Ischaemic small bowel

Case contributed by Dr Jeremy Jones

Presentation

Admitted with abdominal pain and distension. Initially managed conservatively, but worsening pain.

Patient Data

Age: 78
Gender: Female

Admission plain film

Modality: X-ray

No evidence of perforation or obstruction.  Solitary loop of small bowel in the right iliac fossa.

Blood results:

  • Na: 132
  • K: 5.2
  • Urea: 36
  • Creatinie: 160
  • eGFR: 22
  • Lactate: 4.5
  • pH: 7.2

Scanned after symptoms worsened and blood results returned.

Modality: CT

.

Case Discussion

Grossly abnormal small bowel. Jejunal loops are dilated with minimal wall enhancement and mesenteric gas consistent with infarction (series 1; image 50). The proximal ileum has a 30 cm segment of enhancing bowel, but the remainder of the ileum (apart from the most distal 30 cm) is nonenhancing and dilated consistent with infarction. The terminal 30 cm of ileum enhances and is collapsed. No mechanical cause for obstruction demonstrated.

No free intraperitoneal gas. Free fluid which is predominately right-sided and peri-hepatic. Normal appearances of the caecum and large bowel. The stomach and duodenum are markedly dilated but enhance normally. Small hiatus hernia.

Gas within the portal vein at the SMV/splenic vein confluence extra-vascular gas tracking anterior to the SMV within the mesentery (image 38). Multifocal linear gas lucencies peripherally within the liver represent portal venous gas.

Slit-like IVC consistent with significant intravascular depletion. Heavily calcified aorta with calcification around the coeliac and mesenteric ostia. Heavily calcified SMA with calcification and a significantly reduced calibre.

Both kidneys are small: normal enhancement on the left, but multifocal areas of reduced enhancement on the right consistent with ischaemia/infarction although it is difficult to determine if this is acute (normal enhancement in 2008). No upper tract dilatation.

Hypodense mass within the right adrenal measures 2.5 x 1 .5 cm; it may be an adrenal adenoma, but has not been fully characterised on this study. Normal is pancreas apart from two small (5 mm) cysts in the head. Normal liver, spleen and left adrenal. Normal gallbladder and biliary tree.

Urinary bladder collapsed around catheter. Anteriorly within the lower pelvis are multiple flecks of gas. On the coronal imaging, these appear in continuity with the bladder. Hysterectomy and bilateral salpingo-oophorectomy.

Lung bases are clear. Background chronic changes but no consolidation. Tiny trace of pleural fluid on the right.

CONCLUSION :

  1. Two large segments of ischaemic small bowel (jejunum and a large proportion of ileum). Small-volume jejunal mural gas with mesenteric and portal venous gas, but no perforation. Heavily calcified mesenteric vessels make thromboembolic disease the most likely cause.
  2. Small bowel dilatation (with stomach and duodenal dilatation); no mechanical cause. NG tube would be helpful to decompress the stomach.
  3. Significant intra-vascular fluid depletion; right renal parenchymal ischaemia may be acute.
  4. No evidence of abdominal malignancy (a concern voiced by the surgical team).
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Case Information

rID: 16575
Case created: 30th Jan 2012
Last edited: 17th May 2016
Inclusion in quiz mode: Included

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