Gastrointestinal Radiology: Acute Mesenteric Ischaemia on Unenhanced Computer-Tomography Gupta et al.

Acute Mesenteric Ischaemia on Unenhanced

Computer-Tomography

Nidhi Gupta1, Achim Schwenk1, Rudi Borgstein3*

1. Department of Radiology, North Middlesex University Hospital, London, UK

2. Department of Infectious Diseases, North Middlesex University Hospital, London, UK

* Correspondence: Rudi Borgstein, North Middlesex University Hospital, Stirling Way, Edmonton, London N18 1QX, UK
( [email protected])

Radiology Case. 2010 Sep; 4(9):24-30 :: DOI: 10.3941/jrcr.v4i9.417

Journal of Radiology Case Reports

ABSTRACT
We present a 39-year old man with mesenteric ischaemia. The initial
unenhanced images of the, non-oral contrast CT abdomen clearly

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demonstrated increased density in a significant length of the small bowel and
in the veins of the adjacent mesentery. Mesenteric ischaemia is a difficult
diagnosis both clinically and radiologically and we demonstrate the potential
benefits of an unenhanced abdominal scan (often left out if a contrast
enhanced scan is to be performed) and the omission of oral bowel contrast in
emergency scans.

CASE REPORT

CASE REPORT emergency laparotomy at which 70cm of ischaemic small

bowel was identified and resected. Histopathology
A 39-year old gentleman with a 24-hour history of demonstrated blood clots in both the veins and arteries.
epigastric then global abdominal pain. He had no past medical
or significant family history, did not smoke cigarettes and Radiology
drank over 40 units of alcohol a week, for an unknown number 72-hours post surgery, the patient again became febrile
of years. Physical examination revealed a tender epigastrium and a repeat CT with IV contrast indicated free fluid in the
with no rebound or guarding and soft brown stools on digital pelvis, and enlarged para-aortic lymph nodes. On review of the
rectal examination. Initial investigations showed amylase 373 initial CT it was noted that there was increased density in a
(56 - 190 IU)/L), lactate 5.7 (<2 IU/L) and lactate large segment of small bowel, which could only be reliably
dehydrogenase 782 (240 - 460 IU/L), with a normal white cell identified on the unenhanced part of the scan. There was also
count and differential, C-reactive protein and INR. He was increased density of the veins in the adjacent mesentery. See
afebrile and cardiovascularly stable. The initial impression was Figure 1.
of acute pancreatitis and the patient was treated conservatively.
A CT scan, with IV contrast, demonstrated the presence of On investigating his ongoing pyrexia, it was noted that
abdominal free fluid in the pelvis and was initially reported as both pre- and post-operatively, the patient's white cell count
a possible perforated viscus, with all organs reported normal in remained within normal limits. Therefore he proceeded to an
appearance with no focal pathology. HIV test, which was positive. Our patient made a full
recovery from his operation and his HIV infection is being
Clinical Progression followed-up in the outpatient clinic.
After 6 hours the patient became febrile, tachycardia (110
beats per minute) and hypotensive (80/50 mmHg) with diffuse
abdominal tenderness, rebound and guarding. He underwent an

Radiology Case. 2010 Sep; 4(9):24-30 24

 Gastrointestinal Radiology: Acute Mesenteric Ischaemia on Unenhanced Computer-Tomography Gupta et al.

