Large bowel watershed ischemia

Case contributed by Craig Hacking


Per rectal bleeding, diarrhea and abdominal pain.

Patient Data

Age: 85 years
Gender: Male

No active large or small bowel hemorrhage 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.


Long segment of transverse and descending colon wall thickening and surrounding pericolic inflammatory stranding is in the typical distribution for watershed ischemia, 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 ischemia in the SMA/IMA watershed territory.

The lactate was mildly elevated.

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