Mesenteric Ischemia: Silent Killer - Lieberman's eRadiology ...

Joseph M Reardon, HMS3 

Gillian Lieberman, MD 

Mesenteric Ischemia: Silent Killer 



Beth Israel Deaconess Medical Center 

Harvard Medical School 

3/2012



Agenda 

• Patient Presentation 

• Differential Diagnosis 

• Available Imaging Modalities 

• Relevant Anatomy 

• Radiologic Findings 

• Pathophysiology 

• Related Cases 

• Patient Management & Disposition 

• Take-Home Points 

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Agenda 










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Patient Presentation 

Hx: 83yo F with 4d of nausea, vomiting, diarrhea. No 

abdominal pain or fever/chills. Found by EMS unable to 

get out of bed or take POs 

PMH: HTN, CKD (baseline Cr 1.7-2), HLD, hypothyroidism, 

osteoporosis, non-Hodgkin lymphoma s/p radiation 

therapy in remission since 2001, Hx endometrial cancer 

Meds: atenolol, levothyroxine, pravastatin 

SH: Retired radiation researcher; lives with disabled 

relative for whom she is primary caretaker 

Exam: Hypotensive to 70s, A&Ox3, conversant, lungs 

CTAB, RRR, abd soft, NT/ND, no CVA tenderness 

Labs: WBC 14.1 with L shift, INR 1.5, BUN 26, Cr 2.0, 

LFTs, Trop 0.08, nl CK-MB, TSH 6.2, Lactate 5.0, ABG 

65/27/7.4 

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Clinical DDx: N/V/D, Hypotension 

Vascular 

Mesenteric ischemia 

Hypovolemia 

Embolism 

MI 

Infection/Inflammation 

Sepsis 

Gastritis 

Gastroenteritis 

Acute Hepatitis 

Cholecystitis 

Abscess 

UTI 

Perforated ulcer 

Trauma 

Fall 

“V I T A M I N C D” 

Autoimmune 

IBD 

Allergy 

Metabolic 

DKA 

Pancreatitis 

Acute Renal 

Failure 

Iatrogenic 

Ventral hernia 

Partial obstruction 

/ Adhesions 

Neoplastic 

Recurrent lymphoma 

Gastric cancer 

Colon cancer 

Pancreatic cancer 

Hepatic cancer 

Carcinoid 

Congenital 

Intestinal volvulus 

Adrenocortical 

insufficiency 

Drugs 

B-blocker overdose 

Thyroid storm 

EtOH 

TSS, Food poisoning 

(Staph Toxin A) 

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Imaging Modalities 

For our patient with N/V/D, BP 

• CT- abdomen & pelvis with contrast to evaluate for 

bowel inflammation, perforation, looping, vascular 

supply (Rating 8) 

• Ultrasound – RUQ U/S for biliary pathology (Rating 6) 

• MRI – T1 to assess abnormal fat distribution; T2 to 

assess for edema, 1st line in pregnant patient (Rating 6) 

• XR – KUB to evaluate for free air or dilated loops 

(Rating 5) 

• Nuclear Medicine – Ga-67 scan to evaluate for sites of 

metabolic activity (Rating 4) 

• Invasive – ultrasound-guided fluid drainage, ostomy 

placement via Seldinger technique 

Based on: “Acute Abdominal Pain and Fever or Suspected Abdominal Abscess.” ACR 

Appropriateness Criteria. American College of Radiology, 2008. 

