Small bowel ischemia with bowel obstruction

Case contributed by Dr Ammar Ashraf

Presentation

Sudden severe abdominal pain (para-umbilical) for 5 hours, associated with nausea and poor oral intake. No fever or change in bowel habits. Known case of chronic atrial fibrillation, hypertension, and COPD (non-compliant to the treatment).

Patient Data

Age: 85 Years
Gender: Female

Findings:  Atherosclerotic changes are seen in the major vessels of the abdomen and pelvis with mild stenosis at the origin of the superior mesenteric artery. An abrupt filling defect is seen within the distal segment of the superior mesenteric artery most likely related to thromboembolic event. Relatively decreased mucosal enhancement and subtle mural thickening are seen in the distal ileum. No abnormal bowel dilatation, free fluid, pneumatosis intestinalis, or pneumoperitoneum is seen. Surgical sutures are seen around the ileum (past history of strangulated right femoral hernia with resection of a small segment of proximal ileum & primary re-anastomosis). The right kidney is relatively smaller, with an irregular outline and parenchymal thinning. Multiple small hyper enhancing focal lesions are noted in the liver, which are likely flash filling hepatic hemangiomas. Markedly dilated right atrium and hypertrophied left ventricular wall. Small hiatal hernia. Ectatic thecal sac in the lower lumbar spine. 

Impression:  An abrupt filling defect in the distal segment of the SMA with relatively decreased mucosal enhancement and subtle mural thickening in the distal ileum; these radiological features are suggestive of acute small bowel ischemia.

Follow up CT after 5 days

CT

Findings: There is a re-demonstration of the occluded distal segment of the SMA. A non-enhancing small bowel segment (distal ileum) with fat stranding in the surrounding mesentery is noted.  There is interval development of diffuse small bowel dilatation. There is also interval development of moderate bilateral pleural effusions with changes of collapse/consolidation in the underlying bilateral lower lobes.

Case Discussion

The patient underwent diagnostic laparoscopy after the initial CT scan which showed a mildly pale and dusky distal ileal loop (100 cm proximal to the ileocecal valve) without any frank evidence of ischemia. Due to the lack of bowel ischemia, the patient was managed conservatively.

5 days later, the patient’s general condition deteriorated (tachycardia, anuria, septic shock, and severe metabolic acidosis). CT scan was repeated which showed small bowel ischemia with bowel obstruction. Exploratory laparotomy was done which showed a one-meter long gangrenous ileal loop 20 cm proximal to the ileocecal junction. The diseased bowel segment was resected with end to end anastomosis. 

Pathological analysis of the resected bowel segment showed mucosal and full-thickness necrosis of the small bowel consistent with bowel ischemia.

Postoperatively, no improvement was seen in metabolic acidosis and 2 days later, she had a cardiac arrest and died.

 

 

 

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