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Multi–Detector Row CT of Mesenteric Ischemia: Can It Be Done?¹

¹ From the Department of Radiology, Johns Hopkins Medical Institutions, 601 N Caroline St, Rm 3251, Baltimore, MD 21287. Recipient of a Certificate of Merit award for an education exhibit at the 2000 RSNA scientific assembly. Received March 15, 2001; revision requested April 19 and final revision received June 27; accepted July 2. Address correspondence to E.K.F. (e-mail: efishman@jhmi.edu).

View larger version (139K): [in a new window]   Figure 1.   Drawings illustrate the value of using water as an oral contrast agent instead of high-attenuation contrast agents when evaluating small bowel disease and enhancement. Drawings A ("unenhanced CT scan") and B ("contrast material-enhanced CT scan") illustrate the results of using a high-attenuation contrast agent, whereas drawings C (unenhanced CT scan) and D (contrast-enhanced CT scan) illustrate the results of using a low-attenuation contrast agent (eg, water). Intraluminal water clearly allows better visualization of the enhancing bowel wall.

View larger version (160K): [in a new window]   Figure 2a.   Coronal volume-rendered 3D multi-detector row CT scans (b obtained anterior to a) demonstrate the normal small bowel. Water was used as an oral contrast agent, allowing visualization of the enhancing small bowel wall and intestinal folds.

View larger version (162K): [in a new window]   Figure 2b.   Coronal volume-rendered 3D multi-detector row CT scans (b obtained anterior to a) demonstrate the normal small bowel. Water was used as an oral contrast agent, allowing visualization of the enhancing small bowel wall and intestinal folds.

View larger version (155K): [in a new window]   Figure 3a.   (a) Sagittal volume-rendered 3D multi-detector row CT scan demonstrates the normal celiac axis (straight arrow) and superior mesenteric artery (SMA) (curved arrow). (b) Coronal volume-rendered 3D multi-detector row CT scan shows the normal branching pattern of the SMA (arrow). (c) Coronal oblique volume-rendered 3D multi-detector row CT scan shows the normal branching pattern of the inferior mesenteric artery (arrows). (d) Coronal volume-rendered 3D multi-detector row CT scan demonstrates the normal mesenteric veins.

View larger version (190K): [in a new window]   Figure 3b.   (a) Sagittal volume-rendered 3D multi-detector row CT scan demonstrates the normal celiac axis (straight arrow) and superior mesenteric artery (SMA) (curved arrow). (b) Coronal volume-rendered 3D multi-detector row CT scan shows the normal branching pattern of the SMA (arrow). (c) Coronal oblique volume-rendered 3D multi-detector row CT scan shows the normal branching pattern of the inferior mesenteric artery (arrows). (d) Coronal volume-rendered 3D multi-detector row CT scan demonstrates the normal mesenteric veins.

View larger version (135K): [in a new window]   Figure 3c.   (a) Sagittal volume-rendered 3D multi-detector row CT scan demonstrates the normal celiac axis (straight arrow) and superior mesenteric artery (SMA) (curved arrow). (b) Coronal volume-rendered 3D multi-detector row CT scan shows the normal branching pattern of the SMA (arrow). (c) Coronal oblique volume-rendered 3D multi-detector row CT scan shows the normal branching pattern of the inferior mesenteric artery (arrows). (d) Coronal volume-rendered 3D multi-detector row CT scan demonstrates the normal mesenteric veins.

View larger version (169K): [in a new window]   Figure 3d.   (a) Sagittal volume-rendered 3D multi-detector row CT scan demonstrates the normal celiac axis (straight arrow) and superior mesenteric artery (SMA) (curved arrow). (b) Coronal volume-rendered 3D multi-detector row CT scan shows the normal branching pattern of the SMA (arrow). (c) Coronal oblique volume-rendered 3D multi-detector row CT scan shows the normal branching pattern of the inferior mesenteric artery (arrows). (d) Coronal volume-rendered 3D multi-detector row CT scan demonstrates the normal mesenteric veins.

View larger version (168K): [in a new window]   Figure 4a.   Coronal volume-rendered 3D multi-detector row CT scans obtained with different rendering parameters after rectal insufflation of approximately 1 L of air show reflux of the air back into the small bowel. The appearance of the distended bowel is the same as at enteroclysis (a) and at a barium small bowel study (b).

View larger version (121K): [in a new window]   Figure 4b.   Coronal volume-rendered 3D multi-detector row CT scans obtained with different rendering parameters after rectal insufflation of approximately 1 L of air show reflux of the air back into the small bowel. The appearance of the distended bowel is the same as at enteroclysis (a) and at a barium small bowel study (b).

