergold data analysis or interpretation  dr . swergold writing the paper  dr . kozusko oversight  dr . sturt steven d. kozusko on behalf of all authors .
 highlightsto the best of our knowledge , we present the 25th case of isolated celiac artery dissection.this is the first case of hypertensive emergency induced spontaneous isolated celiac trunk dissection in literature.visceral artery dissection is a rare commodity , and celiac artery dissection is less common than dissection in the sma.it is a difficult diagnosis to make on history and physical alone , necessitating contrast enhanced ct imaging.our patient was managed nonoperatively with a labetalol drip and did well . 
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