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CT and MR Imaging Findings of Bowel Ischemia from Various Primary Causes¹

¹ From the Department of Diagnostic Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-Dong, Songpa-Ku, Seoul 138-040, Korea. Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received February 19, 1999; revision requested March 16; revision received and accepted April 21. Address reprint requests to H.K.H.

View larger version (163K): [in a new window]   Figure 1.   Bowel infarct due to mesenteric arterial occlusion of the ileocolic branch with iodized oil (Lipiodol; Guerbet, Roissy, France) in a 57-year-old man. The iodized oil was infused during hepatic arterial embolization for hepatocellular carcinoma. Contrast material-enhanced CT scan shows bowel wall thickening in the ileum with intestinal pneumatosis (arrowheads), as well as thickening of the ascending colon with the target sign (small arrows). Large arrow = iodized oil.

View larger version (142K): [in a new window]   Figure 2a.   Bowel infarct due to mesenteric venous thrombosis in a 52-year-old man. (a) Contrast-enhanced CT scan shows diffuse bowel wall thickening in the jejunum (arrows) and a hypoattenuating thrombus in the SMV (arrowhead). (b) Follow-up CT scan obtained 5 weeks later shows that the thickened bowel wall has become much thinner (arrows). However, at surgery, the involved bowel segment was gangrenous with microperforation.

View larger version (151K): [in a new window]   Figure 2b.   Bowel infarct due to mesenteric venous thrombosis in a 52-year-old man. (a) Contrast-enhanced CT scan shows diffuse bowel wall thickening in the jejunum (arrows) and a hypoattenuating thrombus in the SMV (arrowhead). (b) Follow-up CT scan obtained 5 weeks later shows that the thickened bowel wall has become much thinner (arrows). However, at surgery, the involved bowel segment was gangrenous with microperforation.

View larger version (179K): [in a new window]   Figure 3.   Shock bowel in a 26-year-old woman after cesarean section. Contrast-enhanced CT scan shows diffuse bowel wall thickening in the ileum (arrows) with a large intraperitoneal fluid collection due to hemoperitoneum.

View larger version (159K): [in a new window]   Figure 4a.   Strangulated bowel obstruction due to an internal hernia in the lesser sac in a 50-year-old woman. (a) Contrast-enhanced CT scan shows bowel wall thickening with poor enhancement of the strangulated bowel segment (arrows) in the lesser sac. Regional mesenteric vascular engorgement and haziness are also seen. (b) Photograph of the resected specimen shows diffuse dark discoloration of the ischemic segment of the intestine.

View larger version (131K): [in a new window]   Figure 4b.   Strangulated bowel obstruction due to an internal hernia in the lesser sac in a 50-year-old woman. (a) Contrast-enhanced CT scan shows bowel wall thickening with poor enhancement of the strangulated bowel segment (arrows) in the lesser sac. Regional mesenteric vascular engorgement and haziness are also seen. (b) Photograph of the resected specimen shows diffuse dark discoloration of the ischemic segment of the intestine.

View larger version (194K): [in a new window]   Figure 5a.   Strangulated bowel obstruction due to bands and adhesions in a 25-year-old pregnant woman. (a) Coronal contrast-enhanced MR image shows diffuse small bowel dilatation and poor enhancement (arrows) in the strangulated segment. (b) Coronal half-Fourier single-shot fast spin-echo MR image shows bowel wall thickening with a target appearance (black arrows) and regional mesenteric vascular engorgement (white arrows).

View larger version (157K): [in a new window]   Figure 5b.   Strangulated bowel obstruction due to bands and adhesions in a 25-year-old pregnant woman. (a) Coronal contrast-enhanced MR image shows diffuse small bowel dilatation and poor enhancement (arrows) in the strangulated segment. (b) Coronal half-Fourier single-shot fast spin-echo MR image shows bowel wall thickening with a target appearance (black arrows) and regional mesenteric vascular engorgement (white arrows).

View larger version (133K): [in a new window]   Figure 6a.   Colonic carcinoma with proximal ischemic colitis in a 72-year-old man. (a) Contrast-enhanced CT scan shows concentric bowel wall thickening in the ischemic sigmoid colon (open arrows) with an intervening normal-appearing segment separating the ischemic segment from the tumoral segment in the rectum (solid arrows). (b) Photograph of the resected specimen shows normal colonic mucosa between the tumoral segment (arrows) and ischemic segment (arrowheads).

View larger version (89K): [in a new window]   Figure 6b.   Colonic carcinoma with proximal ischemic colitis in a 72-year-old man. (a) Contrast-enhanced CT scan shows concentric bowel wall thickening in the ischemic sigmoid colon (open arrows) with an intervening normal-appearing segment separating the ischemic segment from the tumoral segment in the rectum (solid arrows). (b) Photograph of the resected specimen shows normal colonic mucosa between the tumoral segment (arrows) and ischemic segment (arrowheads).