DISCUSSION Abdominal ultrasound is the most reliable modality to

demonstrate gallstones. It will confirm/ exclude acute
Acute mesenteric ischaemia is a calamitous event, with cholecystits and may also reveal dilated bileducts or an
mortality beyond 60% (1). It can result from emboli, arterial or oedematous pancreas. Abdominal CT is more reliable if the
venous thrombi. Acute mesenteric artery thrombi are usually gallstones are calcified, and is also an excellent modality to
associated with pre-existing atherosclerotic lesions, which are demonstrate cholecystitis, pancreatitis and the presence of free
estimated to account for 20-30% of all cases of acute gas or fluid within the peritoneal space. MRI has an important
mesenteric ischemia (2,3). Mesenteric venous thrombosis role in the identification of calculi in the bileducts, but is not a
accounts for 10 - 15% of all cases of mesenteric ischaemia (4). useful examination in the emergency setting due to the time
taken to perform the procedure and its relative inaccessibility.
Acute arterial occlusion (usually embolic/
thromboembolic) will result in absent arterial inflow to a Unfortunately there are no specific blood investigations
segment of bowel depending on the site and degree of that can diagnose acute ischaemia and most are done to
occlusion (see Addendum - Figure 3/4). If complete the exclude other conditions. There are however tests that should
segment of bowel may not have time to become oedematous. be done as part of the investigative work-up - a clotting screen
Incomplete occlusion and/ or the opening up of a collateral including an INR, the activated partial thromboplastin time
supply will enable the bowel to become oedematous. and prothrombin time. A leucocytosis and acidosis are late,
non-specific markers of severe ischaemia. Subsequently other
Venous occlusion, often in association with systemic tests to exclude reversible causes, i.e. protein C and S
hypovolaemia and haemoconcentration, results in bowel wall deficiencies; antithrombin III deficiency; and abnormalities in
oedema/ haemorrhage as the outflow is impeded, and lupus anticoagulant, anticardiolipin antibody, and platelet
subsequently to diminished arterial inflow (and hence aggregation.
Journal of Radiology Case Reports

ischaemia).
All too often, patients do not present with the classical
On the unenhanced CT scan it is not possible to symptoms and pre- existing conditions that direct the

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demonstrate arterial occlusion, but acute venous thrombosis investigations to look specifically for mesenteric ischaemia.
may be identified as hyperdense mesenteric vein(s). Bowel The diagnosis of our patient was retrospective in nature due to
wall thickening can be diagnosed if there is gas and or fluid the apparent lack of risk factors predisposing towards such
present in the lumen. Acute bowel wall haemorrhage and/or catastrophic ischaemia and the lack of associated symptoms.
fresh blood in the lumen, if present (as in this case), can enable The dense bowel finding was not recognized at first. Delayed
a pre-operative diagnosis of bowel ischaemia to be made. diagnosis has in part been held responsible for the significant
mortality associated with the condition (6).
The administration of intravenous contrast medium (if not
contraindicated due to poor renal function) can be helpful in The benefits of the unenhanced abdominal scan (often left
demonstrating arterial occlusion and presence/absence of out if a contrast enhanced scan is to be performed) and the
bowel wall enhancement to support the diagnosis. omission of oral bowel contrast in emergency scans are clearly
demonstrated with this case. Recognising on plain CT the
While bowel ischaemia is damaging to the patient, it is the subtle indicators of ischaemia, i.e. bowel loops denser than
subsequent multi-organ failure, which accounts for the normal and/or increased density of mesenteric veins may,
increased mortality rate (5). HIV is been well known to be alongside the medical history lead to earlier diagnosis and as
associated with both hypercoaguable states and Protein S such earlier life-saving surgery, thus improving patient
deficiency (6). The pathophysiology of HIV associated morbidity and mortality.
ischaemia is still unclear and an area of active research. This
alone though is an associated risk factor and should be Addendum
considered as such. Three new cases (the first two surgically proven)
presented themselves to our department during the preparation
The symptoms of acute mesenteric ischaemia are non- of this report and have been included to highlight important
specific (as in this patient) and include abdominal pain, frank points.
blood in stools and post-prandial pain. An ischaemic cardiac
history is a predisposing factor. The differential diagnoses of Case 2: (Fig. 2) dense bowel loops (arrows) on
this patient's symptoms include pancreatitis (our original unenhanced CT scan found to be ischaemic/ haemorrhagic at
clinical diagnosis), severe cholecystitis and a perforated surgery, with evidence of venous thrombosis
abdominal viscus. To differentiate between these, the
examination may demonstrate a rigid abdomen (as in a Case 3: (Fig. 3) occluded major (Rt) branch of the
perforated viscus), or localized pain to the right upper superior mesenteric artery (arrow head) supplying the Rt sided
quadrant (as in cholecystitis), or the epigastrium (as in small bowel loops with no enhancement of the bowel wall
pancreatitis), with the latter associated with an increased (open arrow) compared with enhancing Lt sided loops (closed
amylase. Pancreatitis is also commonly associated with arrow); note absence of wall oedema
gallstones or a prolonged excessive alcohol intake.
A further case (Fig. 4) was found to have incomplete
occlusion of the mesenteric artery (arrow head); enhancement
Radiology Case. 2010 Sep; 4(9):24-30 25
 Gastrointestinal Radiology: Acute Mesenteric Ischaemia on Unenhanced Computer-Tomography Gupta et al.

