CT Imaging of Acute Bowel Ischemia and Infarction

Randy Fanous
University of Toronto PGY3 Radiology

Outline
Anatomy
Vascular supply of bowel

Pathology
Stages Contributing factors Etiologies

CT
Technique Findings

Cases

Anatomy

Vascular Supply of Bowel:

1. Celiac = distal esophagus to descending duodenum 2. SMA = transverse duodenum to splenic flexure

Arterial

GDA (first branch of CHA) = anastomotic connections b/w celiac axis and SMA

Marginal artery of Drummond/ arcade of Riolan = anastomotic connections b/w Distribution provides clues to etiology SMA and IMA

3. IMA = splenic flexure toA. Vascularduodenum rectum = territories (a) Celiac

(b) = jejunum, ileum, Anastomotic connections SMAlumbar arteries (offtransverse to IMA = descendingascending, abdominal aorta) and internal (c) (rectum spared) iliacs

B. Watershed territories

Watershed areas:
Splenic flexure Ileocecal junction Rectosigmoid junction

Anatomy

Vascular Supply of Bowel:

Venous

SMV and IMV parallel the corresponding arteries and their drainage IMV drains into splenic vein; splenic vein and SMV form portal confluence Extensive anastomotic connections b/w mesenteric veins and systemic venous circulation

Bowel is highly vascularized with extensive collaterals (small >> large)

Anatomy

Vascular Supply of Bowel:

Percentage of cardiac output received by bowel
(a) Normal circumstances = 20% (b) Post-prandial (splanchnic auto-regulation) = 35% (c) Sympathetic stress response = 10%

Blood Flow

Proportion of arterial blood to bowel wall

2/3 = mucosa (i.e. susceptible to ischemia) 1/3 = remainder of the mural layers

Ex. Shock = high-risk group (i.e. low flow state + stress response)

Pathology

Ischemia and Infarction:

1 = mucosal ischemia
aka ischemic enteritis/ colitis Reversible mucosal erosions and ulcerations

Stages

2 = submucosal/ muscularis ischemia

Partial mural necrosis with possible repair +/- residual fibrotic strictures

3 = transmural ischemia
aka bowel infarction Non-reversible transmural gangrenous necrosis

Pathology

Ischemia and Infarction:

1 = mucosal ischemia
aka ischemic enteritis/ colitis Reversible mucosal erosions and ulcerations

Contributing Factors

Important to realize that acute bowel 2 = submucosal/ muscularisdoes NOT refer to a single ischemia ischemia Partial mural necrosis with possible repair +/- residual fibrotic strictures entity, but rather a spectrum of disease!

3 = transmural ischemia
aka bowel infarction Non-reversible transmural gangrenous necrosis

Post-ischemic inflammatory response

i.e. release of a myriad of cytokines Contributes to necrosis and further compromises mucosal integrity

Super-infection (esp. colon)

Translocation of intra-luminal bacteria, leading to mural infection, bacteremia and sepsis (high mortality)

Pathology

Etiologies
Occlusive (75%)
Mesenteric arterial (90%)

1. Occlusive (75%): Arterial (thromboembolism) 2. Non-occlusive (25%): Venous (bowel obstruction)

Ex. Thromboembolism (atrial fibrillation, aortic), mesenteric thrombosis, dissection etc. Ex. Neoplasm, infection, hypercoagubility (polycythemia, sickle cell, antithrombin III, protein C/S, oral contraceptives) etc.

Mesenteric venous (10%)

Non-occlusive (25%)
Mechanical (bowel obstruction)
(a) Strangulation of mesenteric veins (b) Over-distension with subsequent compromise of the local mucosal microcirculation Ex. Shock (hemorrhagic, septic, cardiogenic), severe dehydration, IVDU, pheochromocytoma, familial dysautonomia etc. Ex. Pancreatitis, appendicitis, diverticulitis, peritonitis etc. Ex. Vasculitis (i.e. young patients, unusual sites), diabetic vasculopathy, fibromuscular dysplasia etc. Ex. XRT, chemotherapy, immunosuppression, corrosive injury etc.

Hypoperfusion/ Vasospasm

Inflammatory

Vasculopathy Others

Pathology

Etiologies:

Occlusive

IMA atherosclerosis

Pathology

Etiologies:

Occlusive

SMA thromboembolism

Pathology

Etiologies:

Occlusive

SMA Cholesterol embolus

Pathology

Etiologies:

Occlusive

Aortic stent occlusion of IMA

Pathology

Etiologies:

Occlusive

Polycythemia ruba vera

Pathology

Etiologies:

Non-occlusive

Cardiogenic shock

Pathology

Etiologies:

Non-occlusive

Lupus

CT

Technique:

