Bowel Ischemia

Dr. Ahmed Refaey

Consultant radiologist
Riyadh Military Hospital
Blood supply
 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 arterial supply of
the colon

 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
 Venous drainage of the colon
 Veins corresponding with arteries drain to
the superior and inferior mesenteric veins.
Blood supply of large intestine
Etiology
 Risk factors

* atrial fibrillation/flutter
* recent acute myocardial infarction
* hypovolemia or hypotension ( sepsis )
* coagulation disorders or malignancy
* portal hypertension/ cirrhosis
* medications
- vasopressin-digitalis-beta blockers
 Pathogenesis
 Mesenteric arterial or venous narrowing or
occlusion leading to inadequate supply of
oxygen to the bowel.
Classification
 Bowel ischemia
 Acute or chronic
 Occlusive or nonocclusive
 Arterial or venous
 Small bowel or large bowel .
{{ ischemic enteritis or ischemic colitis }}.
 Acute ischemia
 Acute interruption of blood flow to the bowel
 causes :
@ arterial
_ occlusive
* embolism {40-50%} : atrial fibrillation or endocarditis
(SMA most commonly involved)
* thrombosis { 20-40% } : atherosclerosis
* mechanical obstruction: strangulation, tumor
_ nonocclusive
hypoperfusion ( low flow states, hypotension, sepsis or
heart failure with diffuse mesenteric vasoconstriction )
( IMA most commonly involved )
@ venous
* Mesenteric venous thrombosis { 10% }
 .
 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
 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.
 .
 Clinical details :
* clinical triad of {sudden onset of
abdominal pain, diarrhea & vomiting}
* diffuse abdominal pain, out of
proportion to physical examination.
* leukocytosis
* gross rectal bleeding
 Chronic ischemia..
{ abdominal angina}

* * most commonly caused by

atherosclerosis of coeliac and SMAs &
symptoms are unlikely unless at least two
vessels are involved.
 .
** 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
* malabsorption
* weight loss
 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 )
 Ischemia causes increased permeability of
capillaries resulting in both submucosal edema
and hemorrhage.( of radiological importance )
 Ischemic colitis
 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
 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 .
 The clinical picture may mimic acute diverticulitis.
 Most common cause of colitis in elderly & is often self
limiting.
 .
 Prognosis of ischemic colitis

1. complete resolution (75%) within 1-3

months
2. Stricturing ischemia (20%)
3. Gangrenous with necrosis and
perforation (5%)
Imaging
 Imaging
 Plain abdominal radiography
 Barium study
 Angiography
 CT
 Imaging
 Plain abdominal radiograph
* abnormal in 20-40%
* thumbprinting ( non specific finding,
indicating intestinal wall edema with
haemorrhage
* pneumatosis
* PV gas
* pneumoperitoneum
( all indicative of bowel infarction)
 SMA
thrombosis
 .
 81 y old woman
with myocardial
infarction. Plain
abdominal
radiograph
shows air in the
wall of right
colon and small
& large bowel
dilatation.
Barium study
 Barium study
* small bowel
1 - thick, smooth valvulae
conniventes.
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”
 Thick, smooth
.
valvula connivents
(black arrows)
 Interspace
spicking (white
arrows)
 Thumbprinting
(arrow head)
.
 .
* large bowel
1- thumbprinting
(75%)
2- ulceration
3- loss of
interhaustral folds
4- luminal narrowing
5- confined to left
hemicolon (90%)
 .
 Segmental narrowing
of the entire
transverse colon .
Within the narrowed
segment, there are
multiple
thumbprinting
indentations
 .
 Postischemic
stricture , contain
pseudodiverticula
CT
 CT
 Examination of choice
 Sensitivity more than 95% ( MDCT )
 Identifies or excludes other pathologies
 Delineates cause,severity and complications.
 Guides management
 Acute ischemia, why CT ?
 Plain film– 33% sensitivity – non specific –
no information on causes, severity.
 Barium study – do NOT do , non-specific,
interfere with CT
 Angiography – technically difficult,
invasive, contraindicated in hypotensive
patients
 CT technique
 MDCT “if possible”
 Water oral contrast {1000 cc}
“ not positive OC “
 IV contrast : 3-5 ml/sec
 Arterial and PV phase
 .

