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Small bowel ischemia

Case contributed by Ian Bickle
Diagnosis almost certain

Presentation

Short history of diffuse abdominal pain. Prior stroke. Atrial fibrillation. Hard to examine. Lactate elevated.

Patient Data

Age: 80 years
Gender: Male
ct

The small bowel is moderately distended with fluid, without a site of obstruction.

Minimal or absent bowel wall enhancement of the jejunum and ileum distal to the duodenojejunal flexure.  No intramural gas.

Total occlusion of superior mesenteric artery (SMA) several centrimetres distal to its origin.

The large bowel is normal in appearance.

No free gas.  Trace of fluid in the right paracolic gutter.

Simple renal cysts.

Bilateral lower lobe consolidation.

Case Discussion

The clinical history was one with a strong suspicion for ischemic bowel.  Atrial fibrillation and a prior vascular event (stroke), along with a steeply elevated lactate.

The SMA thrombosis is fairly proximal and totally occludes the lumen with end organ consequences.

The small bowel is almost devoid of enhancement.   The other features of ischemic gut, such as intra-mural gas and portal venous gas, are not yet evident.

Take a look at the D3-D4 junction to see the normal bowel wall enhancement vis-a-vis the remaining of the small bowel to be convinced of the absence of enhancement elsewhere.

This patient died on the day of the scan.

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