Ischemic Bowel Protocol

3 Types of contrast (a) IV (150 cc via mechanical injector at a rate of 2-4 ml/sec) (b) Oral (c) Rectal NB: Bowel distension (i.e. assess bowel wall thickness) NB: Positive vs. negative contrast? Positive contrast indicated in suspected bowel obstruction and advantageous for delineation of inner mural layer in setting of hypoattenuating mucosa. Otherwise, negative contrast allows optimal delineation of mural layers. 3 Phases (a) Unenhanced Differentiating hyperattenuating bowel wall caused by hemorrhage from that caused by hyperperfusion Background atherosclerotic disease Hyperattenuating intravascular clot (b) Arterial (30 sec) Arterial occlusion (c) Portovenous (90 sec) Venous occlusion Assessment of the remainder of the organs 3 Planes (a) Axial (b) Coronal (c) Sagittal

Triple contrast Triple phased Triple planar

CT

Findings:

Spectrum

Wide range of CT findings, as expected given the

range of clinical manifestations range of severity range of underlying etiologies +/- intramural hemorrhage +/- superinfection

Example: Diffuse vs. Segmental Bowel wall thickening vs. thinning Bowel wall hypoattenuation vs. hyperattenuation Mucosal hyperenhancement vs. no hyperenhancement

CT

Findings:
Distribution
Diffuse Segmental

Approach

1. 2. 3. 4.

Distribution Ischemia = wall thickening, fluid, air Infarction = dilatation, wall thinning, AFL Perforation

Ischemia

Bowel wall thickening = hypo vs. hyperattenuating; differential wall enhancement Fluid = fat stranding, mesenteric edema, ascites Air = pneumotosis, portomesenteric venous gas Dilatation Bowel wall thinning Fluid-filled loops/ AFLs

Infarction

Perforation
Pneumoperitoneum Intralumenal contrast extravasation Abscess Peritonitis

CT

Findings:
(a) Diffuse (b) Segmental
Vascular territories Watershed areas

Distribution

i.e. may provide clues to etiology

CT

Findings:

Bowel Thickening

s/t mural edema, hemorrhage, superinfection

Most SN, least SP (for ischemia, NOT infarction)

Range of SN = 26-96%
(a) ischemic colitis = 94% (b) mesenteric ischemia = 80% (c) bowel infarction = 26-38%

Occlusive = non-occlusive Venous >> Arterial (a) Hypoattenuating vs. hyperattenuating

Hypoattenuation = edema Hyperattenuation = hemorrhage

(b) Differential bowel wall enhancement

i.e. mucosal hyperenhancement
s/t hyperemia (i.e. reperfusion or superinfection) SN 33% SP 71% Produces target sign

CT

Findings:
Edema

Bowel Thickening

Hemorrhage

Bacterial superinfection

Target sign

CT

Findings:

Fluid

(a) Fat stranding (mesenteric/ pericolonic) (b) Mesenteric edema (c) Ascites NB: study of SN and SP in non-occlusive venous ischemia (i.e. venous congestion from bowel obstruction)
(a) Stranding = SN 58%, SP 79% (b) Edema = SN 88%, SP 90% (c) Ascites = SN 75%, SP 94%
NB: 2+ = SP 94%

CT

Findings:
(a) Pneumotosis

Air

s/t dissection of intra-luminal air s/t loss of mucosal integrity SP approach 100%

Non-dependent locules Dissecting wall

(b) Portomesenteric venous gas

Periphery of liver Mesenteric vessels

CT

Findings:

Air

Pneumotosis

Portal venous gas

Mesenteric venous gas

CT

Findings:

Infarction

(a) Bowel dilatation (b) Bowel wall thinning (i.e. paper thin)
s/t destruction of intramural nerves and muscles

(c) AFLs/ fluid-filled (i.e. gasless bowel)

Fluid exudation into the lumen

NB: SN of dilatation and/or AFL = 56-91% (vs. 40% in ischemia)

CT

Findings:
Perforation

Complications

Pneumoperitoneum Intralumenal contrast extravasation Abscess Peritonitis

Cases

Case #1

Cases

Case #1:

Large bowel ischemia

Cases

Case #2

Cases

Case #2:

Large bowel ischemia

Cases

Case #3

Cases

Case #3:

Small bowel Ischemia

Cases

Case #4

Cases

Case #4:

Small and large bowel infarction

Cases

Case #5

Cases

Case #5:

Small bowel obstruction with ischemia and perforation

References
Wiesner W, et al. CT of acute bowel ischemia. Radiology 2003; 226:635-650 Sung RE, et al. CT and MR imaging findings of bowel ischemia from various causes. Radiographics 200; 20:29-42

Cases
1. 2678623 = large bowel ischemia

1.
2. 3. 4. 5.

804200566 = large bowel ischemia

2319634 = small bowel ischemia 6270051 = small and large bowel infarction 3259333 = small bowel obstruction with ischemia and perforation 800131666 = ischemic small bowel post-laparotomy that is normal at surgery