Presentation
Abdominal pain.
Patient Data
Medium pleural effusions with left lower lobe consolidation.
Diffuse dilation of much of the bowel with fluid. Abrupt occlusion of the proximal SMA (see arterial images). Mild mesenteric edema. Absent enhancement of much of the small bowel, best compared on coronal images where there is normal enhancement of the duodenal sweep and proximal jejunum.
Irregular GEJ mass with gastrohepatic ligament adenopathy (likely adenocarcinoma).
Case Discussion
Sometimes in radiology, it can be hard to see what's not there. In cases of acute SMA ischemia, the bowel wall does not become thickened but instead becomes relatively thin and hypoenhancing, and may be hard to notice at first glance. The wall does not become thickened until there is reperfusion injury (or more typically when there is venous ischemia). When a long segment is involved as in this case, it can be hard to appreciate the absence of enhancement as so much bowel is abnormal. Finding a few "internal controls" can be helpful, such as the duodenum and jejunum in this case. Also note the GEJ mass and gastrohepatic ligament adenopathy typical of esophageal adenocarcinoma.
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