View larger version (142K): [in a new window]   Figure 7a.   Systemic lupus erythematosus with mesenteric ischemia in a 20-year-old man. (a) Contrast-enhanced CT scan shows diffuse circumferential bowel wall thickening in the small intestine with the target sign and mesenteric vascular engorgement and haziness. (b) Contrast-enhanced CT scan obtained at a lower level shows concentric rectal wall thickening (white arrows) and bladder wall thickening (black arrows) due to lupus cystitis.

View larger version (152K): [in a new window]   Figure 7b.   Systemic lupus erythematosus with mesenteric ischemia in a 20-year-old man. (a) Contrast-enhanced CT scan shows diffuse circumferential bowel wall thickening in the small intestine with the target sign and mesenteric vascular engorgement and haziness. (b) Contrast-enhanced CT scan obtained at a lower level shows concentric rectal wall thickening (white arrows) and bladder wall thickening (black arrows) due to lupus cystitis.

View larger version (143K): [in a new window]   Figure 8a.   Polyarteritis nodosa with bowel ischemia in a 58-year-old man. (a) Contrast-enhanced CT scan shows bowel wall thickening in the jejunum (arrows) with minimal engorgement of the vasa recta and the arcade of the jejunal vascular branches. (b) Coronal half-Fourier single-shot fast spin-echo MR image shows bowel wall thickening in the jejunum (arrows) with mesenteric haziness (arrowheads). (c) Digital subtraction angiogram shows multiple berry aneurysms in the proximal SMA (arrows) and multifocal areas of luminal narrowing.

View larger version (148K): [in a new window]   Figure 8b.   Polyarteritis nodosa with bowel ischemia in a 58-year-old man. (a) Contrast-enhanced CT scan shows bowel wall thickening in the jejunum (arrows) with minimal engorgement of the vasa recta and the arcade of the jejunal vascular branches. (b) Coronal half-Fourier single-shot fast spin-echo MR image shows bowel wall thickening in the jejunum (arrows) with mesenteric haziness (arrowheads). (c) Digital subtraction angiogram shows multiple berry aneurysms in the proximal SMA (arrows) and multifocal areas of luminal narrowing.

View larger version (173K): [in a new window]   Figure 8c.   Polyarteritis nodosa with bowel ischemia in a 58-year-old man. (a) Contrast-enhanced CT scan shows bowel wall thickening in the jejunum (arrows) with minimal engorgement of the vasa recta and the arcade of the jejunal vascular branches. (b) Coronal half-Fourier single-shot fast spin-echo MR image shows bowel wall thickening in the jejunum (arrows) with mesenteric haziness (arrowheads). (c) Digital subtraction angiogram shows multiple berry aneurysms in the proximal SMA (arrows) and multifocal areas of luminal narrowing.

View larger version (139K): [in a new window]   Figure 9a.   Chronic pancreatitis with diffuse colonic necrosis in a 44-year-old man. (a) Contrast-enhanced CT scan shows evidence of extensive pancreatitis with diffuse phlegmonous changes and a fluid collection in the peripancreatic space as well as involvement of the duodenum (arrows). (b) CT scan obtained at a lower level shows bowel wall thickening along the descending and sigmoid colon (arrows). (c) Photograph of the gross pathologic specimen after total colectomy shows diffuse ischemic changes in nearly the entire colon, which are especially severe at the sigmoid colon (S) and rectum (R). The ischemia resulted from direct encasement of the branches of mesenteric vessels by the pancreatitic process.

View larger version (131K): [in a new window]   Figure 9b.   Chronic pancreatitis with diffuse colonic necrosis in a 44-year-old man. (a) Contrast-enhanced CT scan shows evidence of extensive pancreatitis with diffuse phlegmonous changes and a fluid collection in the peripancreatic space as well as involvement of the duodenum (arrows). (b) CT scan obtained at a lower level shows bowel wall thickening along the descending and sigmoid colon (arrows). (c) Photograph of the gross pathologic specimen after total colectomy shows diffuse ischemic changes in nearly the entire colon, which are especially severe at the sigmoid colon (S) and rectum (R). The ischemia resulted from direct encasement of the branches of mesenteric vessels by the pancreatitic process.

View larger version (128K): [in a new window]   Figure 9c.   Chronic pancreatitis with diffuse colonic necrosis in a 44-year-old man. (a) Contrast-enhanced CT scan shows evidence of extensive pancreatitis with diffuse phlegmonous changes and a fluid collection in the peripancreatic space as well as involvement of the duodenum (arrows). (b) CT scan obtained at a lower level shows bowel wall thickening along the descending and sigmoid colon (arrows). (c) Photograph of the gross pathologic specimen after total colectomy shows diffuse ischemic changes in nearly the entire colon, which are especially severe at the sigmoid colon (S) and rectum (R). The ischemia resulted from direct encasement of the branches of mesenteric vessels by the pancreatitic process.

