Radiographic Findings of Mesenteric Ischemia

eradiology.bidmc.harvard.edu

Radiographic Findings of Mesenteric Ischemia

Joyce Liu

Gillian Lieberman, MD August 2001

Radiographic Findings of

Mesenteric Ischemia

Joyce Liu, Harvard Medical School, Year IV

Gillian Lieberman, MD


Joyce Liu

Gillian Lieberman, MD

Agenda

• Patient presentation

• Initial presentation

Radiographic findings

• Differential diagnosis

• Clinical course

• Imaging of mesenteric ischemia

• Modalities

Findings

2


Joyce Liu

Gillian Lieberman, MD

Our Patient

Initial Presentation

• 68 yo woman admitted with severe

congestive heart failure and atrial

fibrillation

• Transthoracic echocardiogram revealed

two large 1.5 cm thrombi in left atrial

appendage

• Gradual onset of abdominal pain after

admission

3


Joyce Liu

Gillian Lieberman, MD

KUB: Upright & Supine

Splenic Artery Calcification

PACS PACS

4


Joyce Liu

Gillian Lieberman, MD

CT: Significant findings

• Calcified

splenic artery

• Splenic

infarct

• Free fluid in

abdomen

• Several

thickened

loops of

bowel

5

PACS


Joyce Liu

Gillian Lieberman, MD

CT: Significant findings

• Calcified

splenic artery

• Splenic

infarct

• Free fluid in

abdomen

• Several

thickened

loops of

bowel

6

PACS


Joyce Liu

Gillian Lieberman, MD

CT: Significant findings

• Calcified

splenic artery

• Splenic

infarct

• Free fluid in

abdomen

• Several

thickened

loops of

bowel

7

PACS


Joyce Liu

Gillian Lieberman, MD

CT: Significant findings

• Calcified

splenic artery

• Splenic

infarct

• Free fluid in

abdomen

• Several

thickened

loops of

bowel

8

PACS


Joyce Liu

Gillian Lieberman, MD

• Regular

Differential Diagnosis:

Bowel Wall Thickening

• Coagulation defects

• Trauma

Ischemia/Infarction

• Hypoproteinemia

• Ascites

Mesenteric lymphatic

or venous obstruction

• Giardiasis

• Irregular

• Infection – Giardia,

Histoplasmosis, TB,

Yersinia,

Strongyloides

• Lymphoma

• Metastases

• Crohn’s disease

• Whipple’s disease

• Amyloidosis

9


• Patent superior

mesenteric

artery (SMA)

and celiac trunk

• Calcified

splenic artery

• Free fluid

• Splenic infarct

CT: Vascular Imaging

10

PACS


Joyce Liu

Gillian Lieberman, MD

Clinical Course #1

• Patient received IV antibiotics and

appeared to improve clinically.

• Approximately one week later, patient

again developed abdominal pain,

worsening greatly over 24-36 hours,

with accompanying rise in WBC to

23,000.

11


Joyce Liu

Gillian Lieberman, MD

• Dependent air

• Bubbly appearance of air ?

in lumen

? Bowel wall

CT: Scout Film

PACS

12


Joyce Liu

Gillian Lieberman, MD

• Dilated bowel

loops

• Free fluid

• Heavily calcified

aorta

• No portal venous

air

• No free air

• Bubbly

dependent air ?

In bowel wall

CT: Significant Finding

Air in bowel wall = Pneumatosis Intestinalis

13

PACS


Joyce Liu

Gillian Lieberman, MD

CT: Significant Findings

• Dilated bowel

loops

• Bubbly gas

appearance

noted on lung

windows

? In bowel wall

14

PACS


Joyce Liu

Gillian Lieberman, MD

CT: Significant Findings

• Air in dependent

portions of small

bowel

15

PACS


Joyce Liu

Gillian Lieberman, MD

Differential Diagnosis:

Pneumatosis Intestinalis

• Adults – Mesenteric vascular disease (~30%)

• Infants – Necrotizing enterocolitis

• Pneumatosis cystoides intestinalis (4-15%)

• Bowel obstruction (~30%)

• Crohn’s disease

• Autoimmune diseases – lupus, scleroderma

• Chronic obstructive pulmonary disease

• Transplants – renal, liver

• AIDS

16


Joyce Liu

Gillian Lieberman, MD

Clinical Course #2

• Given patient’s history, exploratory

laparotomy was performed.

• At surgery, the following were found:

• Murky, bloody ascites with foul smell

• 2.5 foot section of necrotic small bowel in

mid-jejunum, with ~1 foot that was

gangrenous and perforated

• Small bowel resection was performed.

