Acute mesenteric ischemia (AMI), which is a consequence of impaired

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1 Dign Interv Rdiol 2009; 15: Turkish Soiety of Rdiology 2009 ABDOMINAL IMAGING PICTORIAL ESSAY Utility of multidetetor CT in n emergeny setting in ute mesenteri ishemi Brış Türkey, Erhn Akpınr, Brros Çil, Muştury Krçltın, Okn Akhn ABSTRACT Prompt dignosis of ute mesenteri ishemi is dilemm whih is unfortuntely generlly mde t the irreversile phse of intestinl dmge. Besides onventionl dignosti imging modlities ontrst enhned multidetetor omputed tomogrphy ngiogrphy enles fst nd detiled evlution of the mesenteri irultion nd dominl viser whih provides urte nd rpid dignosis in the emergeny room. Key words: omputed tomogrphy dominl pin mesenteri vsulr olusion From the Deprtment of Rdiology (B.T. turkey@yhoo. om), Hettepe University Shool of Mediine, Ankr, Turkey. Reeived 29 Ferury 2008; revision requested 29 Ferury 2008; revision reeived 1 Mrh 2008; epted 3 Mrh Pulished online 5 Otoer 2009 DOI / DIR Aute mesenteri ishemi (AMI), whih is onsequene of impired lood flow to the gstrointestinl trt, is life-thretening entity with n estimted mortlity rte rnging etween 60% nd 90% (1 3). Among mjor etiologies of AMI re superior mesenteri rtery (SMA) emolus, SMA thromus, superior mesenteri vein (SMV) thromosis nd non-olusive vsoonstrition (1). Minor uses of AMI inlude orti dissetion, intestinl volvulus, internl herni, nd dhesion nd relted extrinsi ompression of the mesenteri vessels (4, 5). Although it is reltively rre (round 1% of ll ute domen referrls), prompt dignosis nd tretment of AMI is importnt sine erly mngement of this linil entity inreses survivl (6). Dignosis of ute mesenteri ishemi Dignosis of AMI requires strong suspiion sine the linil fetures re usully non-speifi suh s dominl pin, nuse, vomiting, or even dirrhe (7). Until lte 1960s, surgil explortion or utopsy ws used for dignosis; then imging modlities me into use s new dignosti tools (8). Plin rdiogrphy nd ultrsound re generlly initil modlities used in ptients presenting with ute domen in n emergeny room, ut their role is limited in the demonstrtion of primry nd seondry signs of AMI. On plin rdiogrphs, dilted owel segments with ir-fluid levels, pneumtosis nd portl venous gs n e seen, wheres ultrsound n demonstrte mesenteri thromus vi Doppler mode ut the presene of extensive gs within owel segments nd inompline of ptients my limit the ury of this imging modlity (6, 8, 9). Digitl sutrtion ngiogrphy (DSA) hs een regrded s the gold stndrd imging method in the setting of AMI. It not only enles diret visuliztion of the mesenteri vsulture ut lso provides prompt endovsulr intervention opportunity (10). On the other hnd, DSA is invsive, expensive, needs experiene nd, unfortuntely, not redily ville (10). Computed tomogrphy (CT) eme powerful tool in the mngement of AMI with the introdution of multidetetor tehnology, s it provides diret visuliztion of the mesenteri vsulture, intestines nd mesentery (7). With its high sptil resolution nd volumetri 3 dimensionl reonstrutions, multidetetor CT ngiogrphy (MDCTA) llows diret non-invsive visuliztion of the etiology of AMI nd its insults on the intestines, nd ssoited findings/pthologies through gret ntomil detil window (6, 11). Mgneti resonne (MR) ngiogrphy is nother non-invsive tool for the detetion of AMI y determining mesenteri flow. It n e used s seond hoie in hildren ut its power is y fr limited in the demonstrtion of lified plques (12, 13). 256

