Does a CT finding of soft tissue stranding surrounding the celiac axis and proximal superior mesenteric artery, concerning for vasculitis, merit admission to inpatient and a Rheumatology consult?

Management of CT Finding Suggesting Vasculitis of the Celiac Axis and SMA

A CT finding of soft tissue stranding surrounding the celiac axis and proximal superior mesenteric artery concerning for vasculitis does merit hospital admission and rheumatology consultation due to the high risk of mesenteric ischemia and potential life-threatening complications.

Rationale for Admission and Rheumatology Consultation

Clinical Significance of the Finding

• Soft tissue stranding around major mesenteric vessels is concerning for vascular inflammation that could lead to mesenteric ischemia
• According to the World Society of Emergency Surgery guidelines, delay in diagnosis of mesenteric ischemia is the dominant factor accounting for high mortality rates of 30-70% 1
• Every 6 hours of delay in diagnosis doubles mortality in cases of acute mesenteric ischemia 1

Diagnostic Approach

1. Complete the vascular imaging workup:

   • Triple-phase CT angiography (non-contrast, arterial, and venous phases) is recommended to fully evaluate:
     • Extent of stenosis
     • Development of collateral circulation
     • Signs of bowel compromise 2
   • CTA has 94% sensitivity and 95% specificity for diagnosing significant SMA stenosis 2

2. Laboratory assessment:

   • Serum lactate (levels >2 mmol/L associated with irreversible intestinal ischemia) 1
   • D-dimer (elevated in intestinal ischemia with sensitivity of 96%) 2
   • Complete blood count
   • Inflammatory markers (CRP, ESR)
   • Autoimmune workup (ANCA, ANA, RF)

Management Algorithm

Immediate Management

1. Hospital admission for:

   • Close monitoring of vital signs
   • Serial abdominal examinations
   • Pain management
   • NPO status if acute ischemia is suspected
   • IV fluid resuscitation

2. Rheumatology consultation is necessary because:

   • Vasculitis affecting the mesenteric vessels requires specialized evaluation
   • According to the American College of Rheumatology guidelines, vascular imaging findings suggestive of active disease warrant immunosuppressive therapy 1
   • Rheumatologists can determine appropriate immunosuppressive regimens based on the type and extent of vasculitis

Treatment Considerations

1. If acute ischemia is suspected:

   • Systemic anticoagulation (rated 8/9 for appropriateness by ACR) 1
   • Surgical or endovascular intervention may be necessary depending on the degree of stenosis and clinical presentation

2. For confirmed vasculitis:

   • Immunosuppressive therapy is recommended for patients with signs of inflammation in vascular territories 1
   • High-dose glucocorticoids are typically first-line therapy
   • Additional immunosuppressants may be required based on the specific type of vasculitis

Important Caveats

• Not all soft tissue stranding indicates active vasculitis: The finding should be correlated with clinical symptoms and laboratory markers of inflammation

• Differential diagnosis should include:

  • Non-occlusive mesenteric ischemia
  • Atherosclerotic disease
  • Aortomesenteric compression syndromes
  • Mesenteric venous thrombosis
  • Infectious or inflammatory processes in adjacent structures

• Multidisciplinary approach: While rheumatology consultation is essential, involvement of vascular surgery and interventional radiology may also be necessary depending on findings

Conclusion

The finding of soft tissue stranding surrounding the celiac axis and proximal SMA on CT is a serious finding that warrants hospital admission and rheumatology consultation. This approach allows for comprehensive evaluation, close monitoring, and timely intervention to prevent potentially life-threatening complications of mesenteric ischemia or progressive vasculitis.