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Bowel Ischemia Bowel Ischemia Consultant radiologist Consultant radiologist Riyadh Military Hospital Riyadh Military Hospital Dr. Ahmed Refaey.

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Presentation on theme: "Bowel Ischemia Bowel Ischemia Consultant radiologist Consultant radiologist Riyadh Military Hospital Riyadh Military Hospital Dr. Ahmed Refaey."— Presentation transcript:

1 Bowel Ischemia Bowel Ischemia Consultant radiologist Consultant radiologist Riyadh Military Hospital Riyadh Military Hospital Dr. Ahmed Refaey

2 Blood supply

3 Blood supply of small intestine The entire small intestine is supplied by the superior mesenteric artery and drain to the superior mesenteric vein, which in turn drains to the portal vein. The entire small intestine is supplied by the superior mesenteric artery and drain to the superior mesenteric vein, which in turn drains to the portal vein.

4 The arterial supply of the colon That right part of the colon to the midtransverse colon is supplied by the superior mesentric artery That right part of the colon to the midtransverse colon is supplied by the superior mesentric artery The inferior mesenteric artery supplies the colon as far as the upper rectum The inferior mesenteric artery supplies the colon as far as the upper rectum

5 Venous drainage of the colon Veins corresponding with arteries drain to the superior and inferior mesenteric veins. Veins corresponding with arteries drain to the superior and inferior mesenteric veins.

6 Blood supply of large intestine

7 Etiology

8 Risk factors * atrial fibrillation/flutter * atrial fibrillation/flutter * recent acute myocardial infarction * recent acute myocardial infarction * hypovolemia or hypotension ( sepsis ) * hypovolemia or hypotension ( sepsis ) * coagulation disorders or malignancy * coagulation disorders or malignancy * portal hypertension/ cirrhosis * portal hypertension/ cirrhosis * medications * medications - vasopressin-digitalis-beta blockers - vasopressin-digitalis-beta blockers

9 Pathogenesis Mesenteric arterial or venous narrowing or occlusion leading to inadequate supply of oxygen to the bowel. Mesenteric arterial or venous narrowing or occlusion leading to inadequate supply of oxygen to the bowel.

10 Classification

11 Bowel ischemia Acute or chronic Acute or chronic Occlusive or nonocclusive Occlusive or nonocclusive Arterial or venous Arterial or venous Small bowel or large bowel. Small bowel or large bowel. {{ ischemic enteritis or ischemic colitis }}. {{ ischemic enteritis or ischemic colitis }}.

12 Acute ischemia Acute interruption of blood flow to the bowel Acute interruption of blood flow to the bowel causes : causes : @ arterial @ arterial _ occlusive _ occlusive * embolism {40-50%} : atrial fibrillation or endocarditis * embolism {40-50%} : atrial fibrillation or endocarditis (SMA most commonly involved) (SMA most commonly involved) * thrombosis { 20-40% } : atherosclerosis * thrombosis { 20-40% } : atherosclerosis * mechanical obstruction: strangulation, tumor * mechanical obstruction: strangulation, tumor _ nonocclusive _ nonocclusive hypoperfusion ( low flow states, hypotension, sepsis or hypoperfusion ( low flow states, hypotension, sepsis or heart failure with diffuse mesenteric vasoconstriction ) heart failure with diffuse mesenteric vasoconstriction ) ( IMA most commonly involved ) ( IMA most commonly involved ) @ venous @ venous * Mesenteric venous thrombosis { 10% } * Mesenteric venous thrombosis { 10% }

13 . Arterial sources occur more frequently than venous sources by a ratio of 9:1 Arterial sources occur more frequently than venous sources by a ratio of 9:1 Similarly, arterial occlusive disease occur more frequently than nonocclusive disease by a ratio of 9:1 Similarly, arterial occlusive disease occur more frequently than nonocclusive disease by a ratio of 9:1 Large or smaller segments of bowel may be involved, depending on the location of the occlusion Large or smaller segments of bowel may be involved, depending on the location of the occlusion Regardless the mechanism, the disease follows the same course. Regardless the mechanism, the disease follows the same course.

