We would like to report the case of superior mesenteric arterial thrombosis in a woman
with a history of progesterone intake. A 51-year-old woman with a history of progesterone
consumption for delayed menstrual cycles and menorrhagia, presented with severe abdominal
pain, nausea, and a 1-day history of constipation. A contrast-enhanced computed tomography
(CT) scan revealed near-total occlusion of 4.4 cm of the superior mesenteric artery
from its origin ([Fig. 1]).
Fig. 1 CT scan axial arterial phase showing superior mesenteric artery thrombosis. Note
the unenhanced lumen of the artery from its origin.
Subsequently, Digital Subtraction Angiography (DSA) confirmed the thrombosis of the
superior mesenteric artery ([Fig. 2A]) and at the same setting, thromboaspiration was performed ([Fig. 2B]). Residual-narrowing was noted in the post aspiration angiogram ([Fig. 2C]). After 2 days of intensive care unit (ICU) care, a repeat CT angiography showed
recanalization of the superior mesenteric artery for a short segment with severe luminal
narrowing by eccentric plaque, and non-enhancing bowel thinning was observed in the
jejunum indicating ischemia, minimal ascites, and a bulky uterus ([Fig. 3A]). The patient was put on antiplatelet drugs and a balloon expanding stent placement
was performed without any complication ([Fig. 3B]).
Fig. 2 (A-C) DSA scans during and after interventional procedures in the patient. SMA thrombosis
in a lateral view, scan before thromboaspiration (A). Post aspiration DSA scan showing partially restored blood flow (B). Residual stenosis is still noted post aspiration (C).
Fig. 3 (A) CT axial and lateral views of abdominal angiogram showing improved flow through the
superior mesenteric artery after thromboaspiration. However, residual narrowing is
still noted at the SMA osteum (arrow) (A). DSA scan showing the arterial blood supply completely restored after successful
stent placement (B).
However, postprandial abdominal pain continued, this led to the termination of clopidogrel
and scheduling of explorative laparotomy. A 10-cm distal ileal loop and 20-cm jejunal
loop were found ischemic that were resected, and an end-to-end anastomosis was performed.
Several cases of mesenteric venous thrombosis occurring in patients using progesterone
pills have been reported.[1]
[2] However, arterial thrombosis in patients using progesterone is uncommon. In our
case, the woman was consuming progesterone and was scheduled for dilation and curettage
when she developed SMA thrombosis.
Diagnosis of SMA thrombosis is difficult due to non-specific and vague symptoms.[3] Thrombotic occlusion of the artery is known to have an overall mortality rate of
77.4% compared with embolic occlusion that has a mortality rate of 54.1%.[4] Laparotomy may be done to have a second look at the condition of the intestine,
identify viable loops, and resect the infarcted bowel. Arterial thrombosis in patients
on progesterone pills is rare, it is important to consider this in patients presenting
with acute bowel ischemia.