2 d Figure 1. d. A 67- yer-old femle who presented with ute dominl pin. Contrst enhned xil CT imges (, ) show emolus within the superior mesenteri rtery (rrow, ) nd sutle murl thikening of intestinl loops (rrows, ). Coronl volume-rendered () nd reformtted MIP (d) imges show ute esstion of flow within the superior mesenteri rtery (rrowheds). Figure 2.. A 44-yer-old mle who presented with dominl nd flnk pin. Axil ontrst-enhned CT imges show thromus within the left ventrile (rrow, ), tringulr hypodense lesion in the right kidney onsistent with n ute infrt (rrowheds,, ), nd n ishemi smll owel segment (rrows,, ) seondry to ute thromus of rdi origin. MDCT fetures of ute mesenteri ishemi Aute emolism in the SMA is the leding use of AMI ounting for nerly 40 50% of ll ses. Olusive emoli n e redily deteted within the lumen nd is generlly lolized eyond the middle oli rtery origin leding to rupt esstion of ontrst mteril flow within vessel lumen; dditionlly, no or few ollterls re seen seondry to ute nture of the pthology (13) (Figs. 1 nd 2). Volume 15 Issue 4 Utility of multidetetor CT in n emergeny setting in ute mesenteri ishemi 257

3 Figure 3.,. Axil ontrst-enhned CT imges of 77-yer-old femle who presented with dirrhe nd ute dominl pin. A lified therosleroti lesion is seen t the wll of superior mesenteri rtery (thik rrow, ). Adjent to therosleroti plques, long segment of hypodense thromus is seen (thin rrow, ). Moreover, sutle murl thikening (rrow, ) seondry to thromus is seen in intestinl loops on the right. Figure 4.. A 54- yer-old mle with history of hroni liver disese who presented with diffuse dominl pin. Axil ontrst enhned CT imges show thromus within the superior mesenteri vein (rrow, ) nd sites (sterisk, ) nd pneumtosis intestinlis onsistent with smll owel infrtion (rrows, nd ). In AMI seondry to mesenteri rteril thromosis (ounting for nerly 20 30% of ptients), there is lmost lwys n ompnying preexisting theroslerosis (13). Thromus is generlly seen reltively hypodense just djent to n therosleroti lesion, nd there n e ollterls sine the pthology is lmost lwys insidious (7) (Fig. 3). Mesenteri venous thromosis is rre, ut potentilly life-thretening, entity ourring more ommonly in 258 Deemer 2009 Dignosti nd Interventionl Rdiology hyperogulle sttes, trum, portl hypertension, splenetomy, losed loop ostrution nd inflmmtory owel disese (6, 14). It ounts for 5 15% of AMI ses (7). Mesenteri venous thromus is seen s fol rounded hypottenuting lesion with peripherl ontrst enhnement; thikness of enhnement round the venous thromus depends on the degree of ostrution (prtil or totl) (7). Mesenteri venous olusion results in edem of the intestinl muos whih onsequently results in rteril hypoperfusion if remins untreted (15) (Fig. 4). Non-olusive (vsoonstritive) mesenteri ishemi is thought to e responsile for nerly 25% of AMI ses with reltively high mortlity rte (16). It develops seondry to rdiogeni shok following rdi infrtion, hypovolemi nd hemorrhge, ongestive hert filure, rrhythmi, orti insuffiieny, or ingestion of drugs leding to vsoonstrition suh s rdiotonis nd mphetmines (17, 18). Ctheter ngiogrphy is onsidered s the gold stndrd for the dignosis of non-olusive mesenteri ishemi. Mjor ngiogrphi findings re diffuse smll mesenteri rtery rnhes, kflow of mesenteri ontrst mteril to the ort, deresed flow in distl rnhes nd deresed mesenteri venous return. However, ll of these findings n e reversed vi ppverine dministrtion. Nevertheless, CT findings of this entity were defined reently in few se reports Türkey et l.

