Presentation
Known case of atrial fibrillation complaining of right lower abdominal pain, associated with vomiting and constipation for 1 week.
Patient Data
FINDINGS: Mildly thickened non-enhancing cecum and ascending colon with pericolonic fat stranding. A few streaks of air are seen along the medial aspect of the ascending colon. A small air focus is seen in the superior mesenteric vein and multiple air foci are seen in the portal vein branches, mainly in the left hepatic lobe. No free air is seen in the remaining abdominopelvic cavity. No pericolic free fluid, collection, or lymphadenopathy is noted. Appendix is not visualized (past history of appendectomy). Extensive atherosclerotic changes are seen in the abdominal aorta and its branches; however, the mesenteric vessels are still patent. A small cortical cyst measuring about 1 cm, is seen in the left kidney. Peripheral calcifications are seen in the average size spleen showing homogeneous enhancement. Gallbladder, pancreas, and adrenals are normal. Mild bilateral basal atelectatic changes. Generalized osteopenia and degenerative changes are seen in the visualized skeleton.
IMPRESSION: Mildly thickened non-enhancing cecum and ascending colon with pericolonic fat stranding and air in the superior mesenteric & portal veins; these radiological features are suggestive of bowel Ischemia/ischemic colitis.
Case Discussion
- Labortaory investigation showed mild leukocytosis, high CRP, & normal lactic acid.
- Patient underwent urgent exploratory laparotomy which showed dusky grey appearance of the terminal ileum, cecum and ascending colon with foul odor. 20cm of terminal ileum and the whole ascending colon till hepatic flexure was resected (right hemicolectomy with side-to-side ileo-transverse anastomosis).
- Histopathology: Transmural ischemic necrosis of the large bowel with probable perforation, serosal adhesions and congestion. Intravascular thrombosis with extension of acute inflammation in to the mesenteric fat. No significant abnormality seen in the terminal ileum.