14 . Clinical details : Clinical details : * clinical triad of {sudden onset of abdominal pain, diarrhea & vomiting} * clinical triad of {sudden onset of abdominal pain, diarrhea & vomiting} * diffuse abdominal pain, out of proportion to physical examination. * diffuse abdominal pain, out of proportion to physical examination. * leukocytosis * leukocytosis * gross rectal bleeding * gross rectal bleeding

15 . Chronic ischemia. Chronic ischemia. { abdominal angina} { abdominal angina} * * most commonly caused by atherosclerosis of coeliac and SMAs & symptoms are unlikely unless at least two vessels are involved. * * most commonly caused by atherosclerosis of coeliac and SMAs & symptoms are unlikely unless at least two vessels are involved.

16 . ** clinical details ** clinical details * post-prandial abdominal pain, 15-20 minutes after food intake ( due to “gastric steal” diverting blood flow away from intestine ) and the pain subsides 1-2 hours after meal. * fear of eating large meals * fear of eating large meals * malabsorption * malabsorption * weight loss * weight loss

17 Pathophysiology of bowel ischemia Mucosa is most sensitive area to anoxia from arterial / venous occlusion with early ulceration, later on necrosis and perforation occur.( of clinical importance ) Mucosa is most sensitive area to anoxia from arterial / venous occlusion with early ulceration, later on necrosis and perforation occur.( of clinical importance ) Ischemia causes increased permeability of capillaries resulting in both submucosal edema and hemorrhage.( of radiological importance ) Ischemia causes increased permeability of capillaries resulting in both submucosal edema and hemorrhage.( of radiological importance )

18 Ischemic colitis Most cases are thought to be related to diminished blood flow within the bowel Most cases are thought to be related to diminished blood flow within the bowel Predominantly a disease involving the distribution of IMA.i.e., from distal transverse colon to rectum Predominantly a disease involving the distribution of IMA.i.e., from distal transverse colon to rectum When the more proximal colon is involved, it is frequently associated with extensive small bowel ischemia & a correspondingly much graver prognosis. When the more proximal colon is involved, it is frequently associated with extensive small bowel ischemia & a correspondingly much graver prognosis. Patients are usually elderly. Patients are usually elderly. The clinical picture may mimic acute diverticulitis. The clinical picture may mimic acute diverticulitis. Most common cause of colitis in elderly & is often self limiting. Most common cause of colitis in elderly & is often self limiting.

19 . Prognosis of ischemic colitis Prognosis of ischemic colitis 1. complete resolution (75%) within 1-3 months 2. Stricturing ischemia (20%) 3. Gangrenous with necrosis and perforation (5%)

20 Imaging

21 Imaging Plain abdominal radiography Plain abdominal radiography Barium study Barium study Angiography Angiography CT CT

22 Imaging Plain abdominal radiograph Plain abdominal radiograph * abnormal in 20-40% * abnormal in 20-40% * thumbprinting ( non specific finding, indicating intestinal wall edema with haemorrhage * thumbprinting ( non specific finding, indicating intestinal wall edema with haemorrhage * pneumatosis * pneumatosis * PV gas * PV gas * pneumoperitoneum * pneumoperitoneum ( all indicative of bowel infarction) ( all indicative of bowel infarction)

23 SMA thrombosis

24 . 81 y old woman with myocardial infarction. Plain abdominal radiograph shows air in the wall of right colon and small & large bowel dilatation. 81 y old woman with myocardial infarction. Plain abdominal radiograph shows air in the wall of right colon and small & large bowel dilatation.

25 Barium study

26 * small bowel * small bowel 1 - thick, smooth valvulae conniventes. 2 - Barium trapped between the thick folds produces the “ interspace spicking” 2 - Barium trapped between the thick folds produces the “ interspace spicking” 3 – (1:2) cm submucosal fluid or blood collections can form, known as “ thumbprinting” 3 – (1:2) cm submucosal fluid or blood collections can form, known as “ thumbprinting”

27 . Thick, smooth valvula connivents Thick, smooth valvula connivents (black arrows) (black arrows) Interspace spicking (white arrows) Interspace spicking (white arrows) Thumbprinting Thumbprinting (arrow head) (arrow head)

28 .