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Fu 

Imaging and 

Use of Contrast 

• Use of IV Contrast in CT: 

– Contraindicated in chronic renal insufficiency 

– Contraindicated in acute kidney injury 

– Weigh risks and benefits 

• Concern for renal damage: 

– Use Visipaque (iodixanol) rather than Optiray 

(ioversol) 

– Ensure adequate pre-hydration 

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Balance of Benefits & Burdens 

• Renal Damage 

• Radiation Risk 

• Cost 

CT 

• Speed 

• Information 

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Agenda 










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Celiac artery 



Anatomy Review 

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From Gray’s Anatomy 

http://commons.wikim 

edia.org/wiki/File:Gray 

532.png



Anatomy Review, continued 

Superior Mesenteric Artery Inferior Mesenteric Artery 

Most tenuous 

blood supply 

– Marginal 

artery of 

Drummond 

3/2012 

From Gray’s Anatomy 

http://en.wikibooks.org/wiki/File:Gray534.png 13 

http://en.wikibooks.org/wiki/File:Gray537.png



Agenda 










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Axial CT (Portal Venous Phase) 

* 

NG Tube 

Fat Stranding 

Fluid tracking along portal vein 

Anterior Right Portal Vein obliteration 

Posterior Right Portal Vein thrombosis 

Left hydronephrosis 

Axial C+ CT; PACS, BIDMC Note margin of liver hypoattenuation 

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Mesenteric Ischemia on Axial CT 

Axial C+ CT; PACS, BIDMC 

* 

Gallbladder wall edema 

Bowel wall edema & hyperenhancing mucosa 

Hydronephrosis 

* Fat Stranding 

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Pelvic Free Fluid on Axial CT 

Bowel wall edema 

Free fluid in pelvis 

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Arterial Extravasation on Axial CT 


Extravasation from attempted femoral line insertion 

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• How can 



How can we link the patient’s 

presentation with disease 

processes? 

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Putting Together the Findings 

Elevated Cardiac 

Enzymes 

? Acalculous 

Cholecystitis 

Clinical Findings 

Contributing Factors 

? MI 

Aggressive 

Resuscitation 

Mesenteric 

Ischemia 

Hypotension 

? Sepsis 

History of 

Nausea, 

Vomiting, 

Diarrhea 

Coagulopathy 

? UTI 

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Underlying 

Liver Disease

• How can 



How do the disease processes 

manifest radiologically? 

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Putting Together the Findings (2) 


Radiologic Findings 

Bowel Wall 

Edema 

Mesenteric 

Ischemia 

Fat Stranding 

Bowel Wall 

Mucosal 

Enhancement 

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Periportal edema 



Aggressive 

Resuscitation 

Gallbladder 

Wall Edema 

? Acalculous 

Cholecystitis 

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Hypotension 




Clinical Findings 



Portal Vein 

Thrombosis 

Coagulopathy 

Arterial 

Extravasation 

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? Underlying 

Liver Disease



Agenda 










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What is Mesenteric Ischemia? 

• Development 

– Lack of perfusion to bowel 

mesentery 

– Causes: 

• Infarction – arterial or venous 

• Embolism 

• Low-Flow State 

• Pathophysiology: 

– Anoxia Buildup of 

metabolites (H+, K+) Cell 

death Necrosis 

3/2012 

From Al-Shraim MM, Zafer MH, Rahman GA. Acute 

occlusive mesenteric ischemia in high altitude of 

southwestern region of Saudi Arabia. Ann 

26 

Afr Med 

2011;1:5-10.



Presentation of Mesenteric Ischemia 

• S/Sx: 

– Abdominal pain 

– Vomiting 

– Abdominal distension 

– Fever 

– Melena 

• Hx: May have Afib, hypercoagulability 

• DDx: thromboembolic disease, digitalis toxicity, 

drug reaction, small bowel obstruction, cecal 

volvulus, gastroenteritis, compression from 

tumor, complicated diverticulitis, inflammatory 

bowel disease, cholecystitis, appendicitis, peptic 

ulcer disease 

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Mortality Rate (%) 



Why is Mesenteric Ischemia a Silent Killer? 

Mortality Rates of Comparable Conditions 

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Radiologic Diagnostic Signs 

• Mucosal hyperenhancement 

• Bowel wall hypoattenuation 

(edema) 

• Bowel wall thickening >3mm 

From Macari M, Balthazar, EJ. “CT of Bowel Wall 

Thickening: Significance and Pitfalls of Interpretation.” 

Am J Roentgenology. 2001;5:1105-1116. 

