CASE 12669 Published on 26.06.2015

Acute intestinal ischaemia

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Carmen Salvan-Schaschl1, Christian Schnedl2, Marton Magyar3

(1) Division of General Radiology
(2) Division of Vascular and Interventional Radiology
(3) Division of Neuroradiology
Department of Radiology,
Medical University of Graz, Austria
Patient

77 years, male

Categories
Area of Interest Abdomen, Veins / Vena cava ; Imaging Technique Conventional radiography, CT
Clinical History
A 77-year-old patient with a known history of hypertension, presented with diffuse abdominal pain and meteorism, occurring during hospitalization for an intracerebral haemorrhage of the left basal ganglia with right hemiparesis and inability to swallow.
Imaging Findings
The patient was primarily sent for a conventional abdominal X-ray examination showing multiple air-fluid levels in both small and large bowel as well as a distended large bowel, suggesting a paralytic ileus. However, based on the clinical history, a CT examination was suggested. This confirmed the multiple air-fluid levels in the whole gastro-intestinal tract and bowel dilatation with paralytic ileus, but also showed atherosclerotic calcification, with absent enhancement of a short segment of the small bowel as well as parietal pneumatosis of the ascending colon suggesting bowel infarction. There was also air in the intrahepatic portal branches, as sure sign of mesenteric infarction, indicating a disease with advanced stage. No pneumoperitoneum or retropneumoperitoneum was seen.
Discussion
Occlusive and non-occlusive causes are recognized for intestinal ischaemia [1, 2, 3].
Clinical signs and symptoms are often nonspecific [2]. It is associated, especially in elderly patients, with other comorbidities [2, 4, 5] such as cardiac pathology – atrial fibrillation, aneurysmas of the aorta and abdominal vessels, [1, 4], hypovolaemic shock, heat failure [1, 6], heart operation [7], hypovolaemia associated with pancreatitis, haemorrhage, sepsis, cirrhosis [6].
In 95% of cases, the mesenteric ischaemia is acute [2], being arterial or venous in origin [1, 2], divided in 4 categories [2]: embolic occlusion of the superior mesenteric artery, acute mesenteric arterial thrombosis, non-occlusive mesenteric ischaemia and mesenteric venous thrombosis.
Occlusive causes include emboli or thombi with occlusion of the arterial or venous vessels [1, 2, 4, 5]. Non-occlusive causes [1, 2, 3, 4, 6] can be generated by reduction of blood flow and generalized atherosclerotic disease.
Even if the native CT examination can depict submucosal haemorrhage, thrombi and atherosclerotic calcifications [1], the enhanced MD-CT is favoured (arterial phase with detection of arterial stenosis, thrombi, occlusion; venous phase with evaluation of venous thrombosis) [1].
The CT findings include intestinal changes (wall thickening, abnormal mural enhancement, bowel dilatation, pneumatosis), vascular (arterial embolus, arterial thrombus, mesenteric venous thrombus, portomesenteric venous gas, occlusion or severe stenosis in at least two major splachnic arteries) and mesenteric changes (fat stranding, free fluid, free air) [2].
There are different phases of the disease, beginning with spasm of the involved loops [1, 2, 3], absence of enhancement or wall thickening in early stages, hypotonic bowel dilatation [1], ischaemia with intramural air (parietal pneumatosis) [1, 8], intraluminal air in the mesenteric and portal branches [1] as a sign of infarction [1] and very advanced phase, and necrosis. The only pathognomonic sign of transmural necrosis is bowel perforation with pneumo-/retropneumoperitoneum [1]. Parietal and porto-mesenteric pneumatosis and pneumoperitoneum are indicative for an unfavourable outcome [1, 9] and associated with high mortality [1].
Differential diagnosis are multiple, beginning with wall thickening of the bowel seen in tumours, and with hyperenhancement in ischaemic but also in inflammatory disease such as colitis, Morbus Crohn, abscess; however the clinical history and localisation are contributing to the diagnosis, too. The absence of enhancement suggests mesenteric vessel occlusion or bowel obstruction [1]. Iatrogenic visceral dilation, blunt trauma, paralytic and mechanical ileus or infectious processes can cause portomesenteric venous gas [1].
Prompt, early diagnosis is crucial for therapy and patient outcome [1, 2].
Differential Diagnosis List
Acute intestinal ischaemia with mesenteric infarction
Chronic intestinal ischemia
Ogilvie syndrome
Colitis
Morbus Crohn
Non-traumatic abdominal compartment syndrome
Final Diagnosis
Acute intestinal ischaemia with mesenteric infarction
Case information
URL: https://eurorad.org/case/12669
DOI: 10.1594/EURORAD/CASE.12669
ISSN: 1563-4086
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