29 . * large bowel * large bowel 1- thumbprinting (75%) 1- thumbprinting (75%) 2- ulceration 2- ulceration 3- loss of interhaustral folds 3- loss of interhaustral folds 4- luminal narrowing 4- luminal narrowing 5- confined to left hemicolon (90%) 5- confined to left hemicolon (90%)

30 . Segmental narrowing of the entire transverse colon. Within the narrowed segment, there are multiple thumbprinting indentations Segmental narrowing of the entire transverse colon. Within the narrowed segment, there are multiple thumbprinting indentations

31 . Postischemic stricture, contain pseudodiverticula Postischemic stricture, contain pseudodiverticula

32 CT

33 CT Examination of choice Examination of choice Sensitivity more than 95% ( MDCT ) Sensitivity more than 95% ( MDCT ) Identifies or excludes other pathologies Identifies or excludes other pathologies Delineates cause,severity and complications. Delineates cause,severity and complications. Guides management Guides management

34 Acute ischemia, why CT ? Plain film– 33% sensitivity – non specific – no information on causes, severity. Plain film– 33% sensitivity – non specific – no information on causes, severity. Barium study – do NOT do, non-specific, interfere with CT Barium study – do NOT do, non-specific, interfere with CT Angiography – technically difficult, invasive, contraindicated in hypotensive patients Angiography – technically difficult, invasive, contraindicated in hypotensive patients

35 CT technique MDCT “if possible” MDCT “if possible” Water oral contrast {1000 cc} “ not positive OC “ Water oral contrast {1000 cc} “ not positive OC “ IV contrast : 3-5 ml/sec IV contrast : 3-5 ml/sec Arterial and PV phase Arterial and PV phase

36 . CT findings Suggestive signs highly suggestive signs reliable signs

37 CT findings Suggestive signs Suggestive signs 1* “double halo” or “ target” sign. ( edema of 1* “double halo” or “ target” sign. ( edema of the submucosa –low attinuation- with the submucosa –low attinuation- with brighter mucosal and serosal surfaces in CECT ) brighter mucosal and serosal surfaces in CECT ) 2* circumferential bowel wall thickening 2* circumferential bowel wall thickening 3* focal / diffuse bowel dilatation 3* focal / diffuse bowel dilatation 4* increased attinuation of mesenteric fat ( edema ) 4* increased attinuation of mesenteric fat ( edema ) 5* pneumatosis intestinalis 5* pneumatosis intestinalis 6* pneumoperitoneum 6* pneumoperitoneum 7* ascites 7* ascites 8* variable enhancement pattern 8* variable enhancement pattern

38 . highly suggestive signs: highly suggestive signs: 1- bowel wall thickening with dilatation 1- bowel wall thickening with dilatation

39 . reliable signs: reliable signs: 1- thromboembolism in mesenteric vessels. 1- thromboembolism in mesenteric vessels. 2- lack of enhancement of the ischemic segment of bowel. 2- lack of enhancement of the ischemic segment of bowel. 3- Portal venous & mural gas. 3- Portal venous & mural gas.

40 . A reliable method to differentiate arterial causes from venous causes is depiction of the characteristic bowel wall enhancement pattern. Arterial occlusive disease demonstrate no enhancement of the involved segment, whereas venous occlusive disease or hypoperfusion reveal marked contrast enhancement and retention 2ry to stagnant flow, with thickening of bowel wall. A reliable method to differentiate arterial causes from venous causes is depiction of the characteristic bowel wall enhancement pattern. Arterial occlusive disease demonstrate no enhancement of the involved segment, whereas venous occlusive disease or hypoperfusion reveal marked contrast enhancement and retention 2ry to stagnant flow, with thickening of bowel wall.

41 .

42 Differential diagnosis

43 * Causes of intramural edema ( hypoprotinemia, lymphatic blockage 2ry to tumor, inflammatory infiltrate like graft vs host disease and esinophilic enteritis. Inflammatory bowel disease (Crohn disease-UC) Inflammatory bowel disease (Crohn disease-UC) Infectious bowel diseases Infectious bowel diseases Causes of intramural hemorrhage: Causes of intramural hemorrhage: 1-ischemia 1-ischemia 2-radiation 2-radiation 3-vasculitis –CT disease( SLE, RA,Henoch- Schonlein purpura) 3-vasculitis –CT disease( SLE, RA,Henoch- Schonlein purpura) 4-bleeding : from hemophilia, thrombocytopenic purpura, anticoagulant therapy, DIC. 4-bleeding : from hemophilia, thrombocytopenic purpura, anticoagulant therapy, DIC.

