Small bowel infarction

Case contributed by Dr Wayland Wang

Presentation

Abdominal pain, melaena and haematemesis.

Patient Data

Age: 65 years
Gender: Male
CT

Noncontrast, arterial and portal venous phase imaging through the abdomen and pelvis has been performed.

Mesenteric ischemia involving an extensive segment of small bowel with mural non-enhancement of the affected segment, intramural, mesenteric and portal venous gas. Gas is seen within the branches of the superior mesenteric vein, the main portal vein extending into right and left lobes of the liver predominantly located in the antedependent parts of the liver. Intramural gas is also seen within the distal esophagus and grossly distended stomach wall. Duodenum and proximal jejunum demonstrate circumferential bowel wall thickening with some wall enhancement suggestive of mucosal ischemia without established infarction.

Within the thick walled loops of bowel, hyperdense material is identified presumably representing blood products. No contrast blush to indicate active contrast extravasation.

Extensive vascular calcification is noted with calcific plaques at the ostium of the celiac axis and further calcific plaques almost completely occluding the left gastric artery. Calcific plaque is also seen at the origin of the superior mesenteric artery with approximately 50% ostial stenosis with further segmental near occlusive calcification and hypodense material (presumably representing plaque or embolic material) 7 cm distal to the origin. Some contrast however is seen within the distal mesenteric vascular arcades. The inferior mesenteric artery becomes occluded 1 cm distal to a tightly stenosed origin. The superior mesenteric vein opacifies downstream with the upstream tributaries containing gas. No thrombus is demonstrated. The SMA and SMV maintain anatomical orientation without evidence of mid gut malrotation or volvulus.

Opacification of the renal arteries is relatively symmetrical with bilateral renal ostial stenoses secondary to calcific plaque (~60% on the left and ~50% on the right.) Wedge shaped peripheral area of non-enhancement within the superior pole of the right kidney consistent with infarction. Incidental note made of a 4 x 4.5 x 6 .5 cm of right inferior pole renal solid mass. No evidence of renal vein invasion.

Evidence of previous aorto-bi-femoral bypass grafts with the right iliac limb occluded and bypasses by a patent femoro-femoral cross-over graft. Moderate amount of peritoneal free fluid is noted. The IVC is flattened consistent with severe hypovolemia.

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Case information

rID: 50761
Published: 27th Mar 2018
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included

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