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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 73-year-old man with an incarcerated left inguinal hernia. The covering mucosa of upper segment (arrow) is poorly enhancing on contrast-enhanced computed tomography. The patient recovered after surgical reduction without resection of the small bowel. This outcome indicates that transmural necrosis did not occur, though the mucosa might have been damaged or necrotic. The normally enhancing mucosa of the lower segment (arrowhead) was about 1 mm thick. The heaved Kerckring fold, approximately 4–6 mm tall, is composed of a dark edematous submucosa (like a mountain) and covered by a bright mucosa (like a forest)
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Figure 7: A 73-year-old man with an incarcerated left inguinal hernia. The covering mucosa of upper segment (arrow) is poorly enhancing on contrast-enhanced computed tomography. The patient recovered after surgical reduction without resection of the small bowel. This outcome indicates that transmural necrosis did not occur, though the mucosa might have been damaged or necrotic. The normally enhancing mucosa of the lower segment (arrowhead) was about 1 mm thick. The heaved Kerckring fold, approximately 4–6 mm tall, is composed of a dark edematous submucosa (like a mountain) and covered by a bright mucosa (like a forest)

Mentions: Surgical intervention, small-bowel resection and necrosis, and death may happen more commonly in patients whose CT scans show poor enhancement of the thickened wall than in those with normal enhancement.[1114] However, absence of inner-layer enhancement is not proof that the bowel is nonviable [Figure 7]. This is because ischemia-induced bowel necrosis may be mucosal, mural, or transmural depending on the severity of injury. In mucosal necrosis, damage is limited to the mucosa. Mural necrosis involves both the mucosa and the submucosa, or even part of the muscularis externa. When the entire thickness of the muscularis externa is involved, transmural necrosis occurs, and bowel perforation is unavoidable. Small bowel affected by only mucosal or mural necrosis may survive without a need for resection, though late-occurring fibrosis-induced stricture may be a complication. The CT manifestation and clinical outcome of a case with SMV thrombosis presented in another report[27] were compatible with the above descriptions. The post-contrast CT scan of that case revealed poor inner layer enhancement of a symmetrically and circumferentially thickened small-bowel segment, which was darker than the abdominal wall muscles. The patient received anticoagulant therapy and recovered without surgery. However, she developed fibrotic stricture months later. The CT picture and clinical course were consistent with an ischemic injury limited to mucosal or mural necrosis.


CT manifestations of small bowel ischemia due to impaired venous drainage-with a correlation of pathologic findings
A 73-year-old man with an incarcerated left inguinal hernia. The covering mucosa of upper segment (arrow) is poorly enhancing on contrast-enhanced computed tomography. The patient recovered after surgical reduction without resection of the small bowel. This outcome indicates that transmural necrosis did not occur, though the mucosa might have been damaged or necrotic. The normally enhancing mucosa of the lower segment (arrowhead) was about 1 mm thick. The heaved Kerckring fold, approximately 4–6 mm tall, is composed of a dark edematous submucosa (like a mountain) and covered by a bright mucosa (like a forest)
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 7: A 73-year-old man with an incarcerated left inguinal hernia. The covering mucosa of upper segment (arrow) is poorly enhancing on contrast-enhanced computed tomography. The patient recovered after surgical reduction without resection of the small bowel. This outcome indicates that transmural necrosis did not occur, though the mucosa might have been damaged or necrotic. The normally enhancing mucosa of the lower segment (arrowhead) was about 1 mm thick. The heaved Kerckring fold, approximately 4–6 mm tall, is composed of a dark edematous submucosa (like a mountain) and covered by a bright mucosa (like a forest)
Mentions: Surgical intervention, small-bowel resection and necrosis, and death may happen more commonly in patients whose CT scans show poor enhancement of the thickened wall than in those with normal enhancement.[1114] However, absence of inner-layer enhancement is not proof that the bowel is nonviable [Figure 7]. This is because ischemia-induced bowel necrosis may be mucosal, mural, or transmural depending on the severity of injury. In mucosal necrosis, damage is limited to the mucosa. Mural necrosis involves both the mucosa and the submucosa, or even part of the muscularis externa. When the entire thickness of the muscularis externa is involved, transmural necrosis occurs, and bowel perforation is unavoidable. Small bowel affected by only mucosal or mural necrosis may survive without a need for resection, though late-occurring fibrosis-induced stricture may be a complication. The CT manifestation and clinical outcome of a case with SMV thrombosis presented in another report[27] were compatible with the above descriptions. The post-contrast CT scan of that case revealed poor inner layer enhancement of a symmetrically and circumferentially thickened small-bowel segment, which was darker than the abdominal wall muscles. The patient received anticoagulant therapy and recovered without surgery. However, she developed fibrotic stricture months later. The CT picture and clinical course were consistent with an ischemic injury limited to mucosal or mural necrosis.

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