of small bowel wall was present throughout (open arrow Rt; 9. Gennaro M, Ascer E, Matano R, et al. Acute mesenteric
closed arrow Lt) and patient recovered spontaneously (on ischemia after cardiopulmonary bypass. Am. J. Surg.
anticoagulants) and did not require surgery; also had mural 166:231-236, 1993.
thrombus in Lt ventricle and splenic infarcts visible on CT.
10. Allen KB, Salam AA, Lumsden AB. Acute mesenteric
In summary we present a case of mesenteric ischaemia ischemia after cardiopulmonary bypass. J. Vasc. Surg.
secondary to undiagnosed HIV infection, which was 16:391-396, 1992.
demonstrated on unenhanced CT scanning of the abdomen.
11. Jarvinen O, Lqaurikka J, Sisto T, et al. Atherosclerosis of
the visceral arteries. Vasa. 24:1, 9-14, 1995.

12. Sternbach Y, Perler BA. Chapter 3: Acute Mesenteric

Ischaemia. http://scalpel.stanford.edu/articles/AMI.pdf
TEACHING POINT

Acute mesenteric ischaemia has a poor prognosis, partly 13. Kaleya RN, Summartano RJ, Boley SJ. Aggressive
TEACHING
due to delayed diagnosis POINT surgery; the close
and curative approach to acute mesenteric ischemia. Surg. Clin. North
examination of unenhanced CT may aid rapid diagnosis and Am. 72(1):157-182, 1992.
facilitate cure, as it can demonstrate an increased density in the
tissue, which is lost with contrast enhancement. 14. Heys SD, Brittenden J, Crofts TJ. Acute mesenteric
ischemia: The continuing difficulty in early diagnosis.
Postgrad. Med. J. 69:48-51, 1993.
Journal of Radiology Case Reports

15. Klempnauer J, Grothues F, Bektas H, Pichlmayr R. Long-

term results after surgery for acute mesenteric ischemia.
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Burger CD. Acute mesenteric ischemia: a clinical review. 16. Bottger T, Schafer W, Jungiger T. Eine prospektive studie
Arch Intern Med 2004; 164:1054 -1062. zur evaluiering des postoperativen risikos sowie der
langzeitprognose des mesenterialinfarkts. Med. Klin.
2. Hagspiel KD, Angle JF, Spinosa DJ, Matsumoto AH. 86:198-203, 1991.
Mesenteric ischemia: angiography and endovascular
interventions. In: Longo W, Peterson GJ, Jacobs DL, eds. 17. Klempnauer J, Grothues F, Bektas H., et al. Long-term
Intestinal ischemia disorders: pathophysiology and results after surgery for acute mesenteric ischemia. Surgery.
management. St. Louis, MO: Quality Medical 121:239-243, 1997.
Publishing,1999 : 105-154.
18. Miller VE, Beland LL. Pulsed Doppler duplex sonography
3. Lock G. Acute mesenteric ischemia: classification, and CT of portal vein thrombosis. Am. J. Roentgenol.
evaluation and therapy. Acta Gastroenterol Belg 2002;65 : 145:73-76, 1985.
220-225.
19. Smerud MJ, Johnson CD, Stephens DH. Diagnosis of
4. Acosta S, Ogren M, Sternby NH. Mesenteric venous bowel infarction: A comparison of plain films and CT scans
thrombosis with transmural intestinal infarction: a in 23 cases. Am. J. Roentgenol. 154:99-103, 1990.
population-based study. J Vasc Surg. Jan 2005;41(1):59-63.
20. Rahmouni A, Mathieu D, Golli M, et al. Value of CT and
5. Abu-Daff S, Abu-Daff N, Al-Shahed M. Mesenteric venous sonography in the management of acute spleno-renal and
thrombosis and factors associated with mortality: a statistical superior mesenteric venous thrombosis. Gastrointest. Radiol.
analysis with five-year follow-up. J Gastrointest Surg. Jul 17(2): 135- 140, 1992.
2009;13(7):1245-50.
21. Harward TRS, Green D, Bergan JJ, et al. Mesenteric
6. Lijfering WM, Sprenger HG, Georg RR, van der Meulen venous thrombosis. J. Vasc. Surg. 9:328-333, 1989.
PA, van der Meer LJ. Clin Chem 2008; 54(7): 1226-33.
22. Vogelzang RL, Gore RM, Anschnetz SL. Thrombosis of
7. AGA Technical review on Intestinal Ischaemia. the splanchnic veins: CT diagnoses. Am. J. Roentgenol.
Gastroenterology 2000; 118: 954-968 . 150:93-96, 1988.

