What has occurred to the bowel?
The bowel is thickened and some areas demonstrate poor / absent contrast enhancement consistent with ischaemia and infarction.
If ischaemic bowel was a clinical concern at the time of CT request, how should this scan have been protocoled?
In general CT of the abdomen and pelvis should be performed with intravenous contrast and a neutral luminal contrast (e.g. water) so that bowel wall enhancement and thickness can be adequately assessed. ]Multiple contrast phases are typically obtained: 1) non-contrast; 2) arterial phase (e.g. triggered when abdominal aorta reaches >100HU); 3) portal venous phase (e.g. 30 seconds after arterial phase finishes)
Why does the bowel wall thicken in these patients? How does it correlate with outcome?
Back pressure due to poor venous outflow results in plasma +/- red blood cells passing into the bowel wall. The degree of oedema / thickening does not correlate with outcome.
If bowel wall infarction was not present (i.e. if the wall enhanced normally), what non-surgical options could be entertained?
Endovascular thombolysis / thrombectomy is also an option in selected cases.
If you wanted to get a catheter to the superior mesenteric vein, how would you get there?
Probably the safest way to directly access the portal circulation is via a transjugular / transhepatic approach (similar to the initial steps of a TIPS). Direct transhepatic approach have also been performed but are associated with greater risk of haemorrhage.
Multiple loops of mid and distal ilium are markedly oedematous and show reduced contrast enhancement within their walls. The adjacent mesentery is also markedly oedematous. Free fluid of moderate extent in pelvis and also surrounding liver and spleen. No free gas detected to suggest perforation.
The superior mesenteric artery is intact, but the superior mesenteric vein is occluded by thrombus, the leading edge of which extends into the distal end of the superior mesenteric vein, just proximal to its junction with the splenic vein. Large bowel and appendix are normal. Liver diffusely fatty.