Large bowel watershed ischaemia

Case contributed by Dr Craig Hacking

Presentation

PR bleeding, diarrhoea and abdominal pain. GIT bleeding protocol.

Patient Data

Age: 82
Gender: Male
Modality: CT

No active large or small bowel haemorrhage identified. There is a long segment of transverse and descending colon circumferential wall thickening with pericolic fat stranding. No pneumatosis or portal venous gas. No focal mass, stricture or obstruction evident. There are occasional diverticula in the transverse and descending colon, with more numerous uncomplicated diverticula in the sigmoid colon. The remainder of the large bowel is normal. The terminal ilium and remainder of the small bowel is unremarkable also.

No retroperitoneal or mesenteric lymphadenopathy. The aorta is moderately calcified and there is a probable high grade stenosis at the origin of the inferior mesenteric artery. No filling defect identified within the branches of the superior mesenteric artery.

Minor extrahepatic and left intrahepatic bile duct dilatation is within normal limits for cholecystectomy status and the patient's age. Simple cysts in both kidneys. The adrenal glands, spleen and pancreas are normal. No free gas.

Small incidental calcified granuloma in the middle lobe. The lung bases are otherwise clear. No basal pleural effusion. No bony abnormality.

Conclusion

Long segment of transverse and descending colon wall thickening and surrounding pericolic inflammatory stranding is in the typical distribution for watershed ischaemia, particularly given the likely a high-grade stenosis of the origin of the inferior mesenteric artery.

Case Discussion

In an elderly vasculopath, colitis in this distribution is typical for ischaemia in the SMA/IMA watershed territory.

The lactate was mildly elevated.

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Case Information

rID: 38365
Case created: 16th Jul 2015
Last edited: 28th Aug 2015
Inclusion in quiz mode: Included

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