Teaching Case

A 81-year-old male patient presented with a 2-day history of abdominal pain and constipation.
His past medical history was significant for ischaemic heart disease, atrial fibrillation, renal failure and chronic obstructive pulmonary disease.
Past surgical history of coronary artery bypass grafting.

A physical examination showed a distended abdomen with tympanic resonance on percussion.

Plain X-ray abdomen supine and semi-sitting positions show distended small bowel loops with no evidence of acute intestinal obstruction or perforation.
Gastro-jejunostomy tube tip in the left upper quadrant.
Left hip joint partial replacement.

Ct abdomen/pelvis with I.V. and oral contrast showed mildly distended small and large bowel loops with no features of bowel obstruction.

Portal venous gas with preferential affection of the left hepatic lobe.
Streaky linear gas at the splanchnic vein and its tributaries (inferior mesenteric vein & superior mesenteric vein).
Intramural bowel gas with no appreciable mural enhancement in most of the small and large bowel loops.

Calcification of the wall of abdominal aorta and coeliac artery with near-total occlusion of the distal part of the superior mesenteric artery. No thrombosis in the superior mesenteric artery.

Impression:
Findings are indicative of advanced bowel ischaemia / gangrene.

Laparotomy was done with resection of distal jejunum and ileum with side to side anastomosis.

Mesenteric ischaemia is characterized by inadequate blood flow to or from the involved mesenteric vessels supplying a particular segment of the bowel [1].

Abdominal pain is the most common presenting symptom in patients with intestinal ischaemia [2].

Rapid diagnosis is essential among patients with clinical features and risk factors suggestive of acute intestinal ischeamia to reduce the potential for intestinal infarction [2].

Plain abdominal radiography is relatively nonspecific and may be completely normal in more than 25 percent of patients. Findings suggestive of mesenteric ischaemia include the presence of an ileus with distended bowel loops, bowel wall thickening and/or pneumatosis intestinalis. Obvious findings, such as free intraperitoneal air, indicate the need for immediate abdominal exploration [2].

The use of water as oral contrast medium allows better assessment of the bowel wall. A rapidly administered IV bolus of contrast medium and dual-phase imaging are required for accurate mesenteric vessel evaluation [3].
The origins of the coeliac axis and superior mesenteric artery should also be evaluated for the presence of calcification that indicates an underlying atherosclerotic process as a possible aetiology for mesenteric ischaemia [2].
Mesenteric venous thrombosis may be diagnosed with CT angiography or conventional arteriography by performing delayed images [2].

In patients with non-occlusive mesenteric ischaemia (NOMI), angiography can demonstrate areas of segmental narrowing in major branches with a string-of-beads appearance and decreased or absent flow in the smaller blood vessels [2].

The goal of treatment in acute intestinal ischaemia is to restore intestinal blood flow rapidly after initial supportive management [2].

Conclusion:
Timing, proper diagnosis and early management are major factors to improve the prognosis of ischaemic bowel disease. [4]
It is important to be aware of different causes and complications of ischaemic bowel disease and to recognise its characteristic radiological manifestations in both X-ray and CT angiography. [4]