Bowel ischemia secondary to SMA occlusion with extensive portomesenteric venous gas

Case contributed by Dr Benedikt Beilstein


Elderly patient presenting to the ER with rigid abdomen, pain and vomiting. History of dementia with a long history of atrial fibrillation and multiple other cardiac risk factors. Elevated lactate level on ABG.

Patient Data

Age: 85
Gender: Male

FINDINGS: Contrast enhanced CT shows complete occlusion of the SMA ~4 cm distal to its origin (nicely demonstrated on the VRT reconstruction) with subsequent pneumatosis intestinalis of large portions of the small bowel and the proximal half of the large bowel. Extensive gas filled tributaries of the superior mesenteric vein are seen. Portal venous gas is also visualized, predominantly in the left liver lobe. Wedge-shaped splenic hypoperfusion dorso-apical consistent with a small splenic infarction. Traces of free fluid down the paracolic gutter on the right.

Secondary findings include atelectatic lung, a 10 mm left lower lobe pulmonary nodule measuring 10 mm in the left lower lobe dorsally, advanced arteriosclerosis and degenerative as well as osteopenic skeletal changes, renal atrophy with a calcified cyst on the right.

CONCLUSION: Fulminant bowel ischemia due to proximal, thromboembolic SMA occlusion resulting in pneumatosis intestinalis, and extensive portomesenteric venous gas.



Unsurprisingly, the above findings were not compatible with life and the patient died a short time after the CT was performed.

Case Discussion

This case nicely demonstrates the typical sequelae of severe bowel wall ischemia and necrosis with subsequent loss of integrity and barrier function of the bowel wall, as evidenced by the pneumatosis intestinalis and extensive portomesenteric venous gas. This patient suffered from longstanding atrial fibrillation, the likely main contributor to the thromboembolic occlusion of the SMA.

The peripheral distribution of intrahepatic gas makes it easy to distinguish from aerobilia, which is usually located centrally.

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