Presentation
Abdominal pain for three days
Patient Data
There is a filling defect within the SMV from its most proximal part extending to its branches, consistent with acute thrombosis. The vein appears enlarged with a lack of normal enhancement on contrast-enhanced images.
The small bowel and cecum demonstrate generalized significant wall thickening, measuring up to 13 mm in some segments. The thickened walls exhibit a target appearance with hypoattenuation on CT images due to submucosal edema.
There is variable enhancement of the small bowel walls. Some segments show hyperenhancement with a target pattern, while others demonstrate diminished enhancement, raising concern for ischemia.
The mesenteric fat is congested with prominent stranding and edema. Engorged mesenteric vessels are present.
Moderate ascites is present.
A persistent nephrogram is noted on contrast-enhanced CT images, likely due to patient hypotension.
Case Discussion
This case demonstrates acute mesenteric ischemia resulting from superior mesenteric vein (SMV) thrombosis, leading to significant involvement of the small bowel and cecum. The thrombosis impedes venous drainage, causing increased mesenteric venous pressure and subsequent bowel wall edema and thickening, which is evident as the target sign on imaging.
The variable enhancement patterns of the bowel walls indicate differing degrees of ischemia. Hyperenhancement suggests inflammation and increased vascular permeability, while diminished enhancement raises concern for compromised perfusion and potential progression to infarction. Mesenteric fat stranding and engorged vessels further support the diagnosis of mesenteric venous congestion.
Moderate ascites reflects reactive peritoneal fluid due to inflammation or ischemia. The persistent nephrogram observed on contrast-enhanced CT is likely secondary to patient hypotension, which may result from systemic effects of severe mesenteric ischemia.
Early recognition and prompt management are crucial to prevent progression to bowel infarction, perforation, sepsis, and shock. Initial treatment typically involves anticoagulation to address the SMV thrombosis. Surgical intervention may be necessary if there are signs of bowel infarction or perforation. Endovascular therapies, such as catheter-directed thrombolysis or thrombectomy, can be considered to restore venous patency.
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