Small bowel/mesenteric ischemia due to SMA embolus

Case contributed by Michael P Hartung
Diagnosis certain

Presentation

Abdominal pain.

Patient Data

Age: 65 years
Gender: Male

Focal eccentric narrowing at the SMA origin. Additional clot in the mid SMA extending into leftward projecting jejunal branches. These branches supply abnormal thickened and hypoenhancing small bowel loops. There is abrupt transition from enhancement to nonenhancing small bowel in these segments, best appreciated on the coronal reformatted images. 

Annotated images highlight key findings.

Case Discussion

Acute SMA embolus resulting in long segments of jejunal ischemia and infarction. The suspected cause was the narrowing at the SMA origin which was felt to be a probable dissection which caused the distal emboli. It is unclear why this occurred, as it could be spontaneous or related to segmental medial arteriolysis. 

Notice the downstream small bowel loops (jejunum) which characteristic findings of arterial ischemia with reperfusion injury. Specifically, there is abrupt cutoff from enhancing bowel to nonenhancing bowel typical of embolic ischemia to the distal branches, and also thickening, which occurs after some reperfusion is restored and there is injury to the bowel wall. This patient underwent resection of small bowel and embolectomy with a complex post-operative course. 

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