View larger version (159K): [in a new window]   Figure 10.   Ischemia of the ileum after blunt trauma in a 35-year-old man. Contrast-enhanced CT scan shows bowel wall thickening in the ileum (open arrows) with diffuse mesenteric haziness (solid arrows).

View larger version (145K): [in a new window]   Figure 11a.   Chemotherapy-induced enteropathy with diffuse intestinal necrosis in the ileum in a 65-year-old woman who received chemotherapy for leukemia. (a) Contrast-enhanced CT scan shows bowel wall thickening in the distal ileum with a target appearance (arrows) and a regional fluid collection due to hemoperitoneum. (b) CT scan obtained at a lower level shows homogeneous bowel wall thickening in the ileum (open arrows) and a localized collection of intraperitoneal free gas (solid arrows).

View larger version (158K): [in a new window]   Figure 11b.   Chemotherapy-induced enteropathy with diffuse intestinal necrosis in the ileum in a 65-year-old woman who received chemotherapy for leukemia. (a) Contrast-enhanced CT scan shows bowel wall thickening in the distal ileum with a target appearance (arrows) and a regional fluid collection due to hemoperitoneum. (b) CT scan obtained at a lower level shows homogeneous bowel wall thickening in the ileum (open arrows) and a localized collection of intraperitoneal free gas (solid arrows).

View larger version (157K): [in a new window]   Figure 12a.   Chemotherapy-induced enteropathy with diffuse intestinal necrosis in a 72-year-old man who received chemotherapy for central nervous system lymphoma. (a) Contrast-enhanced CT scan shows extensive portal venous gas. (b) CT scan obtained at a lower level shows intestinal pneumatosis (black arrows) and gas in the mesenteric vascular branches (white arrows).

View larger version (153K): [in a new window]   Figure 12b.   Chemotherapy-induced enteropathy with diffuse intestinal necrosis in a 72-year-old man who received chemotherapy for central nervous system lymphoma. (a) Contrast-enhanced CT scan shows extensive portal venous gas. (b) CT scan obtained at a lower level shows intestinal pneumatosis (black arrows) and gas in the mesenteric vascular branches (white arrows).

View larger version (136K): [in a new window]   Figures 13.   (13) Acute radiation enteritis in a 61-year-old woman with a history of radiation therapy after hysterectomy for cervical cancer. (a) Image from a small bowel follow-through study shows luminal narrowing and a thickened bowel wall (open arrows) and mucosal irregularity due to ulceration (solid arrows). (b) Coronal half-Fourier single-shot fast spin-echo MR image also shows luminal narrowing and a thickened bowel wall (arrows).

View larger version (158K): [in a new window]   Figures 13.   (13) Acute radiation enteritis in a 61-year-old woman with a history of radiation therapy after hysterectomy for cervical cancer. (a) Image from a small bowel follow-through study shows luminal narrowing and a thickened bowel wall (open arrows) and mucosal irregularity due to ulceration (solid arrows). (b) Coronal half-Fourier single-shot fast spin-echo MR image also shows luminal narrowing and a thickened bowel wall (arrows).

View larger version (134K): [in a new window]   Figure 14.   Acute radiation enteritis in a 71-year-old man with a history of radiation therapy for periureteral metastases from rectal cancer. Contrast-enhanced CT scan shows diffuse bowel wall thickening with the target sign (arrows) confined to the radiation port.

View larger version (119K): [in a new window]   Figure 15.   Chronic radiation enteritis in a 48-year-old man with a history of radiation therapy after surgery for paraganglioma in the paraaortic space. Contrast-enhanced CT scan shows a stricture of the jejunum with considerable bowel wall thickening (arrows) due to desmoplastic reaction.

View larger version (157K): [in a new window]   Figure 16.   Corrosive enteritis in a 70-year-old man with a history of ingestion of acetic acid. Contrast-enhanced CT scan shows heterogeneous bowel wall thickening in the jejunum (arrows) and a large amount of ascites.

View larger version (130K): [in a new window]   Figure 17a.   Massive corrosive gastritis and enteritis in a 48-year-old woman with a history of ingestion of acetic acid. (a) Contrast-enhanced CT scan shows pneumatosis involving the gastric wall (arrowheads) and portal venous gas (arrows) with multifocal hepatic infarction. Free air is also noted in the perihepatic space. (b) CT scan obtained at a lower level shows intestinal pneumatosis in the jejunum as well as poor bowel wall enhancement.

View larger version (135K): [in a new window]   Figure 17b.   Massive corrosive gastritis and enteritis in a 48-year-old woman with a history of ingestion of acetic acid. (a) Contrast-enhanced CT scan shows pneumatosis involving the gastric wall (arrowheads) and portal venous gas (arrows) with multifocal hepatic infarction. Free air is also noted in the perihepatic space. (b) CT scan obtained at a lower level shows intestinal pneumatosis in the jejunum as well as poor bowel wall enhancement.