Ischaemic gut

Case contributed by Dr Henry Knipe

Presentation

Acute abdomen. Nausea/vomiting.

Patient Data

Age: 75
Gender: Male

Abdomen/Pelvis

Modality: CT

Abdominal aortic luminal narrowing secondary to mural thrombosis including severe stenosis at the origin of the coeliac trunk and SMA where there is very poor/no opacification (indicating near or total occlusion) of these vessels. Extensive calcification along their path. The inferior mesenteric artery is not well seen.

Stomach and small bowel wall is non-enhancing with areas of pneumatosis intestinalis especially in the distal jejunum and ileum without obvious dilated with multiple air fluid levels. No free gas or free fluid.

Liver and spleen are hypoenhancing. Adrenal glands are hyperenhancing. Kidneys are atrophic with bilateral striated nephrograms. They both demonstrate multiple simple appearing cysts. Left renal pelvis calculus.

Bilateral pleural effusions, larger on the right. Dependent pulmonary atelectasis in both lung bases.

False aneurysm at the aortic bifurcations extending down both common iliac arteries and into the internal iliac arteries both of which do not opacify, with an aneurysm of the left. Extensive reflux of contrast down the IVC to the level of the femoral veins.

Conclusion:

Findings are consistent with bowel ischaemia (and almost certainly areas of extensive infarction of small bowel given that there are areas of pneumoatosis) with evidence of severe hypotension. There may also be a degree of liver and spleen hypoperfusion. No perforation at this stage. Proximal SMA thrombosis noted, this being the likely underlying cause.     

Case Discussion

Patient died shortly after the CT scan. Key learning points:

  • signs of severe hypotension in this case are: hyperenhancing adrenal glands (preferential blood flow); hypoenhancement of the liver and spleen (subjective) and bilateral striated nephrograms
  • pneumatosis intestinalis is a sign of bowel infarction (but can have other causes)
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Case Information

rID: 28176
Case created: 13th Mar 2014
Last edited: 15th May 2016
Inclusion in quiz mode: Included

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