A 46-year-old male with a history of hypertension visited the emergency department (ED) by ambulance complaining of sudden pain in the left side of his back. Ultrasonography (USG) performed at ED revealed splenic infarction along with occlusion and dissection of the celiac and splenic arteries without abdominal artery dissection. Contrast enhanced computed tomography (CT) revealed the same result. Consequently, spontaneous isolated celiac artery dissection (SICAD) was diagnosed. Because his blood pressure was high (159/70 mmHg), antihypertensive medicine was administered (nicardipine and carvedilol). After his blood reached optimal levels (130/80 mmHg), symptoms disappeared. Follow-up USG and contrast enhanced CT performed 8 days and 4 months after onset revealed amelioration of splenic infarction and improvement of the narrowed artery. Here, we report a case of SICAD with splenic infarction presenting with severe left-sided back pain and discuss the relevance of USG in an emergency setting.

A 50-year-old male was brought to our emergency department by ambulance with complaints of pain and numbness in both legs. At arrival, purple spots were evident on his neck and face. Examination of the vital sign indicated septic shock. Laboratory data and blood gas analysis revealed disseminated intravascular coagulation, multiple organ failure, and metabolic acidosis. Peripheral blood smears revealed Howell-Jolly bodies, indicating decreased splenic function. A rapid urinary pneumococcal antigen test was also found to be positive. After admission to the intensive care unit, extensive treatment, including polymyxin-B direct hemoperfusion and administration of methylprednisolone and broad spectrum antibiotics was immediately initiated. Despite of our efforts to save his life, the patient died six hours after the arrival. The following day, blood cultures revealed the presence of Streptococcus pneumoniae. An autopsy revealed a hypoplastic spleen and a bilateral adrenal hemorrhage, indicating acute adrenal insufficiency caused by sepsis. Finally, the patient was diagnosed with Waterhouse-Friderichsen syndrome. Although severe infection may be seen in the splenectomized patients, it should be noted that patients with a hypoplastic spleen may have acute severe infections. We, therefore, report a case of Waterhouse-Friderichsen syndrome resulting from an invasive pneumococcal infection in a patient with a hypoplastic spleen.

A thrombus in the superior mesenteric artery (SMA) is a critical condition that requires immediate diagnosis and treatment. We present a case of a thrombus in SMA that was successfully treated by interventional radiology. A 63-year-old male with a history of myocardial infarction, diabetes mellitus, hypertension, and gastric ulcers was admitted to our hospital complaining of severe upper abdominal pain. He had smoked 20 cigarettes per day for 40 years. Upon arrival, his blood pressure was extremely high (254/120 mm Hg). Noncontrast computed tomography (CT) revealed no apparent cause for his symptom. Electrocardiography revealed Q waves in V1 and V2 without ST elevation in other leads. Myocardial angina could not be ruled out. Immediately after the administration of heparin sodium, nicardipine, and nitrates, his symptoms alleviated. On day 2, upper endoscopy revealed multiple gastric ulcers, and a proton pump inhibitor was administered. On day 3, severe upper abdominal pain recurred. Contrast-enhanced CT revealed a thrombus in the proximal SMA. Prostaglandin E1 was intravenously administered. On day 4, abdominal angiography was performed, revealing an occluded thrombus in the proximal SMA with developed circulation in peripheral intestinal arteries. The thrombus was successfully resolved by arterial administration of urokinase and a balloon catheter. On day 5, postoperative CT revealed dilated small bowels. Subsequently, an ileus tube was inserted. The overall clinical course was uneventful, and oral feeding along with oral administration of aspirin and warfarin was initiated on day 18.

We report the case of pancreatic adenosquamous carcinoma (PASC) that had penetrated into the stomach and transverse colon. A 55-yearold male presented to our hospital with general fatigue, melena, and left flank pain. He had no relevant medical history. A laboratory analysis upon arrival revealed marked anemia with a red blood cell count of 13.3 × 10 4 /μL and a hemoglobin level of 3.6 g/dL. There was tenderness over the upper abdomen and a palpable mass on his left upper abdomen. He was admitted for further examination of his severe anemia and abdominal symptoms. Contrast-enhanced computed tomography revealed multiple liver masses and a 10 cm sized tumor in the pancreas tail involving the gastric wall and transverse colon. Upper gastroendoscopy revealed a 4 cm sized elevated tumor with a central depression in the greater curvature of the middle gastric body. Colonoscopy revealed an ulcerative tumor extending from the splenic flexure to the mid transverse colon. Endoscopic biopsied specimens revealed adenosquamous cell carcinoma. From these findings, the diagnosis of PASC in the pancreatic tail invading into the stomach and transverse colon at an advanced stage IV was established. His anemia was treated by the administration of red blood cell concentration (RCC). Although chemotherapy was planned after his malnutrition improved, his circulatory condition worsened on day 20. Despite 10 units of RCC, his anemia did not improve and he died from circulatory insufficiency on day 23. An autopsy revealed PASC in the pancreas tail measuring 14 cm that had penetrated into the gastric wall and transverse colon. A massive amount of blood was discovered in the stomach. His death was caused by massive bleeding from the invaded lesions of the stomach. Adenosquamous carcinoma, consisting of adenocarcinoma and squamous cell carcinoma, is characterized by its aggressive proliferation and poor prognosis. To date, consensuses in the management of PASC have not been established. Further accumulation of knowledge about this carcinoma is required.