Acute arterial mesenteric ischemia

Case contributed by Dr Ahmed Abdelrahman


Known case of atrial fibrillation, admitted as case of cerebral ischemic stroke, then he developed acute abdominal pain.

Patient Data

Age: 75 years
Gender: Male

There is decreased wall enhancement of distal small bowel loops compared to the proximal loops, with total occlusion of the distal superior mesenteric artery. No pneumatosis intestinale, portal venous gas or pneumoperitoneum.

There is also total occlusion of the left renal artery, with delayed global parenchymal enhancement of the left kidney and also demonstrates multifocal wedge-areas of no enhancement indicative of left renal ischemia.  Absent contrast excretion by the left kidney as well in the delayed phase.

Operative notes: Non-viable small bowel 250 cm from DJ junction. Cecum & ascending colon were also dusky & necrotic. Distal small bowels, cecum & ascending colon were resected. Photo courtesy of Dr Alwayah Alahmed

Histopathology report: Extensive mucosal necrosis affecting cecum,  small intestine & appendix with submucosal vascular congestion and edema.

Case Discussion

Acute mesenteric ischemia (AMI) is a life threatening condition. Arterial embolism is the most common cause of acute mesenteric ischemia (representing about 40%–50% of all AMI cases) which is usually resulted from emboli of cardiac origin, including atrial thrombi associated with atrial fibrillation.
Multidetector CT is the most sensitive and specific diagnostic tool for AMI and should be used as the first-line imaging modality when AMI is suspected. Findings at multidetector CT can help exclude other causes of acute abdominal pain as well.

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