8. Rhee RY, Gloviczki P, Medonca CT, et al. Mesenteric 23. Gehl HB, Bohndorf K, Klose KC, et al. Two-dimensional
venous thrombosis: Still a lethal disease in the 1990s. J. MR angiography in the evaluation of abdominal veins with
Vasc. Surg. 20:688-697, 1994. gradient refocused sequences. J. Comput. Assist. Tomogr.
14(4):319-324, 1990.

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 Gastrointestinal Radiology: Acute Mesenteric Ischaemia on Unenhanced Computer-Tomography Gupta et al.

FIGURES
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Figure 1: 39-Year old male with Acute Mesenteric Ischaemia. Axial Contrast Computer Tomography of Abdomen, Unenhanced
(1) and corresponding enhanced (2) abdominal CT scans demonstrating increased density of the small bowel wall (and lumen)
correlated with histopathology slide (3) confirming the presence of haemorrhage in the bowel wall (and lumen). Haemorrhage in
thickened muscularis propria - open arrow; low density submucosal layer - closed arrow; dense vein consistent with recent
thrombosis - arrow head. GE Lightspeed 4 slice CT scanner;5mm slice thickness, omnipaque (iohexol) 300mg/ml 100mls @
2ml/s

Figure 2: Case 2 was found to have haemorrhagic/ ischaemic Figure 3: (Case 3) Arterial occlusion and ischaemic bowel
bowel loops and venous thrombosis at surgery. Unenhanced loops on the Rt side of the abdomen at surgery. Enhanced
abdominal CT scan demonstrating dense bowel loops in left abdominal CT scan demonstrating an occluded major branch
mid-abdomen (GE Lightspeed 4 slice CT scanner;5mm slice (Rt) of the superior mesenteric artery (arrow head) with no
thickness) enhancement of the wall of the Rt sided bowel loops (open
arrow) compared with enhancing Lt sided loops (closed
arrow). (GE Lightspeed 4 slice CT scanner;5mm slice
thickness, omnipaque (iohexol) 300mg/ml 100mls @ 2ml/s)
Radiology Case. 2010 Sep; 4(9):24-30 27
 Gastrointestinal Radiology: Acute Mesenteric Ischaemia on Unenhanced Computer-Tomography Gupta et al.