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Radiologic Diagnostic Signs, Contd 

• Mesenteric vessel occlusion (+/-) 

• Mesenteric fat stranding 

• Ascites 

From Johnson PT, Horton KM, Fishman EK. “Nonvascular 

Mesenteric Disease: Utility of Multidetector CT with 3D 

Volume Rendering.” RadioGraphics. 2009;29:721-740. 

From meddean.luc.edu 

From NYPEmergency.org 

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CT Hypotension Complex 

• “Shock Bowel” 

– Mucosal enhancement 

– Submucosal edema 

– Luminal distension 

• Other: 

– Collapsed vena cava 

– Adrenal hyperenhancement 

– Peripancreatic fat stranding 

– Hypoenhancing spleen 

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Agenda 










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Comparison Patient 

• 41yo F with Hx IBS, colitis, HLD, 

atherosclerosis who presented with LUQ/LLQ 

pain and leukocytosis 

• History notable for smoking, obesity, & family 

history of heart disease 

• Intermittent flare-ups of acute, diffuse 

abdominal pain over preceding 3 yrs, 

associated with loose stools and 35 lb weight 

loss 

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Occluded Celiac Artery 

PACS 




Comparison Patient 1 

1 month prior to presentation 

Stenosed SMA 

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Portal venous gas Pneumatosis Coli 

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• 78yo F transferred from OSH for 2 days of 

NB/NB emesis, nonbloody diarrhea, and 

bilateral lower abdominal pain 

• WBC 6.9, 77% PMNs 

• VS on arrival: HR 120 BP 90/52 T99 O2 95% on 

1L 

• Abdominal distention with palpable loop of 

bowel 

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Portal venous gas 

Aortic calcification 

Axial CT with PO Contrast; PACS, BIDMC 


Bowel wall thickening 

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Agenda 










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Agenda 










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Management of Mesenteric Ischemia 

Options: 

• Emergent Surgery 

– Bowel Resection 

• Stenting 

• Thrombolysis 

Prognosis: 

Julio Murra-Saca, gastrointestinalatlas.com 

• 50-90% mortality rate 

– Lactate level correlates with mortality 

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Our Patient 

• ~23:00 – Patient calls EMS; hypotensive to 

70s; taken to ED 

• ~23:30 – Patient arrives in ED; lactate of 5.0; 

central line placed; empiric antibiotics started 

• 00:10 – Anterior T-wave inversions; Cards 

consult 

• 00:30 – Bedside echo suggests decreased 

cardiac output and possible ischemia 

heparinized 

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Our Patient, Contd 

• 01:30 – Patient complains of feeling “unwell”, 

then becomes unresponsive, HR 40s, BP 50s, 

resuscitated with 1 round of CPR, atropine & 

Ca, intubated 

• 02:05 – CT chest/abdomen with contrast 

shows mesenteric ischemia 

• ~03:00 – Transfer to MICU 

• Immediately after transfer, patient develops 

PEA arrest; CPR resumed 

• After 10 more minutes of CPR, futility is 

determined and patient expires. 

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Agenda 










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Pearls 

• In patients such as ours, mesenteric ischemia may be a 

marker of other life-threatening conditions even if it is not 

the primary cause of death 

• Mesenteric ischemia can be acute (from hypotension, 

hypovolemia, embolism) or chronic (from atherosclerosis) 

• In patient with risk factors, always get abdominal CT with 

contrast to rule out mesenteric ischemia 

• Weigh the risks and benefits of IV contrast in patients at 

risk for renal damage 

• If mesenteric ischemia is on the differential must be 

excluded IMMEDIATELY no matter how remote 

• Use radiologic findings to guide both prediction of 

outcome and amenability to therapy 

• Keep VESSELS on list of organs that could cause pain when 

examining films. 

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References 

• “Acute Abdominal Pain and Fever or Suspected Abdominal Abscess.” ACR 

Appropriateness Criteria. American College of Radiology, 2008. 

