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CT manifestations of small bowel ischemia due to impaired venous drainage-with a correlation of pathologic findings

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ABSTRACT

Acute abdominal pain may result from a wide variety of medical and surgical diseases. One of these diseases is small bowel ischemia, which may result in a catastrophic outcome if not recognized and treated promptly. Computed tomography (CT) by its faster image acquisition, thinner collimation, high resolution, and multiplanar reformatted images has become the most important imaging modality in evaluating the acute abdominal conditions. In this article, the author presents a description of the histology of the small bowel, pathophysiology of small bowel change, and a correlation of the pathologic and CT findings of the small bowel injuries due to impaired venous drainage. A convincing correlation of the microscopic mucosal condition with the enhancement pattern of the thickened small bowel wall on CT is useful in definitely describing the mucosal viability.

No MeSH data available.


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(A–C) An 83-year-old woman with adhesion-induced strangulation. (A) Photomicrograph (hematoxylin and eosin stain, original magnification ×40) shows a predominantly edematous submucosa (SM) and a severely swollen Kerckring fold (KF). (B) On this photomicrograph (hematoxylin and eosin stain, original magnification ×200), ghost villi (V) are swollen and compacted together. Their mean height is approximately 0.5 mm, similar to that of normal villi. Boundaries of some villi are intact; others are lost (arrowheads). The villi are filled with red blood cells, inflammatory cells, and necrotic tissue. BL = basal lamina. (C) Contrast-enhanced computed tomography (CT) scan shows a thickened wall (arrow) of homogeneous attenuation without a recognizable, enhancing inner layer. The thickened wall is hypodense to the adjacent muscles. This appearance is consistent with mucosal necrosis. The patient recovered after surgery. (D) Contrast-enhanced CT scan in an 81-year-old woman with episodes, pathologic results, and an outcome similar to those of the patient in A–C. The thickened ileum (arrow), approximately 2 cm in outer diameter, showed no inner-layer enhancement
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Figure 5: (A–C) An 83-year-old woman with adhesion-induced strangulation. (A) Photomicrograph (hematoxylin and eosin stain, original magnification ×40) shows a predominantly edematous submucosa (SM) and a severely swollen Kerckring fold (KF). (B) On this photomicrograph (hematoxylin and eosin stain, original magnification ×200), ghost villi (V) are swollen and compacted together. Their mean height is approximately 0.5 mm, similar to that of normal villi. Boundaries of some villi are intact; others are lost (arrowheads). The villi are filled with red blood cells, inflammatory cells, and necrotic tissue. BL = basal lamina. (C) Contrast-enhanced computed tomography (CT) scan shows a thickened wall (arrow) of homogeneous attenuation without a recognizable, enhancing inner layer. The thickened wall is hypodense to the adjacent muscles. This appearance is consistent with mucosal necrosis. The patient recovered after surgery. (D) Contrast-enhanced CT scan in an 81-year-old woman with episodes, pathologic results, and an outcome similar to those of the patient in A–C. The thickened ileum (arrow), approximately 2 cm in outer diameter, showed no inner-layer enhancement

Mentions: Of special importance is the density of the inner layer of the thickened wall, which is supposed to reflect the status of the mucosa.[1114] Because the mucosa receives 65% of the blood flow to the intestines, a normally structured and perfused mucosa should be the brightest layer (>120 HUs) of the thickened wall, regardless of the edematous or hemorrhagic submucosa, on the contrast-enhanced scans. An adequately enhancing inner layer represents a normal blood supply to the normally structured mucosa, and the bowel tends to be viable [Figure 4]. However, the lack of an enhancing inner layer may represent poor blood circulation in the mucosa, which may have become necrotic or even sloughed [Figures 2, 5 and 6]. The non-enhancing mucosa is indistinguishable from the submucosa and not visible on CT. This finding represents further injury of the bowel wall (at least mucosal necrosis), and it results in a prognosis worse than that associated with normal inner-layer enhancement.[14]


