Small bowel ischemia

Case contributed by Dr Matt Adams

Presentation

Severe generalized abdominal pain. Multiple comorbidities including end stage renal failure and atrial fibrillation.

Patient Data

Age: 45 years
Gender: Male
CT

Initial CT scout images

The initial CT scout image shows dilated loops of small bowel with multiple air-fluid levels. Pneumatosis intestinalis (intramural gas) can be identified on the right side of the abdomen.

CT

Three phase abdominal CT

Distended small bowel loops (diameter 40mm) with caliber change approximately 5cm proximal to the ileocecal valve. Loss of bowel enhancement and pneumatosis intestinalis of the distal small bowel and cecum.

Portal venous gas both within the mesenteric vessels and peripherally in the liver.
No evidence of vascular filling defects, particularly of the superior mesenteric artery or vein to suggest embolic or thrombotic occlusions.

Small volume free fluid, but no convincing evidence of free intraperitoneal gas (extraluminal gas appears to be intramural or intravascular).

Extensive calcific atherosclerotic changes of the abdominal aorta and the majority of the arteries within the abdomen and pelvis.

Innumerable small calcifications throughout the pancreas, consistent with chronic pancreatitis.

Longstanding bilateral renal atrophy compared with prior imaging (not shown).

Flattened appearance of the IVC.

Case Discussion

This case highlights the striking changes that can occur with bowel ischemia and the use of the CT scout image when observing the patient being scanned in real-time. The patient underwent an emergency laparotomy with over a meter of infarcted bowel resected extending to the ascending colon. No underlying obstruction or acute vascular cause was identified. Unfortunately, the individual did not recover from their ischemic bowel and passed away several days following.

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Case information

rID: 75965
Published: 10th Apr 2020
Last edited: 8th May 2020
Inclusion in quiz mode: Included

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