View larger version (171K): [in a new window]   Figure 5a.   Acute mesenteric ischemia in a 59-year-old man who was admitted to the hospital with atrial fibrillation and acute abdominal pain. (a) Coronal 3D multi-detector row CT scan demonstrates segmental thickening of a small bowel loop in the left side of the abdomen (straight arrow). This loop is narrowed compared with the remainder of the small bowel, which is minimally dilated. The small mesenteric vessels feeding the loop are distended (curved arrows). (b) Coronal 3D multi-detector row CT scan obtained 4 days later demonstrates pneumatosis of the small bowel loop (arrow), a finding that is compatible with infarction. Note that the dilated mesenteric vessels are no longer visible.

View larger version (154K): [in a new window]   Figure 5b.   Acute mesenteric ischemia in a 59-year-old man who was admitted to the hospital with atrial fibrillation and acute abdominal pain. (a) Coronal 3D multi-detector row CT scan demonstrates segmental thickening of a small bowel loop in the left side of the abdomen (straight arrow). This loop is narrowed compared with the remainder of the small bowel, which is minimally dilated. The small mesenteric vessels feeding the loop are distended (curved arrows). (b) Coronal 3D multi-detector row CT scan obtained 4 days later demonstrates pneumatosis of the small bowel loop (arrow), a finding that is compatible with infarction. Note that the dilated mesenteric vessels are no longer visible.

View larger version (150K): [in a new window]   Figure 6a.   Acute mesenteric ischemia in a 57-year-old man with long-standing atherosclerotic heart disease who presented with acute abdominal pain and watery diarrhea. (a) Axial contrast-enhanced volume-rendered multi-detector row CT scan demonstrates pneumatosis of several small bowel loops in the right side of the abdomen (arrows). (b) Lateral volume-rendered 3D multi-detector row CT scan demonstrates calcified plaque at the origins of the celiac axis (straight arrow) and SMA (curved arrow) as well as moderate calcified plaque in the aorta. (c) On axial oblique 3D multi-detector row CT scans (right image obtained inferior to left image), the SMA (curved arrow) has a smaller caliber than the celiac axis (straight arrow). Surgery revealed infarction of the distal small bowel with associated ischemic changes in the right colon. Severe stenosis was noted at the origin of the SMA with minimal stenosis at the celiac origin. Endarterectomy of the SMA was performed along with a bypass graft procedure.

View larger version (171K): [in a new window]   Figure 6b.   Acute mesenteric ischemia in a 57-year-old man with long-standing atherosclerotic heart disease who presented with acute abdominal pain and watery diarrhea. (a) Axial contrast-enhanced volume-rendered multi-detector row CT scan demonstrates pneumatosis of several small bowel loops in the right side of the abdomen (arrows). (b) Lateral volume-rendered 3D multi-detector row CT scan demonstrates calcified plaque at the origins of the celiac axis (straight arrow) and SMA (curved arrow) as well as moderate calcified plaque in the aorta. (c) On axial oblique 3D multi-detector row CT scans (right image obtained inferior to left image), the SMA (curved arrow) has a smaller caliber than the celiac axis (straight arrow). Surgery revealed infarction of the distal small bowel with associated ischemic changes in the right colon. Severe stenosis was noted at the origin of the SMA with minimal stenosis at the celiac origin. Endarterectomy of the SMA was performed along with a bypass graft procedure.

View larger version (171K): [in a new window]   Figure 6c.   Acute mesenteric ischemia in a 57-year-old man with long-standing atherosclerotic heart disease who presented with acute abdominal pain and watery diarrhea. (a) Axial contrast-enhanced volume-rendered multi-detector row CT scan demonstrates pneumatosis of several small bowel loops in the right side of the abdomen (arrows). (b) Lateral volume-rendered 3D multi-detector row CT scan demonstrates calcified plaque at the origins of the celiac axis (straight arrow) and SMA (curved arrow) as well as moderate calcified plaque in the aorta. (c) On axial oblique 3D multi-detector row CT scans (right image obtained inferior to left image), the SMA (curved arrow) has a smaller caliber than the celiac axis (straight arrow). Surgery revealed infarction of the distal small bowel with associated ischemic changes in the right colon. Severe stenosis was noted at the origin of the SMA with minimal stenosis at the celiac origin. Endarterectomy of the SMA was performed along with a bypass graft procedure.

