Bowel infarction

Case contributed by RMH Core Conditions

Presentation

Abdominal pain. History of melena and haematemesis.

Patient Data

Age: 72
Gender: Male
CT

Mesenteric ischaemia involving an extensive segment of small bowel with mural non-enhancement of the affected segment, intramural, mesenteric and portal venous gas.

Gas is seen within the branches of the superior mesenteric vein, the main portal vein extending into right and left lobes of the liver predominantly located in the antedependent left and medial right lobes of the liver.

Intramural gas is also seen within the distal oesophagus and grossly distended stomach wall.

Duodenum and proximal jejunum demonstrate circumferential bowel wall thickening with some wall enhancement suggestive of mucosal ischaemia without established infarction.

Within the thick walled loops of bowel, hyperdense material is identified presumably representing blood products.

No evidence of a contrast blush to suggest active contrast extravasation.

Extensive vascular calcification is noted with calcific plaques at the ostium of the coeliac axis and further calcific plaques almost completely occluding the left gastric artery.

Calcific plaque is also seen at the origin of the superior mesenteric artery with approximately 50% osteal stenosis with further segmental near occlusive calcification and hypodense material (presumably representing plaque or embolic material) 7 cm distal to the origin.

Some contrast however is seen within the distal mesenteric vascular arcades. The inferior mesenteric artery becomes occluded 1 cm distal to a tightly stenosed origin. The superior mesenteric vein opacifies it distally with the more proximal tribute trees containing gas. No thrombus is observed.

The SMA and SMV maintain anatomical orientation without evidence of mid gut malrotation and volvulus.

Wedge shaped peripheral area of non-enhancement within the superior pole of the right kidney consistent with infarction.

Incidental note made of a 4 x 4.5 x 6 .5 cm of right inferior pole renal solid mass most likely representing a renal cell carcinoma.

Evidence of previous aorto bi-femoral bypass grafts with the right iliac limb occluded and bypasses by a patent femoro-femoral cross over graft.

Moderate amount of free intra-abdominal fluid is noted.

The IVC is flattened consistent with severe hypovolaemia.

Conclusion

  1. Mesenteric infarction of a long segment of small bowel with intramural, mesenteric and portal venous gas. Intramural gas within grossly distended stomach and oesophagus representing further ischaemia.
  2. Blood products within the lumen of circumferentially thickened duodenum and proximal jejunum representing further ischaemia without transmural end-stage infarction at this stage.
  3. Extensive atheromatous disease with calcific plaque within the left gastric artery and the SMA.
  4. Approximately 50% SMA osteal stenosis with further segmental near occlusive calcification and hypodense material (presumably representing plaque or embolic material) 7 cm distal to the origin. However some contrast is seen within the distal mesenteric vascular arcades.
  5. Right renal infarct and incidental right solid renal mass most likely representing a renal cell carcinoma.
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Case information

rID: 30296
Case created: 1st Aug 2014
Last edited: 8th Nov 2015
Inclusion in quiz mode: Included

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