Presentation
Uncontrolled diabetes mellitus and previous lower limb amputations presented with marked abdominal pain, abdominal distention, and very high lactic acid.
Patient Data
Marked diffuse calcified atheromatous plaques involving the aorta, celiac, superior and inferior mesenteric arteries.
Dilated small bowel loops with mild diffuse wall thickening and gas density seen in the bowel wall ( pneumatosis intestinalis).
Multiple peripheral linear branching gas density inside the portal vein and its branches, superior mesenteric vein and its mesenteric tributaries (pneumatosis portalis).
High density of the left adrenal gland denoting adrenal hemorrhage. Multiple linear non enhancing areas seen at the splenic and renal parenchyma. Stranding of the mesenteric fat and mild free fluid.
Decreased enhancement of the bowel loops with complete loss of enhancement of ileal loops (bowel infarction).
Case Discussion
Many features of venous bowel ischemia seen in this case: dilated bowel loops with diffuse wall thickening, bowel wall gas, extensive gas seen inside the portomesenteric circulation and intrahepatic portal vein branches (pneumatosis portalis). Also, there is stranding of the mesenteric fat and mild free fluid, which are sequelae of venous blood flow compromise.
Post IV contrast study shows non-enhancement of bowel loops (i.e. bowel infarction) with no contrast enhancement of the mesenteric, portal and splenic veins.
Extraintestinal CT findings of venous ischemia seen in this case include splenic and bilateral renal infarcts in terms of multiple linear non-enhancing areas.
Due to extensive infarction process and critical condition of the patient, left adrenal hemorrhage is also noted.
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