Intestinal ischemia refers to vascular compromise of the bowel which in the acute setting has a very high mortality if not treated expediently. Diagnosis is often straightforward, provided appropriate imaging is obtained and sometimes subtle findings sought out. The disease can be arbitrarily classified into broad groups according to time of onset, or the portion of bowel involved or the underlying cause.
- acute or chronic
- occlusive or non-occlusive
- small bowel or large bowel
- superior mesenteric artery or vein occlusion
- small bowel obstruction
This article is a general discussion. For discussion of specific types of intestinal ischemia, please refer to the following:
- acute superior mesenteric artery occlusion
- acute superior mesenteric vein occlusion
- small bowel ischemia
- large bowel ischemia (ischemic colitis)
- small bowel obstruction
- chronic intestinal ischemia
The presentation can vary with the underlying cause. Severe abdominal pain that is disproportionate to examination findings and that responds poorly to analgesia is a classic mode of presentation.
A raised lactate or metabolic acidosis can be suggestive lab findings.
Impairment of normal vascular supply can result from a number of insults including:
- general hypotension/hypoxia especially in the setting of arterial insufficiency due to stenosis
- arterial occlusion
- bowel obstruction
- venous outflow obstruction
In other words anything which result in a deficiency in the normal supply of blood and metabolites to the bowel can result in ischemia.
Bowel ischemia severity ranges from mild (generally transient superficial changes of intestinal mucosa) to more dangerous and potentially life-threatening transmural bowel wall necrosis 1. If ischemia is severe enough, and is not relieved quickly, then a predictable sequence of events will usually be observed:
- necrosis of the bowel wall
- bacteria proliferation in the bowel wall, releasing gas in the wall itself (pneumatosis intestinalis)
- gas goes through mesenteric vessels into portal vein (pneumatosis portalis)
- sepsis and/or intestinal perforation
Although historically catheter angiography was the gold standard for imaging of suspected intestinal ischemia, CT has replaced it, with its ability to volumetrically assess the whole abdomen in multiple vascular phases, e.g. arterial, portal venous, delayed. It also has the added advantage of being able to diagnose alternative causes of acute abdominal pain. As such CT is now the investigation of choice for patients with suspected intestinal ischemia.
In general CT of the abdomen and pelvis should be performed with intravenous contrast and a neutral luminal contrast (e.g. water) so that bowel wall enhancement and thickness can be adequately assessed 7. Ideally, positive oral contrast is best avoided to better delineate wall enhancement. Administration of positive rectal contrast may help define colonic wall thickening, but is more useful when it is the distal colon which is affected (inferior mesenteric artery) - see ischemic colitis.
Multiple contrast phases are typically obtained:
- non-contrast (some studies demonstrate that this phase is not necessary for the diagnosis of acute mesenteric ischemia 10)
- arterial phase (e.g. triggered when abdominal aorta reaches >100 HU)
- portal venous phase, e.g. 30 seconds after arterial phase finishes
Imaging features can vary depending on the time course and etiology, and are therefore discussed separately in the articles above. A number of features are however common to most advanced acute cases and result from the bowel wall necrosis and perforation:
- pneumatosis intestinalis: gas in intestinal wall
pneumatosis portalis: gas in the portal vein or in mesenteric vein
- can be differentiated by pneumobilia because gas usually reaches the periphery of the liver while pneumobilia is usually about 2 cm short of external liver border, and is more clustered at the hilum
- pneumoperitoneum: perforation of the bowel
- submucosal hemorrhage: sensitivity for diagnosis is low (10%) with all true-positive cases having other CT findings present at diagnosis 10
- variable amounts of free fluid
It is important to note that bowel wall thickness is not increased in all causes, and can in fact be thinned in complete arterial occlusion or bowel obstruction 7.
Dual energy CT
The addition of iodine maps and 40-keV monoenergetic images to standard single energy CT images was found to increase reader confidence and accuracy in diagnosing acute bowel ischemia. Ischemic segments have been found to have lower densities and iodine concentrations compared to non-ischemic segments 12.
Treatment and prognosis
Although treatment will vary according to the severity and cause of the ischemia, in general treatment is surgical. The bowel needs to be assessed for viability and if necrotic needs to be resected.
In some instances endovascular thrombolysis/thrombectomy may be beneficial 8.
- 1. Wiesner W, Khurana B, Ji H et-al. CT of acute bowel ischemia. Radiology. 2003;226 (3): 635-50. doi:10.1148/radiol.2263011540 - Pubmed citation
- 2. Rha SE, Ha HK, Lee SH et-al. CT and MR imaging findings of bowel ischemia from various primary causes. Radiographics. 20 (1): 29-42. Radiographics (full text) - Pubmed citation
- 3. Cognet F, Ben salem D, Dranssart M et-al. Chronic mesenteric ischemia: imaging and percutaneous treatment. Radiographics. 22 (4): 863-79. Radiographics (full text) - Pubmed citation
- 4. Shih MC, Hagspiel KD. CTA and MRA in mesenteric ischemia: part 1, Role in diagnosis and differential diagnosis. AJR Am J Roentgenol. 2007;188 (2): 452-61. doi:10.2214/AJR.05.1167 - Pubmed citation
- 5. De filippo M, Sagone C, Zompatori M. Unenhanced MDCT findings of acute bowel ischemia. AJR Am J Roentgenol. 2008;190 (4): W271. doi:10.2214/AJR.07.3064 - Pubmed citation
- 6. Chou CK. CT manifestations of bowel ischemia. AJR Am J Roentgenol. 2002;178 (1): 87-91. AJR Am J Roentgenol (full text) - Pubmed citation
- 7. Furukawa A, Kanasaki S, Kono N et-al. CT diagnosis of acute mesenteric ischemia from various causes. AJR Am J Roentgenol. 2009;192 (2): 408-16. doi:10.2214/AJR.08.1138 - Pubmed citation
- 8. Goldberg MF, Kim HS. Treatment of acute superior mesenteric vein thrombosis with percutaneous techniques. AJR Am J Roentgenol. 2003;181 (5): 1305-7. AJR Am J Roentgenol (citation) - Pubmed citation
- 9. Rha SE, Ha HK, Lee SH et-al. CT and MR imaging findings of bowel ischemia from various primary causes. Radiographics. 20 (1): 29-42. Radiographics (citation) - Pubmed citation
- 10. Schieda N, Fasih N, Shabana W. Triphasic CT in the diagnosis of acute mesenteric ischaemia. Eur Radiol. 2013;23 (7): 1891-900. doi:10.1007/s00330-013-2797-y - Pubmed citation
- 11. Sugi MD, Menias CO, Lubner MG, Bhalla S, Mellnick VM, Kwon MH, Katz DS. CT Findings of Acute Small-Bowel Entities. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (5): 1352-1369. doi:10.1148/rg.2018170148 - Pubmed
- 12. Lourenco PDM, Rawski R, Mohammed MF, Khosa F, Nicolaou S, McLaughlin P. Dual-Energy CT Iodine Mapping and 40-keV Monoenergetic Applications in the Diagnosis of Acute Bowel Ischemia. (2018) AJR. American journal of roentgenology. 211 (3): 564-570. doi:10.2214/AJR.18.19554 - Pubmed