Radiographic Findings of Mesenteric Ischemia
Radiographic Findings of Mesenteric Ischemia
Radiographic Findings of Mesenteric Ischemia
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Joyce Liu<br />
Gillian Lieberman, MD August 2001<br />
<strong>Radiographic</strong> <strong>Findings</strong> <strong>of</strong><br />
<strong>Mesenteric</strong> <strong>Ischemia</strong><br />
Joyce Liu, Harvard Medical School, Year IV<br />
Gillian Lieberman, MD
Joyce Liu<br />
Gillian Lieberman, MD<br />
Agenda<br />
• Patient presentation<br />
• Initial presentation<br />
• <strong>Radiographic</strong> findings<br />
• Differential diagnosis<br />
• Clinical course<br />
• Imaging <strong>of</strong> mesenteric ischemia<br />
• Modalities<br />
• <strong>Findings</strong><br />
2
Joyce Liu<br />
Gillian Lieberman, MD<br />
Our Patient<br />
Initial Presentation<br />
• 68 yo woman admitted with severe<br />
congestive heart failure and atrial<br />
fibrillation<br />
• Transthoracic echocardiogram revealed<br />
two large 1.5 cm thrombi in left atrial<br />
appendage<br />
• Gradual onset <strong>of</strong> abdominal pain after<br />
admission<br />
3
Joyce Liu<br />
Gillian Lieberman, MD<br />
KUB: Upright & Supine<br />
Splenic Artery Calcification<br />
PACS PACS<br />
4
Joyce Liu<br />
Gillian Lieberman, MD<br />
CT: Significant findings<br />
• Calcified<br />
splenic artery<br />
• Splenic<br />
infarct<br />
• Free fluid in<br />
abdomen<br />
• Several<br />
thickened<br />
loops <strong>of</strong><br />
bowel<br />
5<br />
PACS
Joyce Liu<br />
Gillian Lieberman, MD<br />
CT: Significant findings<br />
• Calcified<br />
splenic artery<br />
• Splenic<br />
infarct<br />
• Free fluid in<br />
abdomen<br />
• Several<br />
thickened<br />
loops <strong>of</strong><br />
bowel<br />
6<br />
PACS
Joyce Liu<br />
Gillian Lieberman, MD<br />
CT: Significant findings<br />
• Calcified<br />
splenic artery<br />
• Splenic<br />
infarct<br />
• Free fluid in<br />
abdomen<br />
• Several<br />
thickened<br />
loops <strong>of</strong><br />
bowel<br />
7<br />
PACS
Joyce Liu<br />
Gillian Lieberman, MD<br />
CT: Significant findings<br />
• Calcified<br />
splenic artery<br />
• Splenic<br />
infarct<br />
• Free fluid in<br />
abdomen<br />
• Several<br />
thickened<br />
loops <strong>of</strong><br />
bowel<br />
8<br />
PACS
Joyce Liu<br />
Gillian Lieberman, MD<br />
• Regular<br />
Differential Diagnosis:<br />
Bowel Wall Thickening<br />
• Coagulation defects<br />
• Trauma<br />
• <strong>Ischemia</strong>/Infarction<br />
• Hypoproteinemia<br />
• Ascites<br />
• <strong>Mesenteric</strong> lymphatic<br />
or venous obstruction<br />
• Giardiasis<br />
• Irregular<br />
• Infection – Giardia,<br />
Histoplasmosis, TB,<br />
Yersinia,<br />
Strongyloides<br />
• Lymphoma<br />
• Metastases<br />
• Crohn’s disease<br />
• Whipple’s disease<br />
• Amyloidosis<br />
9
• Patent superior<br />
mesenteric<br />
artery (SMA)<br />
and celiac trunk<br />
• Calcified<br />
splenic artery<br />
• Free fluid<br />
• Splenic infarct<br />
CT: Vascular Imaging<br />
10<br />
PACS
Joyce Liu<br />
Gillian Lieberman, MD<br />
Clinical Course #1<br />
• Patient received IV antibiotics and<br />
appeared to improve clinically.<br />
• Approximately one week later, patient<br />
again developed abdominal pain,<br />
worsening greatly over 24-36 hours,<br />
with accompanying rise in WBC to<br />
23,000.<br />
11
Joyce Liu<br />
Gillian Lieberman, MD<br />
• Dependent air<br />
• Bubbly appearance <strong>of</strong> air ?<br />
in lumen<br />
? Bowel wall<br />
CT: Scout Film<br />
PACS<br />
12
Joyce Liu<br />
Gillian Lieberman, MD<br />
• Dilated bowel<br />
loops<br />
• Free fluid<br />
• Heavily calcified<br />
aorta<br />
• No portal venous<br />
air<br />
• No free air<br />
• Bubbly<br />
dependent air ?<br />
In bowel wall<br />
