Very challenging case with an overwhelming number of abnormal findings. The large amount of free intraperitoneal contrast is the major distractor from the true abnormality, and may lead you to attribute the findings to duodenal perforation alone.

The key to understanding the case is to review the vascular anatomy. The celiac and SMA share a common origin, and celiac artery is completely occluded at it's origin. The SMA occludes near the pancreatic head after giving off a few tiny pancreaticoduodenal branches. The IMA does not look acutely occluded, but is severely narrowed near the origin.

This results in ischemia of the entire abdomen:

• liver: portions of the right hepatic lobe relatively spared due to collateral flow from inferior pancreaticoduodenal collaterals supplying whispy flow to the GDA and hepatic arteries; caudate and left hepatic lobe hypoenhancing/ischemic
• pancreas: head is supplied by inferior PD from SMA and enhances normally; body and tail are supplied by pancreatic branches of the splenic artery and are therefore ischemic
• spleen: small and completely infarcted; this is hard to appreciate at first because it is surrounded by dense oral contrast.
• kidneys: small embolic infarcts, left worse than right
• adrenals: left adrenal is hypoenhancing likely related to occlusion of the suprarenal artery; right adrenal hyperenhancing, possible due to shock.
• stomach and duodenal bulb: ischemic due to occlusion of the gastric and gastroepipfrom splenic, and reliance on collateral inferior PD arcade flow to supply the GDA
• jejunum: relatively spared likely due to small jejunal or collateral branches of the SMA before it becomes occluded; they have typical findings of peritonitis or shock bowel
• ileum: ischemic and hypoehancing, blending in with the ascites due to SMA occlusion
• colon: areas of variable thickening, submucosal edema, and hyperenhancement, which likely is a combination of ischemia and peritonitis/shock bowel