• Al-Shraim MM, Zafer MH, Rahman GA. Acute occlusive mesenteric ischemia in high 

altitude of southwestern region of Saudi Arabia. Annals of African Medicine 2011;1:5- 

10. 

• Ames JT, Federle, MP. “CT Hypotension Complex (Shock Bowel) is not always due to 

traumatic hypovolemic shock.” Am J Roentgenology. 2009:192:W230-W235. 

• “Ascites.” Surgery Curriculum, Loyola University-Chicago. 

http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/Ascites.htm 

• Broder, JS. “Mesenteric Ischemia.” Feature Article CME. EMedHome.com. 2011, Jan 1. 

• Donnan GA, Fisher M, Macleod M, Davis SM. “Stroke.” Lancet 2008;371:1612-1623. 

• Furukawa A, Kansaki S, Naoaki K et al. “CT Diagnosis of Acute Mesenteric Ischemia from 

Various Causes.” Gastrointestinal Imaging. 2009;192:408-416. 

• Gray’s Anatomy of the Human Body, 20 th Edition. 

• Helton WS, Fisichella PM. “Intestinal Obstruction” in ACS Surgery. WebMD. 2004. 4:10. 

• Johnson PT, Horton KM, Fishman EK. “Nonvascular Mesenteric Disease: Utility of 

Multidetector CT with 3D Volume Rendering.” RadioGraphics. 2009;29:721-740. 

• Kaewlai R, Kurup D, Singh A. “Imaging of Abdomen and Pelvis: Uncommon Acute 

Pathologies.” Seminars in Roentgenology. 2009;228-236. 

• Levy AD. “Mesenteric Ischemia.” Radiologic Clin N Am. 2007;593-599. 

• Macari M, Balthazar, EJ. “CT of Bowel Wall Thickening: Significance and Pitfalls of 

Interpretation.” Am J Roentgenology. 2001;5:1105-1116. 

45 

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References, contd 

• “Mesenteric Panniculitis.” New York – Presbyterian Emergency Medicine. Sept 2008. 

http://nypemergency.org/radiology/radiology_2008/case-of-the-month-0908.html 

• “Mesenteric Ischemia” in El Salvador Atlas of Gastrointestinal Video Endoscopy. 

http://www.gastrointestinalatlas.com/English/Jejuno_and_Ileum/Etc__Etc_/etc__etc_.html 

• Mirvis SE, Shanmuganathan K, Erb R. “Diffuse Small-Bowel lschemia in Hypotensive Adults After Blunt 

Trauma (Shock Bowel): CT Findings and Clinical Significance.” Am J Roentgenology. 1994;163:1375- 

1379. 

• Nishijima DK, Su M. “Mesenteric Ischemia in Emergency Medicine.” Medscape eMedicine. 

http://emedicine.medscape.com/article/758674-overview 

• Oldenburg WA, Lau LL, Rodenberg TJ et al. “Acute Mesenteric Ischemia: A Clinical Review.” Arch Int 

Med. 2004;164:1054-1062 

• Reeder MM. “G-69: Mesenteric Vascular Compromise.” in Reeder & Felson’s Gamuts in Radiology. 

Springer, 2003. 

• Rha SE, H HK, Lee SH, et al. “CT and MR Imaging Findings of Bowel Ischemia from Various Causes.” 

RadioGraphics. 2000;20:29-42. 

• “Universal differential diagnosis.” Musculoskeletal Radiology, University of Washington. 

http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/onlinemusculoskeletal-radiology-book/general-principles 

• Zafari AM. “Myocardial Infarction.” Medscape eMedicine. 

http://emedicine.medscape.com/article/155919-overview 

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Acknowledgements 

• Gillian Lieberman, MD 

• Mark Masciocchi, MD, PGY1 reviewed the 

presentation and provided comparison cases 

• Elizabeth Asch, MD, PGY2 reviewed the 

presentation and index case 

• Grant Smith, HMS3; Christian Strong, HMS3; 

Michael Honigberg, HMS3 

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