Presentation
Diabetic hypertensive patient presented at ER with severe abdominal pain and vomiting
Patient Data
SCOUT IMAGE
Significant proximal bowel loops dilatation with concertina sign
No significant air-fluid levels
NGT is seen in situ
Partially occlusive thrombus of the proximal SMA. Just distal to its origin there is a filling defect occluding 80-90% of the lumen and encroaching mainly on jejunal branches sparing ileal branches, right middle colic, ileocolic, and right colic arteries.
Additional findings:
There is edematous wall thickening of mid, distal jejunal as well as proximal ileal loops (maximum thickness about 12 mm) associated with subtle blurring of surrounding fat planes, moreover reduced wall enhancement as well as minimal intra-mural gases foci (pneumatosis intestinalis)- representing early ischemic changes.
Significantly distended stomach with NGT in situ as well as moderate dilatation of proximal small bowel loops.
No portal venous air.
Minimal to mild free fluid mainly at the pelvis.
These features are consistent with acute mesenteric ischemia due to superior mesenteric artery thrombosis with early ischemic bowel loops.
SMA thrombus (blue arrow)
Non opacified jejunal branches (red arrow)
Minimal intramural gases (pneumatosis intestinalis) (black arrow)
Intra-operative images
Intra-operative photos show clear demarcation between the pink color of viable distal ileal loops and dark gangrenous jejunal loops.
Intraoperative photos courtesy of Dr Adel Abdelwahed.
Case Discussion
This is a very tricky case with unexpected outcomes radiologically. The patient is in his 6th decade, presented with rigid abdomen, no cardiac disease or relevant past history. Why would anyone expect mesenteric ischemia on such a presentation? One important clinical sign is present and could be helpful: the pain is not relieved by analgesics.
In this case, we note how mild bowel changes are in acute arterial ischemia, the affected bowel wall was slightly thickened and the pneumatosis intestinalis was very subtle.
This is completely different from acute venous ischemia in which there is marked wall thickening, intramural hemorrhage, and blurred edematous mesenteric fat.
Multidetector CT is the most sensitive and specific diagnostic tool for acute mesenteric ischemia (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. In a routine single-phase portal venous CT study, the mission will be more and more difficult as the degree of arterial enhancement will not be conclusive.
Against medical expectations, the patient survived postoperatively and was uneventfully discharged.
Unable to process the form. Check for errors and try again.