Superior mesenteric vein thrombosis with bowel ischemia

Case contributed by Dr Ian Bickle


No past medical history aside from C section. 4 am. Septic. Clinical concern of biliary sepsis.

Patient Data

Age: 40 years
Gender: Female

Ultrasound performed by on call radiologist in view of biliary sepsis query. Adynamic dilated small bowel - radiologist recommended CT


Large volume thrombosis in SMV and probably in several of its tributaries.

Many loops of small bowel poorly enhancing and mildly dilated (jejunum and proximal ileum).

Small bowel feces sign.

Congested small bowel mesentery.

Small volume free fluid.

Histology report following emergency surgery.

Case Discussion

Ischemic bowel, if not promptly identified, carries high morbidity and mortality.  It may, but not always, occur in the context of a visible vascular thrombosis on CT.

It can be a difficult diagnosis to confidently make. Appearances include:

a. poorly enhancing or non-enhancing bowel wall

b. pneumatosis intestinalis (intramural gas)

c. small bowel feces sign

d. portomesenteric venous gas

e. arterial or venous thrombosis

f. free abdominal fluid or gas

From a practical perspective, as a radiologist:

  • always think out of the box
  • be politely skeptical of all you are told
  • follow your instincts
  • finish the business you start: "own" your patient and score the diagnosis for their welfare 

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