4 Figure 5.. A 44-yer-old mle with history of hroni kidney disese nd reent kidney iopsy (10 dys erlier) who presented with hypovolemi shok. Axil ontrst enhned dominl CT imge () shows signifint hyperdense symmetri enlrgement of the left psos musle onsistent with ute retroperitonel hemtom (sterisk); the superior mesenteri rtery lier is signifintly thinner thn norml (rrow); moreover, pneumtosis intestinlis is seen on the right side (rrowheds). Axil CT imge t the superior liver level () shows ir within the portl vein rnhes (rrows). Seletive superior mesenteri rtery injetion during theter ngiogrphy () is negtive for olusive uses; however, reflux of the seletively dministered ontrst mteril to the ort is seen. Figure 6. A 70-yer-old mle who presented with ute dominl pin. Axil ontrst enhned CT imge shows ute olusion of the inferior mesenteri rtery (rrow) nd signifint mesenteri strnding (rrowhed) djent to the desending olon seondry to ute ishemi. s ptent SMA trunk, diffuse smll side rnhes tht n not e visulized within distl 3 m of mesentery, nd sene of owel wll thikening (19) (Fig. 5). The most ommon finding of AMI regrding the intestines is murl thikening whih is typilly symmetri nd irumferentil (20) (Fig. 6). Bowel wll thikening is more ommonly seen in mesenteri venous olusion rther thn in mesenteri rteril olusion in whih owel wll n e s thin s pper due to the ishemi insult on musle nd nerve tissues (21, 22). Murl thikening n e homogenous or heterogeneous with high density res refleting hemorrhge ompnying hypoperfusion (23). Lk of ontrst enhnement in owel segments is diret finding of sene of lood flow to the relted owel segment inditing infrtion (24) (Fig. 7). Bowel dilttion is generlly pronouned in the stge of irreversile trnsmurl ishemi or infrtion tht interferes with peristlsis (21). Intrmurl gs (pneumtosis) nd portl venous gs re strong inditors of infrtion nd worse prognosis, ut they my e seen in other onditions suh s over-distension, trum, infetions, neoplsm, nd penetrting ulers (25) (Fig. 8). Volume 15 Issue 4 Utility of multidetetor CT in n emergeny setting in ute mesenteri ishemi 259

5 Figure 7.. A 87-yer-old femle who presented with ute dominl pin. Coronl olique volume-rendered () nd mximum intensity projetion () CT imges show ute olusion of the distl superior mesenteri rtery (rrow, ; thin rrow, ). Lk of wll enhnement onsistent with infrtion is seen t the level of the distl ileum nd ileoel vlve on oth oronl mximum intensity projetion nd xil CT () imges (thik rrow, ; rrow, ). Figure 8.,. A 70-yer-old mle who presented with vgue ute dominl pin. Axil ontrst enhned CT imge t lung prenhym window setting () shows extensive ir within rnhes of the left portl vein onsistent with pneumoport (rrows). Additionlly, extensive ir within the intestinl wll inditing pneuomtosis intestinlis () is seen. Figure 9.,. A 41-yer-old femle who presented with ute oliky dominl pin ongoing for 4 hours. Coronl reformtted CT imge () shows rupt esstion of flow within the superior mesenteri rtery seondry to volvulus (rrowhed). Axil ontrst enhned CT imge () shows mlrotted owel segments on the left with prominent perfusion defet ompred to the right side (rrows). Moreover, distension of the proximl owel segments with ompnying whirlpool sign is seen (rrowhed, ). In se of smll owel dilttion, strngultion nd ishemi should e suspeted if there is sites, diffuse mesenteri edem, mesenteri vsulr engorgement, smll owel fees sign, nd whirlpool sign of mesenteri vessels. These signs re regrded s nillry CT findings of AMI, in ddition to deresed murl enhnement (26) (Fig. 9). These findings, however, re nonspeifi nd n e seen in wide rnge of ute domen ptients suh s those with pnretitis, peritonitis, inflmmtory owel disese, perforted uler, nd sess (7). 260 Deemer 2009 Dignosti nd Interventionl Rdiology Türkey et l.

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