View larger version (155K): [in a new window]   Figure 7a.   Acute mesenteric ischemia in a patient with severe abdominal pain. Axial (a) and coronal (b) 3D multi-detector row CT scans demonstrate a mesenteric mass (arrows in a, straight arrows in b) encasing the mesenteric vessels. Focal calcification is seen within the mass (curved arrow in b). The small bowel loops are thickened, and ascites and mesenteric stranding are also noted. Biopsy revealed sclerosing mesenteritis.

View larger version (162K): [in a new window]   Figure 7b.   Acute mesenteric ischemia in a patient with severe abdominal pain. Axial (a) and coronal (b) 3D multi-detector row CT scans demonstrate a mesenteric mass (arrows in a, straight arrows in b) encasing the mesenteric vessels. Focal calcification is seen within the mass (curved arrow in b). The small bowel loops are thickened, and ascites and mesenteric stranding are also noted. Biopsy revealed sclerosing mesenteritis.

View larger version (146K): [in a new window]   Figure 8a.   Acute mesenteric ischemia in a 56-year-old woman with severe abdominal pain. The patient had undergone Whipple surgery for pancreatic cancer 5 days earlier. (a) Axial multi-detector row CT scan demonstrates thrombosis of the superior mesenteric vein (arrow). (b) Axial CT scan obtained inferior to a demonstrates thickened small bowel loops with a halo appearance, findings that are compatible with ischemia.

View larger version (121K): [in a new window]   Figure 8b.   Acute mesenteric ischemia in a 56-year-old woman with severe abdominal pain. The patient had undergone Whipple surgery for pancreatic cancer 5 days earlier. (a) Axial multi-detector row CT scan demonstrates thrombosis of the superior mesenteric vein (arrow). (b) Axial CT scan obtained inferior to a demonstrates thickened small bowel loops with a halo appearance, findings that are compatible with ischemia.

View larger version (142K): [in a new window]   Figure 9a.   Acute mesenteric ischemia in a 76-year-old woman with severe abdominal pain. The patient had undergone successful laparoscopic cholecystectomy 2 days earlier. (a) Multi-detector row CT scan demonstrates focal narrowing of the SMA approximately 2 cm from its origin (arrow). This finding was most likely caused by atherosclerotic plaque. (b) On a CT angiogram, the branches of the SMA appear small and narrowed (arrows), possibly due to vasospasm. The bowel wall (not shown) appeared normal with no evidence of thickening. The CT angiographic findings were confirmed at conventional angiography. The patient was treated conservatively, and the symptoms resolved within a week. The patient was discharged in good condition.

View larger version (157K): [in a new window]   Figure 9b.   Acute mesenteric ischemia in a 76-year-old woman with severe abdominal pain. The patient had undergone successful laparoscopic cholecystectomy 2 days earlier. (a) Multi-detector row CT scan demonstrates focal narrowing of the SMA approximately 2 cm from its origin (arrow). This finding was most likely caused by atherosclerotic plaque. (b) On a CT angiogram, the branches of the SMA appear small and narrowed (arrows), possibly due to vasospasm. The bowel wall (not shown) appeared normal with no evidence of thickening. The CT angiographic findings were confirmed at conventional angiography. The patient was treated conservatively, and the symptoms resolved within a week. The patient was discharged in good condition.

View larger version (148K): [in a new window]   Figure 10.   Chronic mesenteric ischemia in a 68-year-old woman with the classic symptoms of the disease. Multi-detector row CT scan demonstrates atherosclerotic plaque and minimal narrowing at the origins of the celiac axis (straight arrow) and SMA (curved arrow), which otherwise appear normal. The small bowel and colon (not shown) demonstrated normal enhancement with no evidence of thickening. Because of the CT findings and clinical symptoms, the patient underwent aortomesenteric bypass surgery. Although the CT findings may be subtle, they may also be hemodynamically significant, especially in situations that put stress on the mesenteric circulation (eg, after meals).

View larger version (185K): [in a new window]   Figure 11a.   Chronic mesenteric ischemia. (a) Sagittal volume-rendered 3D multi-detector row CT scan demonstrates occlusion at the origins of the celiac axis (straight arrow) and SMA (curved arrow). (b) Coronal volume-rendered 3D multi-detector row CT scan demonstrates an enlarged inferior mesenteric artery filling the celiac axis and SMA in a retrograde fashion through collateral vessels (arrows).

View larger version (150K): [in a new window]   Figure 11b.   Chronic mesenteric ischemia. (a) Sagittal volume-rendered 3D multi-detector row CT scan demonstrates occlusion at the origins of the celiac axis (straight arrow) and SMA (curved arrow). (b) Coronal volume-rendered 3D multi-detector row CT scan demonstrates an enlarged inferior mesenteric artery filling the celiac axis and SMA in a retrograde fashion through collateral vessels (arrows).