44

45 . SBFT shows “stack of coins” small bowel fold pattern due to ischemia,intramural hge. SBFT shows “stack of coins” small bowel fold pattern due to ischemia,intramural hge.

46

47 . Axial CECT in 23 y old woman with hypercoagulable state + bowel ischemia. Dilated fluid filled small bowel + thrombosis of SMV. Axial CECT in 23 y old woman with hypercoagulable state + bowel ischemia. Dilated fluid filled small bowel + thrombosis of SMV.

48 . Axial CECT shows dilates small bowel with areas of wall thickening (arrow). Patient has severe abdominal pain. Bowel infarction from atrial fibrillation. Axial CECT shows dilates small bowel with areas of wall thickening (arrow). Patient has severe abdominal pain. Bowel infarction from atrial fibrillation.

49 . Patient with acute ischemia, grossly thickened wall of the splenic flexure and descending colon. There is intraperitoneal air in the subhepatic region & Morrison’s pouch. Patient with acute ischemia, grossly thickened wall of the splenic flexure and descending colon. There is intraperitoneal air in the subhepatic region & Morrison’s pouch.

50 . CT demonstrate distension of the caecum. The bowel wall is thickened, and contains multiple small intramural gas bubbles. CT demonstrate distension of the caecum. The bowel wall is thickened, and contains multiple small intramural gas bubbles.

51 . CT scan shows thickening of the transverse colon. These findings suggest a distribution in superior mesenteric artery territory. CT scan shows thickening of the transverse colon. These findings suggest a distribution in superior mesenteric artery territory.

52 . CT confirms the presence of air in the portal venous system and proximal small bowel mucosal edema. These findings suggest ischemia of the affected bowel. CT confirms the presence of air in the portal venous system and proximal small bowel mucosal edema. These findings suggest ischemia of the affected bowel.

53 . Top CT image shows gas in the portal venous system (blue circle). Top CT image shows gas in the portal venous system (blue circle). Center image shows thrombosed SMA (blue arrow). Center image shows thrombosed SMA (blue arrow). Lower cuts show extensive pneumatosis intestinalis. Lower cuts show extensive pneumatosis intestinalis.

54 SMV thrombosis

55 Ischemic colitis The enema confirms the appearance of mucosal thickening and localizes the affected bowel to distal transverse colon, splenic flexure and proximal descending colon The enema confirms the appearance of mucosal thickening and localizes the affected bowel to distal transverse colon, splenic flexure and proximal descending colon

56 Ischemic colitis The enema confirms the appearance of mucosal thickening and localizes the affected bowel to distal transverse colon, splenic flexure and proximal descending colon. The enema confirms the appearance of mucosal thickening and localizes the affected bowel to distal transverse colon, splenic flexure and proximal descending colon.

57 . Pneumatosis coli Pneumatosis coli

58 . Splenic flexure to descending colon watershed Splenic flexure to descending colon watershed Ischemic colitis Ischemic colitis

59 . Abscent enhancement Abscent enhancement IMA occlusion {left colic bransh} IMA occlusion {left colic bransh}

60 . SMA embolus SMA embolus

61 . SMV thrombosis SMV thrombosis

62 Ischemic colitis CT image in 22 y old woman with ischemic colitis after blunt abdominal trauma to right flank demonestrate marked thickening of hepatic flexure and right colon, with abrupt transition (arrows) between abnormal and normal wall in the transverse colon. CT image in 22 y old woman with ischemic colitis after blunt abdominal trauma to right flank demonestrate marked thickening of hepatic flexure and right colon, with abrupt transition (arrows) between abnormal and normal wall in the transverse colon.

63 . Diffuse wall thickening of all colon. Diffuse wall thickening of all colon. 50 y old male 50 y old male Diarrhea, abdominal pain, fever, leukocytosis Diarrhea, abdominal pain, fever, leukocytosis Antibiotic (cephalosporin) treatment since 2 weeks Antibiotic (cephalosporin) treatment since 2 weeks Pseudomembranous colitis Pseudomembranous colitis

64 . Marked low attinuation caecal wall thickening as well as proximal transverse colon with moderate pericolonic inflammatory stranding Marked low attinuation caecal wall thickening as well as proximal transverse colon with moderate pericolonic inflammatory stranding 45 y old male 45 y old male Bloody diarrhea/ abdominal pain/ fever/vomiting. Bloody diarrhea/ abdominal pain/ fever/vomiting. History of leukemia History of leukemia Neutropenia Neutropenia Typhlitis ( neutropenic colitis) Typhlitis ( neutropenic colitis)