CT findings

highly suggestive
Suggestive signs reliable signs
signs
 CT findings
• Suggestive signs
1* “double halo” or “ target” sign. ( edema of
the submucosa –low attinuation- with
brighter mucosal and serosal surfaces in CECT )
2* circumferential bowel wall thickening
3* focal / diffuse bowel dilatation
4* increased attinuation of mesenteric fat ( edema )
5* pneumatosis intestinalis
6* pneumoperitoneum
7* ascites
8* variable enhancement pattern
 .
 highly suggestive
signs:
1- bowel wall
thickening with
dilatation
 .
• reliable signs:
1- thromboembolism in
mesenteric vessels.
2- lack of enhancement of
the ischemic segment of
bowel.
3- Portal venous & mural
gas.
 .
 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.
.
Differential diagnosis
* 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)
 Infectious bowel diseases
 Causes of intramural hemorrhage:
1-ischemia
2-radiation
3-vasculitis –CT disease( SLE, RA,Henoch-
Schonlein purpura)
4-bleeding : from hemophilia, thrombocytopenic purpura,
anticoagulant therapy, DIC.
 .

 SBFT shows “stack of

coins” small bowel
fold pattern due to
ischemia,intramural
hge.
 .
 Axial CECT in 23 y old
woman with
hypercoagulable state
+ bowel ischemia.
Dilated fluid filled
small bowel +
thrombosis of SMV.
 .
 Axial CECT shows
dilates small bowel
with areas of wall
thickening (arrow).
Patient has severe
abdominal pain.
Bowel infarction from
atrial fibrillation.
 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.

.
CT demonstrate distension of the caecum. The bowel wall is
thickened, and contains multiple small intramural gas bubbles.
 .
 CT scan shows
thickening of the
transverse colon .
These findings
suggest a distribution
in superior mesenteric
artery territory.
 .
 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.
 .
 Top CT image shows
gas in the portal
venous system (blue
circle).
 Center image shows
thrombosed SMA
(blue arrow) .
 Lower cuts show
extensive
pneumatosis
intestinalis.
SMV thrombosis
 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
 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.
 .

 Pneumatosis coli
 .

 Splenic flexure to
descending colon
watershed
 Ischemic colitis
 .

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

 SMA embolus
 .

 SMV thrombosis
 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.
 .
 Diffuse wall thickening of
all colon.
 50 y old male
 Diarrhea, abdominal pain,
fever, leukocytosis
 Antibiotic (cephalosporin)
treatment since 2 weeks
 Pseudomembranous
colitis
 .
 Marked low attinuation caecal
wall thickening as well as
proximal transverse colon with
moderate pericolonic
inflammatory stranding
 45 y old male
 Bloody diarrhea/ abdominal
pain/ fever/vomiting.
 History of leukemia
 Neutropenia
 Typhlitis ( neutropenic colitis)
 .
 18 y old female
 Small bowel wall
thickening ( not
dilated)
 Mesenteric
inflammatory
stranding
 Mesenteric
adenopathy
 Crohn’s disease
 .
 15 y old boy
 Circumferential wall
thickening of
ascending colon
 Pericolic inflammatory
mesenteric fat
stranding
 Crohn’s 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
 .
 Axial CECT shows
mural thickening of
ascending + transvrse
colon plus dilated
mesenteric vessels.
 Infectious colitis
( campylobacter
colitis)
 .
 Diffuse colonic wall
thickness
 Antibiotic treatment
since 10 days
 Pseudomembranous
colitis
 .

 Thumbprinting of
transverse colon
 Ulcerative colitis
 .

 Pancolitis
 Diffuse wall
thickening of all colon
 Pseudomembranous
colitis.
 Complications

 Sepsis
 Septic shock
 Multiple system organ failure
 death
Mortality
 .
 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 colitis-------- 10% mortality rate
Conclusion
 .
 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.
 .

 Ischemic bowel disease is a clinico-

radiological diagnosis
 High clinical suspecion is key to early
diagnosis
 Prognosis depends on underlying cause
not imaging.
 Many classifications for bowel ischemia
{ arterial or venous}
{ occlusive or nonocclusive}
{ small or large bowel}
{ acute or chronic}
• Regardless the mechanism, the disease follows
the same course.
• Clinical picture is very important
• Vascular supply is important ( location predicts
distribution)
• CT findings are important { highly suggestive &
reliable}
• DD: inflammatory & infectious bowel diseases-
diseases causing submucosal hge and edema.