PMC9870673_01
(December 15, 2016) CT scan of the patient on first admission. (A-F): The CT shows that the left middle and upper abdomen is partially empty, and the ileal bowel wall is thickened and swollen; filling defects can be seen in the lumen of the main portal vein and its branches and the superior mesenteric vein and its branches. A small amount of effusion is seen around the liver, spleen, and intestine. The enhancement of the right hepatic lobe is not uniform in the arterial phase of the enhanced scan, and the portal venous phase and the delayed phase are in isodensity. A small circular low-density shadow with a diameter of approximately 0.5 cm is seen in the IV segment of the liver near the diaphragm. There is no enhancement on the enhanced scan. The uterine shadow is enlarged, its internal density is uneven, and multiple lumpy and patchy areas of reduced density can be seen. The enhancement scan is uneven; (G): The upright abdominal plain film shows that the intestinal tube in the abdomen is slightly dilated. (H): Uterine arteriography shows that the left and right uterine arteries are thickened and disordered, and the uterus is enlarged in the parenchymal stage. (I): After uterine artery embolization, most left and right uterine arteries are blocked.
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F1
The boundary was not clear (Figures 1A-F). An upright abdominal radiograph showed a slightly dilated bowel in the abdomen (Figure 1G). Repeated angiography after embolization revealed that most of the left and right uterine arteries were blocked (Figures 1H,J).
(January 13, 2017) The patient's second visit. (A): The shape of the discharge is strip brown. (B,C): Under the pathological microscope of the excluded objects, there are large degenerated dead objects, red stained muscle bundle like structures, and no nucleus is found. (D-G): Whole abdominal CT after 1 month shows eccentric filling defects in the main portal vein, superior mesenteric vein, and some branch lumens. The extent is significantly smaller than before. The original right posterior thrombus is basically absorbed, and some proximal mesenteric branch veins are unobstructed, which is improved compared with the previous one. In the mid-abdominal region, the segmental small bowel wall is still thickened and swollen, which is reduced compared with the previous one, and now the enhancement is obvious.
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F2
One month later, the patient was readmitted with occasional dull pain in the left lower quadrant and a long brown discharge (Figure 2A). Scattered exudation and a small amount of fluid in the pelvic and abdominal cavities were absorbed earlier (Figures 2D-G). Under the pathological microscope of the discharge, a large area of degeneration and necrosis was observed, a red-stained muscle bundle-like structure was observed, and no nuclei were observed (Figures 2B, c).
(May 22, 2017) CT examination of the patient's third admission. The coronal view shows a filling defect in the lumen at the origin of the linear filling defect in the superior mesenteric vein (A,B). The sagittal view shows a reduced angle between the superior mesenteric artery and the abdominal aorta (C). Maximal intensity projection shows a localized widening of the superior mesenteric vein with a hypodense filling defect (D). The axial view shows the filling defect sign of the superior mesenteric vein, a marked dilation of the horizontal segment of the duodenum and proximal jejunum, and a local constriction of the intestinal lumen near the origin of the superior mesenteric artery (E). The horizontal section of the duodenum is markedly expanded in the transverse axis, with a beak-like narrowing in the near midline area, and the proximal end of the ascending colon is also significantly expanded (F). The transverse axis shows inflammatory thickening and edema of the small intestinal wall at multiple sites, with a little mesentery, exudation and local thickening of blood vessels (G). Local small bowel dilatation in the left lower abdomen, with local wall thickening and enhancement, and the corresponding organ cavity is narrowing (H). (I): Preoperative upright abdominal plain film shows multiple lesions in the middle, and lower abdomen gas and liquid levels are seen, and the elastic ring sign is seen in a part of the dilated bowel. (J): Postoperative re-examination of the upright abdominal plain film shows changes after a part of the small bowel was resected. A CT scan after resection shows postoperative changes in the small bowel in the coronal view, and no signs of intestinal obstruction are found (K). After treatment, there is a little punctate filling defect sign in the superior mesenteric vein, which is more absorbed than before (L,M).
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F3
After myomectomy and bilateral uterine artery embolization, lump-like shadows with abnormal density were seen on the posterior wall of the uterus, and the enhancement showed uneven and obvious enhancement, with a size of about 5.2 x 3.9 x 4.3 cm (Figures 3A-C, E-H). The maximal intensity projection (MIP) image showed that the local lumen of the superior mesenteric vein was slightly widened, and a longitudinal linear hypodense filling defect was observed (Figure 3D). The upright abdominal radiograph showed multiple gas-liquid levels in the middle and lower abdomen, and the elastic ring sign was seen in a part of the dilated bowel (Figure 3I). A small punctate filling defect in the superior mesenteric vein was absorbed earlier (Figure 3K-M). The upright abdominal radiograph showed that the multiple gas-liquid levels in the original abdomen had disappeared before surgery (Figure 3J).
Postoperative pathological findings of the third admission procedure. (A): Small bowel removed for partial jejunectomy. (B-D): The pathology of the small intestine resected after the operation shows a chronic inflammation of the jejunal mucosa with ulceration, necrosis, and exfoliation of a part of the mucosa, pus on the surface of the intestinal mucosa, and infiltration of many lymphocytes, plasma cells, and a small number of neutrophils and eosinophils in the full thickness of the intestinal wall. Full-thickness blood vessels in the intestinal wall are proliferated, dilated, and congested with hemorrhage, and fibrinous necrosis is seen in some blood vessels.
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F4
Therefore, an exploratory laparotomy was performed, and partial jejunal resection and gastrointestinal bypass anastomosis were performed during the operation (Figure 4A). Vascular hyperplasia, dilation and congestion with hemorrhage, and fibrinoid necrosis were observed in some blood vessels (Figure 4B-D).