17


Joyce Liu

Gillian Lieberman, MD

Mesenteric Ischemia

• Acute or chronic

• Three pathophysiologic mechanisms:

• Arterial occlusion

• Venous occlusion

• Low-flow state

• Commonly used imaging modalities:

• Plain film (KUB)

• CT

• Angiography

• MR angiography (MRA) – in development

18


Joyce Liu

Gillian Lieberman, MD

Imaging Mesenteric Ischemia: KUB

• Dilated bowel loops

• Bowel wall thickening

• Paucity of gas in

abdomen

• Pneumatosis

• Portal vein gas

• Fixation of infarcted

loops on serial

examinations

19


Joyce Liu

Gillian Lieberman, MD

Pneumatosis Coli = Air in bowel wall

• Dilated bowel loops

• Bowel wall thickening

• Paucity of gas in

abdomen

• Pneumatosis

• Portal vein gas

• Fixation of infarcted

loops on serial

examinations

20


Joyce Liu

Gillian Lieberman, MD

Air in portal venous system on KUB

• Dilated bowel loops

• Bowel wall thickening

• Paucity of gas in

abdomen

• Pneumatosis

• Portal vein gas

• Fixation of infarcted

loops on serial

examinations

21


Joyce Liu

Gillian Lieberman, MD

Imaging Mesenteric Ischemia: CT

• Dilated bowel loops

• Bowel wall thickening

• Large mesenteric

vessels

• Pneumatosis

• Free fluid

• Portal vein vein gas gas

Mesenteric venous gas

• Infarction of other

viscera

• Thrombus

• Pneumoperitoneum

22


Joyce Liu

Gillian Lieberman, MD

Imaging Mesenteric Ischemia: CT

• Dilated bowel loops

• Bowel wall thickening

• Large mesenteric

vessels

• Pneumatosis

• Free fluid

• Portal Portal vein gas

Mesenteric venous gas

• Infarction of other

viscera

• Thrombus

• Pneumoperitoneum

23


Joyce Liu

Gillian Lieberman, MD

Imaging Mesenteric Ischemia: CT

• Dilated bowel loops

• Bowel wall thickening

• Large mesenteric

vessels

• Pneumatosis

• Free fluid

• Portal Portal vein gas

Mesenteric venous gas

• Infarction of other

viscera

• Thrombus

• Pneumoperitoneum

24


Joyce Liu

Gillian Lieberman, MD

Imaging Mesenteric Ischemia:

Aortogram

Stenosis

Angiography

Selective Celiac Arteriogram

PACS PACS

25


Joyce Liu

Gillian Lieberman, MD

Imaging Mesenteric Ischemia:

• Tortuous Arc

of Riolan

Angiography

PACS

26


Joyce Liu

Gillian Lieberman, MD

Imaging Mesenteric Ischemia:

• Tortuous Arc

of Riolan

Angiography

PACS

27


Joyce Liu

Gillian Lieberman, MD

Imaging Mesenteric Ischemia:

• Tortuous Arc

of Riolan

Angiography

PACS

28


Joyce Liu

Gillian Lieberman, MD

Imaging Mesenteric Ischemia:

• Tortuous Arc

of Riolan

Angiography

PACS

29


Joyce Liu

Gillian Lieberman, MD

Imaging Mesenteric Ischemia: MRA

SMA

celiac

30


Joyce Liu

Gillian Lieberman, MD

Summary

• Modalities for imaging mesenteric ischemia:

• KUB

• CT

• Radiologic findings with mesenteric ischemia:

• KUB

• Dilated bowel loops

• Bowel wall thickening

(Thumbprinting)

• Pneumatosis

(air in bowel wall)

• Portal vein gas

• Angiography

• Filling defects

• Stenoses/blockage

• Tortuous Arc of Riolan

• Angiography

• MRA (in development)

• CT

• Large mesenteric vessels

• Free fluid

Mesenteric venous gas

• Thrombus in vessels

• Bowel wall thickening

• Air in bowel wall

• Air in portal venous system

31


Joyce Liu

Gillian Lieberman, MD

References

• Baden JG, Racy DJ, Grist TM. Contrast-Enhanced Three-Dimensional Magnetic Resonance

Angiography of the Meseteric Vasculature. Journal of Magnetic Resonance Imaging, 1999.

10: 369-375.

• Brancatelli G, Rosello M. Images in Hepatology: Gas in the Portal Vein. Journal of

Hepatology, 1999. 30: 1151.

• Friedman S, DeMuro JP, Brebbia J, Ortega D, Barraco R, Brathwaite C, Perez JM, Smith T.

Pneumatosis Cystoides Intestinalis in a Patient with Celiac Sprue. Contemporary Surgery,

Jan 2001. 57(1): 11-13.

• Hofmann LV, Beall DP, Jones B, Fishman EK, Heitmiller R. Hepatic-portal venous gas and

pneumatosis intestinalis: Two cases with open jejunostomy tubes. Applied Radiology, Nov

1997.

• Lund EC, Han SY, Holley HC, Berland LL. Intestinal ischemia: Comparison of plain

radiographic and computed tomographic findings. RadioGraphics, Nov 1988. 8(6): 1083-

1108.

• Scholz, FJ. Ischemic Bowel Disease. Radiologic Clinics of North America. Nov 1993. 31(6):

1197-1218.

• Sebastia C, Quiroga S, Espin E, Boye R, Alvarez-Castelis A, Armengol M. Portomesenteric

Vein Gas: Pathologic Mechanisms, CT Findings, and Prognosis. RadioGraphics, Sep 2000.

20(5): 1213-1226.

32


Joyce Liu

Gillian Lieberman, MD

Acknowledgments

Many thanks to the following individuals

for their invaluable assistance:

Dr. Gillian Lieberman

Dr. Scott Lin

Pamela Lepkowski

Larry Barbaras and Cara Lyn D’amour

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