Figure 4: Case 4 was found to have incomplete occlusion of the mesenteric artery (enhanced CT) with evidence of ventricular
thrombus and splenic infarcts. Bowel wall enhancement could be identified throughout. The patient recovered spontaneously (on
anticoagulants) and did not require surgery. 4a: Enhanced abdominal CT scan demonstrating a filling defect in the superior
mesenteric artery (arrow head); enhancement of small bowel wall present throughout (open arrow Rt; closed arrow Lt). 4b:
thrombus attached to wall of Lt ventricle (arrow). 4c: splenic infarcts (arrows).
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Duplex Scanning Abdominal X-Ray Abdominal CT MRI
Presence of normal flow in the Excludes other causes of Increased density in both arteries and High degree of
portal and mesenteric venous abdominal pain. veins accuracy in
system helps exclude portal vein Mesenteric Vein
thrombosis Thrombosis (23)
Ascites and absent flow suggest 25% of confirmed Acute Maybe normal or non-diagnostic for
mesenteric venous thrombosis Mesenteric Ischaemia acute mesenteric ischaemia
(18) will be normal (19)
Contrast administration may show
vessel occlusion, but chronic
occlusion cannot be discriminated
from acute vessel thrombosis
Diagnostic modality for mesenteric
vein thrombosis, sensitivity >90%
(20-22) with following indications:
 Superior mesenteric or
portal vein appears large,
with a central area of low
attenuation
 Contrast phase: rim may
enhance vein wall
 Bowel thickening and
presence of ascites
Table 1: Differential table of acute mesenteric ischaemia on imaging

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 Gastrointestinal Radiology: Acute Mesenteric Ischaemia on Unenhanced Computer-Tomography Gupta et al.

Aetiology Acute Occlusive:

Arterial emboli from the heart
 Atrial fibrillation
 Mural thrombus
 Valvular lesions
 Atherosclerotic emboli post surgery
Non-occlusive
 Intra-abdominal tumours causing vascular compression
 Poor perfusion secondary to congestive cardiac failure, myocardial
infarction or hypovolaemia
Chronic Narrowing due to atherosclerosis
Incidence Range from 0.06 to 0.36% (8-10)
Gender Ratio No specific gender ratio
Age Predilection In unselected autopsies mesenteric ischaemia in 67% of those aged over 80
years. 29% in all unselected autopsies. (11)
Risk Factors (12) Thrombosis Systemic atherosclerosis
Embolism Recent myocardial infarction
Congestive cardiac failure
Arrythmias
Rheumatic fever
Non-occlusive Cardiogenic shock
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mesenteric ischaemia Cardiopulmonary bypass

Vasopressor agents
Sepsis
Burns

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Pancreatitis
Mesenteric venous Hypercoagulability
thrombosis Portal hypertension
Inflammation
Prior surgery
Trauma
Treatment [12] Medical Aggressive fluid resuscitation
Systemic blood pressure monitoring
Nasogastric tubing to decompress the stomach
Interventional Indicated for non-occlusive mesenteric ischaemia
radiology
Surgery Primary curative treatment
 Perform revascularisation
 Resect nonviable bowel
Prognosis 1-year (13-15) >60%
2-year (16) 70%
5-year (17) 50%
Findings on Imaging Duplex Scanning Presence of normal flow in the portal and mesenteric venous system helps
exclude portal vein thrombosis
Ascites and absent flow suggest mesenteric venous thrombosis (18)
Abdominal X-ray Excludes other causes of abdominal pain.
25% of confirmed Acute Mesenteric Ischaemia will be normal (19)
Abdominal CT Increased density in both arteries and veins
Maybe normal or non-diagnostic for acute mesenteric ischaemia
Contrast administration may show vessel occlusion, but chronic occlusion
cannot be discriminated from acute vessel thrombosis
Diagnostic modality for mesenteric vein thrombosis, sensitivity >90% (20-22)
 Superior mesenteric or portal vein appears large, with a central area of
low attenuation
 Contrast phase: rim may enhance vein wall
 Bowel thickening and presence of ascites
MRI High degree of accuracy in Mesenteric Vein Thrombosis (23)
Table 2: Summary table of acute mesenteric ischaemia

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 Gastrointestinal Radiology: Acute Mesenteric Ischaemia on Unenhanced Computer-Tomography Gupta et al.

ABBREVIATIONS
CT = Computer Tomogaphy
IV = intravenous
IU/L = international units/litre
HIV = human immunodeficiency virus
INR = International Normalisation Ratio
IU = International Units
L = Litre
Lt = Left
mmHg = millimeters of mercury
Rt = Right

KEYWORDS

Mesenteric Ischaemia, HIV

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