CT: Significant Finding<br />
Air in bowel wall = Pneumatosis Intestinalis<br />
13<br />
PACS
Joyce Liu<br />
Gillian Lieberman, MD<br />
CT: Significant <strong>Findings</strong><br />
• Dilated bowel<br />
loops<br />
• Bubbly gas<br />
appearance<br />
noted on lung<br />
windows<br />
? In bowel wall<br />
14<br />
PACS
Joyce Liu<br />
Gillian Lieberman, MD<br />
CT: Significant <strong>Findings</strong><br />
• Air in dependent<br />
portions <strong>of</strong> small<br />
bowel<br />
15<br />
PACS
Joyce Liu<br />
Gillian Lieberman, MD<br />
Differential Diagnosis:<br />
Pneumatosis Intestinalis<br />
• Adults – <strong>Mesenteric</strong> vascular disease (~30%)<br />
• Infants – Necrotizing enterocolitis<br />
• Pneumatosis cystoides intestinalis (4-15%)<br />
• Bowel obstruction (~30%)<br />
• Crohn’s disease<br />
• Autoimmune diseases – lupus, scleroderma<br />
• Chronic obstructive pulmonary disease<br />
• Transplants – renal, liver<br />
• AIDS<br />
16
Joyce Liu<br />
Gillian Lieberman, MD<br />
Clinical Course #2<br />
• Given patient’s history, exploratory<br />
laparotomy was performed.<br />
• At surgery, the following were found:<br />
• Murky, bloody ascites with foul smell<br />
• 2.5 foot section <strong>of</strong> necrotic small bowel in<br />
mid-jejunum, with ~1 foot that was<br />
gangrenous and perforated<br />
• Small bowel resection was performed.<br />
17
Joyce Liu<br />
Gillian Lieberman, MD<br />
<strong>Mesenteric</strong> <strong>Ischemia</strong><br />
• Acute or chronic<br />
• Three pathophysiologic mechanisms:<br />
• Arterial occlusion<br />
• Venous occlusion<br />
• Low-flow state<br />
• Commonly used imaging modalities:<br />
• Plain film (KUB)<br />
• CT<br />
• Angiography<br />
• MR angiography (MRA) – in development<br />
18
Joyce Liu<br />
Gillian Lieberman, MD<br />
Imaging <strong>Mesenteric</strong> <strong>Ischemia</strong>: KUB<br />
• Dilated bowel loops<br />
• Bowel wall thickening<br />
• Paucity <strong>of</strong> gas in<br />
abdomen<br />
• Pneumatosis<br />
• Portal vein gas<br />
• Fixation <strong>of</strong> infarcted<br />
loops on serial<br />
examinations<br />
19
Joyce Liu<br />
Gillian Lieberman, MD<br />
Pneumatosis Coli = Air in bowel wall<br />
• Dilated bowel loops<br />
• Bowel wall thickening<br />
• Paucity <strong>of</strong> gas in<br />
abdomen<br />
• Pneumatosis<br />
• Portal vein gas<br />
• Fixation <strong>of</strong> infarcted<br />
loops on serial<br />
examinations<br />
20
Joyce Liu<br />
Gillian Lieberman, MD<br />
Air in portal venous system on KUB<br />
• Dilated bowel loops<br />
• Bowel wall thickening<br />
• Paucity <strong>of</strong> gas in<br />
abdomen<br />
• Pneumatosis<br />
• Portal vein gas<br />
• Fixation <strong>of</strong> infarcted<br />
loops on serial<br />
examinations<br />
21
Joyce Liu<br />
Gillian Lieberman, MD<br />
Imaging <strong>Mesenteric</strong> <strong>Ischemia</strong>: CT<br />
• Dilated bowel loops<br />
• Bowel wall thickening<br />
• Large mesenteric<br />
vessels<br />
• Pneumatosis<br />
• Free fluid<br />
• Portal vein vein gas gas<br />
• <strong>Mesenteric</strong> venous gas<br />
• Infarction <strong>of</strong> other<br />
viscera<br />
• Thrombus<br />
• Pneumoperitoneum<br />
22
Joyce Liu<br />
Gillian Lieberman, MD<br />
Imaging <strong>Mesenteric</strong> <strong>Ischemia</strong>: CT<br />
• Dilated bowel loops<br />
• Bowel wall thickening<br />
• Large mesenteric<br />
vessels<br />
• Pneumatosis<br />
• Free fluid<br />
• Portal Portal vein gas<br />
• <strong>Mesenteric</strong> venous gas<br />
• Infarction <strong>of</strong> other<br />
viscera<br />
• Thrombus<br />
• Pneumoperitoneum<br />
23
Joyce Liu<br />
Gillian Lieberman, MD<br />
Imaging <strong>Mesenteric</strong> <strong>Ischemia</strong>: CT<br />
• Dilated bowel loops<br />
• Bowel wall thickening<br />
• Large mesenteric<br />