CT manifestations of small bowel ischemia due to impaired venous drainage-with a correlation of pathologic findings
(A–C) An 83-year-old woman with adhesion-induced strangulation. (A) Photomicrograph (hematoxylin and eosin stain, original magnification ×40) shows a predominantly edematous submucosa (SM) and a severely swollen Kerckring fold (KF). (B) On this photomicrograph (hematoxylin and eosin stain, original magnification ×200), ghost villi (V) are swollen and compacted together. Their mean height is approximately 0.5 mm, similar to that of normal villi. Boundaries of some villi are intact; others are lost (arrowheads). The villi are filled with red blood cells, inflammatory cells, and necrotic tissue. BL = basal lamina. (C) Contrast-enhanced computed tomography (CT) scan shows a thickened wall (arrow) of homogeneous attenuation without a recognizable, enhancing inner layer. The thickened wall is hypodense to the adjacent muscles. This appearance is consistent with mucosal necrosis. The patient recovered after surgery. (D) Contrast-enhanced CT scan in an 81-year-old woman with episodes, pathologic results, and an outcome similar to those of the patient in A–C. The thickened ileum (arrow), approximately 2 cm in outer diameter, showed no inner-layer enhancement
© Copyright Policy - open-access
Related In: Results  -  Collection

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Show All Figures
getmorefigures.php?uid=PMC5036332&req=5

Figure 5: (A–C) An 83-year-old woman with adhesion-induced strangulation. (A) Photomicrograph (hematoxylin and eosin stain, original magnification ×40) shows a predominantly edematous submucosa (SM) and a severely swollen Kerckring fold (KF). (B) On this photomicrograph (hematoxylin and eosin stain, original magnification ×200), ghost villi (V) are swollen and compacted together. Their mean height is approximately 0.5 mm, similar to that of normal villi. Boundaries of some villi are intact; others are lost (arrowheads). The villi are filled with red blood cells, inflammatory cells, and necrotic tissue. BL = basal lamina. (C) Contrast-enhanced computed tomography (CT) scan shows a thickened wall (arrow) of homogeneous attenuation without a recognizable, enhancing inner layer. The thickened wall is hypodense to the adjacent muscles. This appearance is consistent with mucosal necrosis. The patient recovered after surgery. (D) Contrast-enhanced CT scan in an 81-year-old woman with episodes, pathologic results, and an outcome similar to those of the patient in A–C. The thickened ileum (arrow), approximately 2 cm in outer diameter, showed no inner-layer enhancement
Mentions: Of special importance is the density of the inner layer of the thickened wall, which is supposed to reflect the status of the mucosa.[1114] Because the mucosa receives 65% of the blood flow to the intestines, a normally structured and perfused mucosa should be the brightest layer (>120 HUs) of the thickened wall, regardless of the edematous or hemorrhagic submucosa, on the contrast-enhanced scans. An adequately enhancing inner layer represents a normal blood supply to the normally structured mucosa, and the bowel tends to be viable [Figure 4]. However, the lack of an enhancing inner layer may represent poor blood circulation in the mucosa, which may have become necrotic or even sloughed [Figures 2, 5 and 6]. The non-enhancing mucosa is indistinguishable from the submucosa and not visible on CT. This finding represents further injury of the bowel wall (at least mucosal necrosis), and it results in a prognosis worse than that associated with normal inner-layer enhancement.[14]

View Article: PubMed Central - PubMed

ABSTRACT

Acute abdominal pain may result from a wide variety of medical and surgical diseases. One of these diseases is small bowel ischemia, which may result in a catastrophic outcome if not recognized and treated promptly. Computed tomography (CT) by its faster image acquisition, thinner collimation, high resolution, and multiplanar reformatted images has become the most important imaging modality in evaluating the acute abdominal conditions. In this article, the author presents a description of the histology of the small bowel, pathophysiology of small bowel change, and a correlation of the pathologic and CT findings of the small bowel injuries due to impaired venous drainage. A convincing correlation of the microscopic mucosal condition with the enhancement pattern of the thickened small bowel wall on CT is useful in definitely describing the mucosal viability.

No MeSH data available.


Related in: MedlinePlus