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CT Manifestations of Bowel Ischemia

¹ Department of Radiology, Chi Mei Foundation Hospital, 901 Chung Hwa Rd., Tainan 71010, Taiwan, Republic of China.

View larger version (105K): [in a new window]   Fig. 1. —51-year-old man with aortic dissection. Patient did not receive oral contrast material as evidenced by low-density gastric fluid. Contrast-enhanced axial CT scan reveals clear distinction between normally enhanced (arrows) and unenhanced (arrowheads) collapsed small-bowel loops. Normally enhanced duodenum and proximal jejunum were supplied by anastomotic branches from gastroduodenal artery and possible minimally patent jejunal artery. Aorta (A) and superior mesenteric artery (SMA) were occluded with thrombi-filled false lumen.

View larger version (111K): [in a new window]   Fig. 2. —63-year-old man with aortic dissection. Contrast-enhanced axial CT scan shows wall of fluid-distended small-bowel loops either normally enhanced (arrow) or totally unenhanced (arrowheads). Unenhanced bowel wall was isodense and not differentiable from intraluminal fluid.

View larger version (111K): [in a new window]   Fig. 3. —62-year-old woman with abdominal angina. Contrast-enhanced axial CT scan shows some small-bowel loops (arrowhead) with bowel wall density lower than other loops (arrow) but higher than luminal fluid. This enhancement is graded as suboptimal, implying that blood flow is present but less than normal.

View larger version (170K): [in a new window]   Fig. 4A. —74-year-old woman with atrial fibrillation. Superior mesenteric arteriogram clearly shows embolus (arrow) and suboptimally enhanced zones (arrowheads).

View larger version (162K): [in a new window]   Fig. 4B. —74-year-old woman with atrial fibrillation. Superior mesenteric arteriogram (same as A) obtained during venous phase shows suboptimally enhanced zones (arrowheads) with much less venous return than normally enhanced zones (arrow). This indicates intermediate degree of blood supply between normally enhanced and nearly totally unenhanced status.

View larger version (112K): [in a new window]   Fig. 5. —42-year-old man with small-bowel necrosis. Contrast-enhanced axial CT scan shows dilated small bowel with normally enhanced (arrow) and unenhanced mucosal folds (arrowheads).

View larger version (116K): [in a new window]   Fig. 6. —76-year-old man with hypotension before CT examination. Contrast-enhanced axial CT scan reveals some small-bowel loops with poor wall enhancement along antimesenteric side (arrowheads), so-called watershed zone, consistent with nonocclusive ischemia.

View larger version (108K): [in a new window]   Fig. 7A. —76-year-old man with atrial fibrillation. Contrast-enhanced axial CT scan reveals free gas in small-bowel mucosal folds and bowel wall (arrows, A), ascending colonic wall (c), and mesenteric (arrowhead) and intrahepatic portal veins. Poor portal perfusion of zones (asterisks, B) supplied by gas-filled portal veins was noted.

View larger version (130K): [in a new window]   Fig. 7B. —76-year-old man with atrial fibrillation. Contrast-enhanced axial CT scan reveals free gas in small-bowel mucosal folds and bowel wall (arrows, A), ascending colonic wall (c), and mesenteric (arrowhead) and intrahepatic portal veins. Poor portal perfusion of zones (asterisks, B) supplied by gas-filled portal veins was noted.

View larger version (85K): [in a new window]   Fig. 8. —57-year-old man with aortic dissection. Contrast-enhanced axial CT scan shows mucosa was edematous and suboptimally enhanced (arrow) compared with other normally enhanced mucosa (arrowhead). Submucosal edema was evident.

View larger version (105K): [in a new window]   Fig. 9A. —70-year-old man with septic shock. Unenhanced axial CT scan shows ascending and transverse colonic wall was thickened (arrowheads) and of attenuation.

View larger version (95K): [in a new window]   Fig. 9B. —70-year-old man with septic shock. Contrast-enhanced axial CT scan shows mucosa was normally enhanced (arrow) after IV contrast administration. Edematous submucosa (arrowhead) reveals mild enhancement, with increase of approximately 10 H on average, indicating contrast medium extravasation.

View larger version (101K): [in a new window]   Fig. 10. —64-year-old man with paroxysmal atrial fibrillation. Superior mesenteric arteriogram obtained during venous phase shows contrast medium stasis in thickened wall (arrow) consistent with contrast extravasation into edematous submucosa during reperfusion stage.

View larger version (85K): [in a new window]   Fig. 11A. —70-year-old woman with atrial fibrillation. Unenhanced axial CT scan shows intermediate density—thickened transverse colonic wall (arrowhead).

View larger version (83K): [in a new window]   Fig. 11B. —70-year-old woman with atrial fibrillation. Contrast-enhanced axial CT scan obtained after IV contrast administration shows bowel wall was enhanced (arrowhead), with increase of approximately 30-40 H on average, consistent with contrast medium extravasation into hemorrhagic wall.

View larger version (138K): [in a new window]   Fig. 12A. —84-year-old man with atrial fibrillation who received digitalis. Contrast-enhanced axial CT scan shows mucosa was normally enhanced (black arrowheads). Submucosa shows either edematous change (arrow), nearly isodense to ascites, or hemorrhagic change (white arrowhead), hyperdense to ascites.

View larger version (133K): [in a new window]   Fig. 12B. —84-year-old man with atrial fibrillation who received digitalis. Angiogram obtained during venous phase shows normal mucosal enhancement (arrowhead) and thickened unenhanced submucosa (arrow), indicating submucosa has been mainly occupied by reperfused extravasated blood.

View larger version (103K): [in a new window]   Fig. 13. —77-year-old woman with portal vein encasement by tumor infiltration. Contrast-enhanced axial CT scan shows mucosa (arrowheads) was not enhanced and not differentiable from submucosal edema. Other small bowels showed various degrees of enhancement.

View larger version (102K): [in a new window]   Fig. 14. —68-year-old man with adhesion-induced small-bowel obstruction. Contrast-enhanced axial CT scan shows mucosa was normally enhanced and submucosa was thickened and of various densities (arrows), indicating extravasation of contrast material or blood.

View larger version (147K): [in a new window]   Fig. 15A. —Three patients with small-bowel volvulus. Contrast-enhanced axial CT scan shows small bowel in 76-year-old man with normal mucosal enhancement (arrowhead) and submucosal enhancement or hemorrhage (arrow). Mesentery (asterisk) has density higher than simple fluid, consistent with hemorrhagic component.

View larger version (116K): [in a new window]   Fig. 15B. —Three patients with small-bowel volvulus. Contrast-enhanced axial CT scan shows that closed bowel loop (arrowheads) in 48-year-old man was nearly totally filled with fluid. Bowel wall was thin and unenhanced.

View larger version (158K): [in a new window]   Fig. 15C. —Three patients with small-bowel volvulus. Contrast-enhanced axial CT scan shows intermediate density of luminal fluid (asterisk) in 40-year-old woman was consistent with, but not diagnostic of, bloody contents, which was confirmed by surgical specimen.

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