vessels<br />
• Pneumatosis<br />
• Free fluid<br />
• Portal Portal vein gas<br />
• <strong>Mesenteric</strong> venous gas<br />
• Infarction <strong>of</strong> other<br />
viscera<br />
• Thrombus<br />
• Pneumoperitoneum<br />
24
Joyce Liu<br />
Gillian Lieberman, MD<br />
Imaging <strong>Mesenteric</strong> <strong>Ischemia</strong>:<br />
Aortogram<br />
Stenosis<br />
Angiography<br />
Selective Celiac Arteriogram<br />
PACS PACS<br />
25
Joyce Liu<br />
Gillian Lieberman, MD<br />
Imaging <strong>Mesenteric</strong> <strong>Ischemia</strong>:<br />
• Tortuous Arc<br />
<strong>of</strong> Riolan<br />
Angiography<br />
PACS<br />
26
Joyce Liu<br />
Gillian Lieberman, MD<br />
Imaging <strong>Mesenteric</strong> <strong>Ischemia</strong>:<br />
• Tortuous Arc<br />
<strong>of</strong> Riolan<br />
Angiography<br />
PACS<br />
27
Joyce Liu<br />
Gillian Lieberman, MD<br />
Imaging <strong>Mesenteric</strong> <strong>Ischemia</strong>:<br />
• Tortuous Arc<br />
<strong>of</strong> Riolan<br />
Angiography<br />
PACS<br />
28
Joyce Liu<br />
Gillian Lieberman, MD<br />
Imaging <strong>Mesenteric</strong> <strong>Ischemia</strong>:<br />
• Tortuous Arc<br />
<strong>of</strong> Riolan<br />
Angiography<br />
PACS<br />
29
Joyce Liu<br />
Gillian Lieberman, MD<br />
Imaging <strong>Mesenteric</strong> <strong>Ischemia</strong>: MRA<br />
SMA<br />
celiac<br />
30
Joyce Liu<br />
Gillian Lieberman, MD<br />
Summary<br />
• Modalities for imaging mesenteric ischemia:<br />
• KUB<br />
• CT<br />
• Radiologic findings with mesenteric ischemia:<br />
• KUB<br />
• Dilated bowel loops<br />
• Bowel wall thickening<br />
(Thumbprinting)<br />
• Pneumatosis<br />
(air in bowel wall)<br />
• Portal vein gas<br />
• Angiography<br />
• Filling defects<br />
• Stenoses/blockage<br />
• Tortuous Arc <strong>of</strong> Riolan<br />
• Angiography<br />
• MRA (in development)<br />
• CT<br />
• Large mesenteric vessels<br />
• Free fluid<br />
• <strong>Mesenteric</strong> venous gas<br />
• Thrombus in vessels<br />
• Bowel wall thickening<br />
• Air in bowel wall<br />
• Air in portal venous system<br />
31
Joyce Liu<br />
Gillian Lieberman, MD<br />
References<br />
• Baden JG, Racy DJ, Grist TM. Contrast-Enhanced Three-Dimensional Magnetic Resonance<br />
Angiography <strong>of</strong> the Meseteric Vasculature. Journal <strong>of</strong> Magnetic Resonance Imaging, 1999.<br />
10: 369-375.<br />
• Brancatelli G, Rosello M. Images in Hepatology: Gas in the Portal Vein. Journal <strong>of</strong><br />
Hepatology, 1999. 30: 1151.<br />
• Friedman S, DeMuro JP, Brebbia J, Ortega D, Barraco R, Brathwaite C, Perez JM, Smith T.<br />
Pneumatosis Cystoides Intestinalis in a Patient with Celiac Sprue. Contemporary Surgery,<br />
Jan 2001. 57(1): 11-13.<br />
• H<strong>of</strong>mann LV, Beall DP, Jones B, Fishman EK, Heitmiller R. Hepatic-portal venous gas and<br />
pneumatosis intestinalis: Two cases with open jejunostomy tubes. Applied Radiology, Nov<br />
1997.<br />
• Lund EC, Han SY, Holley HC, Berland LL. Intestinal ischemia: Comparison <strong>of</strong> plain<br />
radiographic and computed tomographic findings. RadioGraphics, Nov 1988. 8(6): 1083-<br />
1108.<br />
• Scholz, FJ. Ischemic Bowel Disease. Radiologic Clinics <strong>of</strong> North America. Nov 1993. 31(6):<br />
1197-1218.<br />
• Sebastia C, Quiroga S, Espin E, Boye R, Alvarez-Castelis A, Armengol M. Portomesenteric<br />
Vein Gas: Pathologic Mechanisms, CT <strong>Findings</strong>, and Prognosis. RadioGraphics, Sep 2000.<br />
20(5): 1213-1226.<br />
32
Joyce Liu<br />
Gillian Lieberman, MD<br />
Acknowledgments<br />
Many thanks to the following individuals<br />
for their invaluable assistance:<br />
Dr. Gillian Lieberman<br />
Dr. Scott Lin<br />
Pamela Lepkowski<br />
Larry Barbaras and Cara Lyn D’amour<br />
33
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