65 . 18 y old female 18 y old female Small bowel wall thickening ( not dilated) Small bowel wall thickening ( not dilated) Mesenteric inflammatory stranding Mesenteric inflammatory stranding Mesenteric adenopathy Mesenteric adenopathy Crohn’s disease Crohn’s disease

66 . 15 y old boy 15 y old boy Circumferential wall thickening of ascending colon Circumferential wall thickening of ascending colon Pericolic inflammatory mesenteric fat stranding Pericolic inflammatory mesenteric fat stranding Crohn’s disease Crohn’s disease

67 . Axial CECT shows narrowed lumen and thickened wall of descending colon. Submucosal halo of low density (edema) and engorged blood vessels indicate active disease. Axial CECT shows narrowed lumen and thickened wall of descending colon. Submucosal halo of low density (edema) and engorged blood vessels indicate active disease. Ulcerative colitis Ulcerative colitis

68 . Axial CECT shows mural thickening of ascending + transvrse colon plus dilated mesenteric vessels. Axial CECT shows mural thickening of ascending + transvrse colon plus dilated mesenteric vessels. Infectious colitis ( campylobacter colitis) Infectious colitis ( campylobacter colitis)

69 . Diffuse colonic wall thickness Diffuse colonic wall thickness Antibiotic treatment since 10 days Antibiotic treatment since 10 days Pseudomembranous colitis Pseudomembranous colitis

70 . Thumbprinting of transverse colon Thumbprinting of transverse colon Ulcerative colitis Ulcerative colitis

71 . Pancolitis Pancolitis Diffuse wall thickening of all colon Diffuse wall thickening of all colon Pseudomembranous colitis. Pseudomembranous colitis.

72 Complications Sepsis Sepsis Septic shock Septic shock Multiple system organ failure Multiple system organ failure death death

73 Mortality

74 . Occlusive mesenteric infarction { embolus or thrombosis } has a 90% mortality rate, whereas non-occlusive disease has a 10% mortality rate. Occlusive mesenteric infarction { embolus or thrombosis } has a 90% mortality rate, whereas non-occlusive disease has a 10% mortality rate. Ischemic enteritis----- 90% mortality rate Ischemic enteritis----- 90% mortality rate Ischemic colitis-------- 10% mortality rate Ischemic colitis-------- 10% mortality rate

75 Conclusion

76 . The diagnosis of mesenteric ischemia often is a challenge to both clinicians and radiologists. Patients with inflammatory bowel disease and infectious colitis can present with similar physical signs and symptoms, including cramping abdominal pain,bloody diarrhea & leukocytosis. The diagnosis of mesenteric ischemia often is a challenge to both clinicians and radiologists. Patients with inflammatory bowel disease and infectious colitis can present with similar physical signs and symptoms, including cramping abdominal pain,bloody diarrhea & leukocytosis. Bowel wall thickening is a finding common to all 3 types of disease, however,the pattern of vascular distribution can sometime narrow the differential diagnosis. Bowel wall thickening is a finding common to all 3 types of disease, however,the pattern of vascular distribution can sometime narrow the differential diagnosis.

77 . Ischemic bowel disease is a clinico- radiological diagnosis Ischemic bowel disease is a clinico- radiological diagnosis High clinical suspecion is key to early diagnosis High clinical suspecion is key to early diagnosis Prognosis depends on underlying cause not imaging. Prognosis depends on underlying cause not imaging.

78 Many classifications for bowel ischemia Many classifications for bowel ischemia { arterial or venous} { arterial or venous} { occlusive or nonocclusive} { occlusive or nonocclusive} { small or large bowel} { small or large bowel} { acute or chronic} { acute or chronic} Regardless the mechanism, the disease follows the same course. Regardless the mechanism, the disease follows the same course. Clinical picture is very important Clinical picture is very important Vascular supply is important ( location predicts distribution) Vascular supply is important ( location predicts distribution) CT findings are important { highly suggestive & reliable} CT findings are important { highly suggestive & reliable} DD: inflammatory & infectious bowel diseases- diseases causing submucosal hge and edema. DD: inflammatory & infectious bowel diseases- diseases causing submucosal hge and edema.

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